Endovascular Treatment Of Carotid Cavernous Fistulas With The Willis Covered Stent

Objective: To investigate the optimal treatment of carotid cavernous fistulas(CCF)and to analyze the effectiveness and safety of the Willis covered stents in the treatment of CCF.This study aimed to reveal the single-center clinical results and experience with the Willis covered stents for CCF by statistically analyzing the outcomes of patients with CCF treated with a detachable balloon in our institution.Methods: Patients with CCF admitted to the Department of Interventional Therapy of the First Hospital of Dalian Medical University between December 2002 and December 2022 were retrospectively analyzed and further screened according to the inclusion criteria to collect patients treated with Willis covered stents and those treated with detachable balloons.Relevant baseline data,preoperative clinical data(gender,age,current medical history,presence of trauma history,admission ocular specialist signs,type of fistula assessed according to Barrow classification),preoperative relevant examination data(preoperative CT,DSA),intraoperative clinical data(intraoperative CT data,embolization materials and embolization agents used intraoperatively,fistula access,and intraoperative immediate angiographic images),postoperative clinical data(postoperative CT data,ocular specialist signs,time to recurrence,recurrence signs),prognostic performance of the patients before discharge and clinical assessment of the follow-up patients(cure,recurrence and death).To analyze the clinical symptom relief of patients in both groups before and three days after surgery.To analyze the prognosis of patients under the two treatment modalities.To analyze the treatment outcome and follow-up of patients in both groups.Results: A total of 55 patients(67.3% male,32.7% female,mean age 46.49 ±13.54.Ten of the patients had Willis covered stents,and all of the Willis covered stents were successfully placed in the responsible vessel.The angiographic findings after stent placement also showed that 10 patients achieved complete occlusion of 10 fistulas and 1fistula was incompletely occluded but did not show endoleaks.1 patient still had an endoleak on the angiogram immediately after the first Willis covered stent was placed,and the endoleak improved significantly after the second stent was placed.45 with detachable balloon embolization were technically successful,with 42 fistulas completely occluded,6 incompletely occluded,and 5 taking internal carotid artery(ICA)occlusion in 45 patients.Postoperative and pre-discharge neurological examinations showed no new neurological symptoms or recurrent pulsatile proptosis or retro-orbital murmur in all patients.In 10 patients treated with the Willis covered stents,9 patients underwent outpatient review and follow-up angiography at 1,3,6,and 12 months postoperatively.9patients had complete resolution of symptoms and 1 patient died postoperatively due to brainstem hemorrhage from a displaced detachable balloon.45 patients treated with the detachable balloon underwent outpatient review and follow-up angiography at 1,3,6,and 12 months postoperatively.Two patients with detachable balloon embolization experienced recurrent disease,with patients reporting worse symptoms than before,such as pulsatile proptosis,retro-orbital murmur,or conjunctival edema.Patients with Willis covered stents experienced a 100% symptom relief rate.These preliminary results show that a comparative evaluation of treatment outcomes with the Willis covered stents and a detachable balloon reveals that the use of the Willis covered stents for the treatment of patients with CCF has good efficacy,few complications,and a low recurrence rate,which warrants its widespread use.Conclusions: The clinical outcome of Willis covered stents in CCF is satisfactory.The treatment of CCF with a detachable balloon may be difficult due to incomplete closure after insertion,or leakage of the balloon from a fracture fragment at the base of the skull,or a small fistula,which may be difficult to access during treatment and can only be treated with a Willis covered stents,or other adjunctive materials such as coils or onyx glue,even if the fistula is large and requires sacrifice of the ICA to treat the recurrent carotid spongy sinus fistula.Therefore,our study concluded that in high flow CCF,where a detachable balloon cannot be easily placed,or where the ICA has a large fistula tear,the Willis covered stents can be used to protect the ICA while achieving closure of the fistula.In contrast to the high recurrence rate of detachable balloons and the tendency for incomplete occlusion and failure to achieve anatomical cure,the Willis covered stents embolization approach significantly reduces the recurrence rate,significantly increases the efficiency of fistula occlusion and achieves complete anatomical reconstruction of the vessel.