The Dilemma of treating Direct Carotico-cavernous fistula : Should we sacrifice the ICA?

Abstract

Introduction
Direct carotid-cavernous fistulas (CCFs) require urgent intervention to prevent irreversible ocular morbidity and intracranial hemorrhage. While endovascular reconstruction is the gold standard, device-related complications like stent thrombosis can severely limit transarterial access. We present a case utilizing therapeutic parent artery occlusion as a definitive rescue strategy when conventional reconstructive routes are exhausted.

Materials and Methods
A 16-year-old male with a post-traumatic Barrow Type A CCF underwent initial stent-assisted coiling. An inadvertent interruption of his dual antiplatelet therapy led to acute stent thrombosis, precluding further transarterial navigation. The residual high-flow fistula exhibited persistent cortical venous reflux, posing an imminent hemorrhagic risk. Multiple transvenous salvage attempts via the inferior petrosal sinus, superior ophthalmic vein, and vein of Labbé were unsuccessful due to acquired venous occlusions and acute vessel angulations.

Results
High-resolution C-arm CT was utilized to delineate the complex fistula anatomy. Diagnostic cerebral angiography confirmed robust collateral cross-circulation via the anterior communicating artery (ACom). Given the inaccessible shunt and imminent risk of hemorrhage from cortical reflux, a clinical decision was made to proceed with parent vessel sacrifice. The right internal carotid artery was therapeutically occluded at the cavernous and proximal segments using detachable coils. Post-embolization angiography demonstrated complete fistula exclusion with preserved hemispheric perfusion. The patient achieved rapid clinical stability with no ischemic neurological deficits.

Conclusion
Therapeutic internal carotid artery sacrifice remains a safe, definitive rescue maneuver for complex, residual CCFs when standard endovascular pathways are compromised, provided good contralateral flow from the ACOM or ipsilateral flow from the PCOM. Meticulous angiographic validation of collateral hemodynamics is mandatory to ensure patient safety while neutralizing the risk of secondary hemorrhage.