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Abstract：
We report our experience in treatment of traumatic direct carotid cavernous fistula (CCF) via endovascular intervention. We hereof recommend an additional classification system for type A CCF and suggest respective treatment strategies. Only type A CCF patients (Barrow\'s classification) would be recruited for the study. Based on the angiographic characteristics of the CCF, we classified type A CCF into three subtypes including small size, medium size and large size fistula depending on whether there was presence of the anterior carotid artery (ACA) and/or middle carotid artery (MCA). Angiograms with opacification of both ACA and MCA were categorized as small size fistula. Angiograms with opacification of either ACA or MCA were categorized as medium size fistula and those without opacification of neither ACA nor MCA were classified as large size fiatula. After the confirm angiogram, endovascular embolization would be performed impromptu using detachable balloon, coils or both. All cases were followed up for complication and effect after the embolization. A total of 172 direct traumatic CCF patients were enrolled. The small size fistula was accountant for 12.8% (22 cases), medium size 35.5% (61 cases) and large size fistula accountant for 51.7% (89 cases). The successful rate of fistula occlusion under endovascular embolization was 94% with preservation of the carotid artery in 70%. For the treatment of each subtype, a total of 21/22 cases of the small size fistulas were successfully treated using coils alone. The other single case of small fistula was defaulted. Most of the medium and large size fistulas were cured using detachable balloons. When the fistula sealing could not be obtained using detachable balloon, coils were added to affirm the embolization of the cavernous sinus via venous access. There were about 2.9% of patient experienced direct carotid artery puncture and 0.6% puncture after carotid artery cut-down exposure. About 30% of cases experienced sacrifice of the parent vessels and it was associated with sizes of the fistula. Total severe complication was about 2.4% which included 1 death (0.6%) due to vagal shock; 1 transient hemiparesis post-sacrifice occlusion of the carotid artery but the patient had recovered after 3 months; 1 acute thrombus embolism and the patient was completely saved with recombinant tissue plaminogen activator (rTPA); 1 balloon dislodgement then got stuck at the anterior communicating artery but the patient was asymptomatic. Endovascular intervention as the treatment of direct traumatic CCF had high cure rate and low complication with its ability to preserve the carotid artery. It also can supply flexible accesses to the fistulous site with various alternative embolic materials. The new classification of type A CCF based on angiographic features was helpful for planning for the embolization. Coil should be considered as the first embolic material for small size fistula meanwhile detachable balloons was suggested as the first-choice embolic agent for the medium and large size fistula.
摘要：
我们报告了通过血管内介入治疗创伤性直接颈动脉海绵窦瘘（CCF）的经验。我们在此推荐A型CCF的额外分类系统，并提出相应的治疗策略。仅A型CCF患者（巴罗分类）将被招募用于研究。根据CCF的血管造影特征,我们将A型CCF分为三个亚型，包括小尺寸，根据是否存在颈前动脉（ACA）和/或颈中动脉（MCA），中尺寸和大尺寸瘘。ACA和MCA均混浊的血管造影图被归类为小尺寸瘘管。ACA或MCA混浊的血管造影图被归类为中型瘘管，而ACA和MCA均未混浊的血管造影图被归类为大型瘘管。确认血管造影后，血管内栓塞将使用可拆卸的球囊即兴进行，线圈或两者。所有病例均随访栓塞后并发症及疗效。共纳入172例直接创伤性CCF患者。小尺寸瘘管占12.8%(22例)，中型瘘管占35.5%(61例)，大型瘘管占51.7%(89例)。血管内栓塞下瘘闭塞的成功率为94%，颈动脉保留率为70%。对于每个亚型的治疗，仅使用线圈成功治疗了21/22例小尺寸瘘。另一例小瘘管被违约。大多数中型和大型瘘管是使用可拆卸的气球治愈的。当使用可拆卸的球囊无法获得瘘管密封时，添加线圈以确认通过静脉通路栓塞海绵窦。约有2.9％的患者经历了直接颈动脉穿刺，颈动脉切开暴露后发生了0.6％的穿刺。大约30％的病例经历了亲代血管的牺牲，并且与瘘管的大小有关。总的严重并发症约为2.4％，其中包括1例迷走神经休克导致的死亡（0.6％）；1例短暂的颈动脉闭塞后偏瘫，但患者在3个月后已康复；1例急性血栓栓塞，患者完全被重组组织血浆激活剂（rTPA）保存；1例球囊脱出后卡在前交通动脉，但患者无症状。血管内介入治疗直接外伤性CCF治愈率高，并发症少，具有保留颈动脉的能力。它还可以使用各种替代栓塞材料为瘘管部位提供灵活的通道。基于血管造影特征的A型CCF新分类有助于栓塞计划。应考虑将线圈作为小型瘘管的首选栓塞材料，同时建议将可拆卸球囊作为中型和大型瘘管的首选栓塞剂。
