Introduction: Carotid Cavernous Fistula (CCF) development after Pipeline Embolization Device (PED) treatment of Cavernous Carotid Aneurysms (CCA) can be a challenging pathology to treat for the neurointerventionalist.
Methods: We retrospectively reviewed our database of aneurysms that underwent treatment with the PED since its FDA approval in 2011. This group was analyzed for demographics, aneurysm characteristics, treatment, antiplatelet regimen and follow-up data. We also undertook a literature review of studies that describe PED treatment of CCA.
Results: A total of 45 patients with CCA were identified (39 females, 6 males). The mean age was 59.8 ± 8.9 yrs. The mean maximal aneurysm diameter was 15.9 ± 6.9 mm (mean neck 7.1 ± 3.6 mm). A single PED was deployed in 32 patients with two PEDs deployed in 10 patients and three PEDs in 3 patients. Adjunctive coiling was performed in 3 patients. Mean follow-up duration based on final imaging (MRA or DSA) was 14.1 ± 12.2 months. Five patients (11.1%) developed CCFs in the post-procedural period after PED treatment, with four CCFs occurring within two weeks of device placement and one CCF within six months. These CCFs were treated with a balloon test occlusion followed by parent artery sacrifice. Our literature review yielded only three reports of CCFs after PED placement with the largest series having a CCF rate of 2.3%.
Conclusions: CCF formation is a known risk of PED treatment of CCA. Although transvenous embolization can be used for treating CCFs, parent artery sacrifice remains a viable option as seen in our series. Some studies have posited that adjunctive coiling may have a protective effect and we are prospectively accumulating this data. None of the coiled aneurysms in our database or within the literature review have ruptured. Follow-up data should assist us in better understanding the safety profile of the PED for CCA.
Patient Care: Pipeline Embolization Device treatment has grown significantly since its initial FDA approval for wide necked Internal Carotid Artery aneurysms. As such, it is critical to understand the associated safety profile to anticipate and better counsel patients on the associated risks.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Understand treatment options for Carotid Cavernous Fistulas after Pipeline placement
2) Estimate the risk of Carotid Cavernous Fistula formation after Pipeline placement
3) Describe the best available evidence for the underlying pathophysiology that leads to Cavernous Carotid Fistula formation after Pipeline placement
References: Tanweer O, Raz E, Brunswick A, et al. Cavernous carotid aneurysms in the era of flow diversion: a need to revisit treatment paradigms. AJNR Am J Neuroradiol. Dec 2014;35(12):2334-2340.
Park MS, Kilburg C, Taussky P, et al. Pipeline Embolization Device with or without Adjunctive Coil Embolization: Analysis of Complications from the IntrePED Registry. AJNR Am J Neuroradiol. Jan 14 2016