Direct Carotid-Cavernous Fistula due to Aneurysmal Rupture with Residual Aortic Dissection Treated by Coil Embolization via Direct Puncture of the Common Carotid Artery: A Case Report

Abstract

Objective: This case report describes the successful coil embolization of a direct carotid-cavernous fistula (d-CCF) caused by aneurysmal rupture in an older patient with residual aortic dissection, via direct puncture of the common carotid artery (CCA).

Case Presentation: A 95-year-old woman presented with progressive right periorbital swelling, pain, and eye redness. Cranial imaging revealed proptosis, dilated superior and inferior ophthalmic veins, and a ruptured aneurysm of the right internal carotid artery (ICA), leading to a diagnosis of d-CCF. Conventional endovascular access was not feasible due to residual aortic dissection extending from the brachiocephalic artery to the right CCA, despite prior stent graft placement. Under general anesthesia, a 6-Fr sheath was inserted directly into the distal CCA. Coil embolization was then performed using a balloon-assisted technique, targeting the cavernous sinus and the aneurysm. The procedure successfully occluded the fistula and preserved the ICA flow. Postoperatively, her ocular symptoms improved significantly, and she was discharged 1 week later without complications.

Conclusion: This case demonstrates that d-CCF can be safely and effectively treated with careful vascular evaluation and a tailored endovascular strategy, even in extremely old patients with difficult vascular access and complex aneurysmal anatomy.

Introduction

Direct carotid-cavernous fistula (d-CCF) is a rare but severe complication typically associated with traumatic brain injury or rupture of an intracavernous internal carotid artery (ICA) aneurysm.¹⁾ Prompt endovascular treatment is essential to prevent visual loss, ophthalmoplegia, elevated intraocular pressure, or cerebral venous congestion; however, achieving vascular access can be extremely challenging in patients with complex vascular anomalies, such as aortic dissection. Although similar approaches—including direct carotid access and coil embolization—have been reported, the present case is unique owing to the involvement of a 95-year-old patient with residual aortic dissection, a wide-neck ruptured aneurysm, and severely limited vascular access—posing multiple technical challenges simultaneously. Remarkably, endovascular treatment was successfully achieved via direct puncture of the common carotid artery (CCA), combined with a balloon-assisted coiling technique that preserved the parent artery. This case emphasizes the feasibility and safety of an individualized endovascular strategy in extremely old patients with anatomically complex d-CCFs and compromised access routes, providing practical insights for neuroendovascular surgeons facing similarly difficult cases.

Case Presentation

A 95-year-old woman presented with a 9-day history of worsening right periorbital pain, swelling, and eye redness. She had a history of hypertension, dyslipidemia, and aortic dissection treated with thoracic endovascular aortic repair (TEVAR) 3 years earlier. On examination, she was alert (Glasgow Coma Scale score = 15) but showed marked right proptosis, ptosis, ophthalmoplegia, and conjunctival injection. The patient had total visual loss in the right eye, and ocular motility was completely restricted.

Contrast-enhanced CT revealed proptosis and significant dilation of the superior and inferior ophthalmic veins (SOV and IOV) (Fig. 1A and 1B). CTA identified a ruptured aneurysm in the right ICA at the cavernous segment (Fig. 1C), and 3D reconstruction demonstrated residual dissection involving the aortic arch and brachiocephalic artery (Fig. 1D and 1E).

Fig. 1 Pre-treatment contrast-enhanced CT and CTA images demonstrating a direct carotid-cavernous fistula caused by aneurysmal rupture and residual aortic dissection. (A, B) Axial contrast-enhanced CT images show clear proptosis of the right globe (yellow asterisk), the ruptured aneurysm (yellow arrow), cavernous sinus (yellow arrowhead), and marked dilation of the SOV (yellow dashed arrow). (C) 3D-CTA image showing a dilated cavernous sinus (yellow arrowhead) and tortuous ophthalmic veins (SOV, yellow dashed arrow). (D) 3D-CTA image and (E) cross-sectional CTA image depicting the dissected brachiocephalic artery (red arrow), right common carotid artery (red dashed arrow), and the flap formed by the dissection (red arrowhead). SOV, superior ophthalmic vein

Since the residual dissection involved the brachiocephalic artery and the right CCA, conventional transfemoral or transradial access was not feasible. Therefore, a direct puncture of the right CCA was planned as an alternative access route for endovascular treatment. The patient had been taking aspirin (100 mg daily) for thrombosis prevention following the TEVAR procedure. Given the limited invasiveness of the planned intervention and the low risk of hemorrhage, aspirin therapy was continued during the perioperative period.

Under general anesthesia, the patient was placed in a supine position with the head turned slightly to the left. A 3-cm transverse incision was made in the anterior neck on the right side under ultrasound guidance; the platysma was divided, and blunt dissection was performed along the anterior border of the sternocleidomastoid muscle to expose the CCA. The carotid sheath was dissected to expose the artery, and systemic heparinization was then performed, further targeting an activated clotting time of more than 250 s. A CV-6 suture (Gore-Tex suture; W. L. Gore & Associates, Newark, DE, USA) was preplaced in a tobacco-pouch manner, encircling the anticipated puncture site on the arterial wall to facilitate secure closure after removing the sheath (Fig. 2A). A 6-Fr, 10-cm short sheath was then inserted by percutaneous puncture of the CCA through the skin and subcutaneous tissue under direct visualization and ultrasound guidance. The puncture was intentionally done through the overlying soft tissues to improve the mechanical stability of the sheath during subsequent manipulation and patient transfer. The guidewire was advanced under real-time ultrasound monitoring to a depth of approximately 10 cm, ensuring safe intraluminal placement. The sheath was inserted 4 cm from the puncture site as measured using a sterile ruler, with the distal tip remaining securely in the arterial lumen. To prevent accidental dislodgement during patient transfer from the operating room to the angiography suite, the sheath was fixed to the skin using sutures, and the wound was packed with sterile gauze without skin closure. The patient was then transferred to the angiography suite, where endovascular treatment was commenced.

Fig. 2 Intraoperative and angiographic images demonstrating the access and hemodynamic characteristics of the d-CCF. (A) Serial intraoperative photograph showing direct cervical puncture of the right CCA. A tobacco-pouch suture was preplaced around the anticipated puncture site on the arterial wall to facilitate secure closure after removing the sheath. A 6-Fr, 10-cm short sheath was inserted percutaneously by puncturing the CCA through the skin and subcutaneous tissue under ultrasound guidance. The tip of the guidewire was advanced under ultrasound visualization to a depth of approximately 10 cm, and the sheath was inserted 4 cm deep from the puncture site, measured using a sterile ruler. The sheath was fixed to the skin, and the wound was left unsutured and packed with sterile gauze. (B) DSA revealing a d-CCF originating from a ruptured aneurysm of the intracavernous ICA, with prominent venous reflux into the SOV, inferior ophthalmic vein, and superficial middle cerebral vein. (C, D) 3D rotational angiography images of the right ICA showing the ruptured aneurysm (yellow arrow; neck and height: 8.6 and 6.2 mm), the cavernous sinus (yellow arrowhead), and the SOV (yellow dashed arrow). The fistulous point connecting the aneurysm to the cavernous sinus is indicated by red circles. CCA, common carotid artery; d-CCF, direct carotid-cavernous fistula; ICA, internal carotid artery; SOV, superior ophthalmic vein

Using a 115-cm AXS Vecta 71 intermediate catheter (Stryker, Kalamazoo, MI, USA), an AXS Offset delivery assist catheter (Stryker), and a Traxcess 0.014-inch microwire (MicroVention, Aliso Viejo, CA, USA), the system was successfully advanced to the C5 segment of the ICA. DSA confirmed a high-flow d-CCF with retrograde venous drainage into the SOV, IOV, and the superficial middle cerebral vein (Fig. 2B). Further, 3D rotational angiography of the right ICA revealed the fistulous point connecting the aneurysm to the cavernous sinus (Fig. 2C and 2D). The aneurysm was located inferior to the cavernous segment of the ICA and exhibited a wide-neck morphology (neck and height: 8.6 and 6.2 mm). The aneurysm and cavernous sinus partially encased the ICA, rendering it difficult to obtain a working angle that clearly separated the parent vessel from the aneurysmal neck. Consequently, we used 3D rotational angiography to completely understand the anatomical relationships and guide procedural planning. Considering the vascular anatomy, we opted for a balloon-assisted coiling approach to preserve antegrade ICA flow. If balloon protection proved insufficient, deployment of a rescue stent was preconsidered. Furthermore, preoperative CTA demonstrated a patent anterior communicating artery and a prominent right posterior communicating artery, indicating well-developed collateral flow. Although a balloon occlusion test was not feasible because of direct carotid access, the presence of these collaterals suggested potentially adequate ischemic tolerance should ICA sacrifice become necessary. After performing angiography with a working angle (Fig. 3A), an Excelsior SL-10 microcatheter (Stryker) was carefully advanced through the aneurysm and the fistulous tract into the cavernous sinus and then into the laterocavernous sinus under roadmap guidance. A Scepter XC balloon catheter (MicroVention) was positioned across the aneurysmal neck in the ICA; however, balloon inflation was not performed during catheter navigation. Selective angiography through the microcatheter allowed us to visualize the laterocavernous sinus and venous drainage (Fig. 3B). Coil embolization was then performed in a reverse sequence, beginning from the laterocavernous sinus, proceeding to the cavernous sinus, through the fistulous point, and finally into the aneurysm (Fig. 3C). Balloon inflation was initiated during coiling of the aneurysm to prevent coil prolapse into the parent vessel. A total of 10 Target XL 360 detachable coils (4–7 mm and 8–20 cm; Stryker) were deployed. Post-embolization angiography confirmed complete obliteration of the fistula and the aneurysm, with preservation of antegrade ICA flow (Fig. 3D). Subsequently, 3D DSA was performed to confirm the success of the embolization in detail. The aneurysm and fistulous connection were completely occluded, and no residual shunting was observed; antegrade flow through the ICA was also preserved (Fig. 3E).

Fig. 3 Intraoperative imaging demonstrating microcatheter navigation and coil embolization using a balloon-assisted technique. (A) Working-angle DSA showing the aneurysm (yellow arrow), the fistulous point (red circle), the cavernous sinus (yellow arrowhead), and the laterocavernous sinus (red arrowhead). (B) Selective angiography through a microcatheter placed in the laterocavernous sinus via the fistulous point, showing opacification of the laterocavernous sinus (red arrowhead) and the superficial middle cerebral vein. (C) Fluoroscopic images of coil embolization demonstrating stepwise packing from the laterocavernous sinus (red arrowhead), followed by the cavernous sinus (yellow arrowhead), the fistulous point (red circle), and finally the aneurysmal sac (yellow arrow). (D) Post-embolization angiography demonstrating complete obliteration of the aneurysm and the direct carotid-cavernous fistula. (E) Post-embolization 3D DSA of the right ICA. The coil mass is visualized in purple, confirming complete occlusion of the fistulous connection while preserving antegrade ICA flow. (F) Serial intraoperative photographs showing sheath removal and closure of the puncture site. After sheath withdrawal, the preplaced tobacco-pouch suture was tied for hemostasis. Subsequently, the muscular layer, subcutaneous tissue, and skin were closed in anatomical layers. ICA, internal carotid artery

Following the procedure, the patient was returned to the operating room. The sheath was carefully removed, and hemostasis at the puncture site was achieved by tying the preplaced CV-6 suture in a tobacco-pouch fashion (Fig. 3F). The muscular fascia, subcutaneous tissue, and skin were closed in anatomical layers to complete the procedure.

Postoperatively, the patient’s ocular pain and swelling improved immediately, and no new neurological deficits were observed. MRI confirmed the absence of cerebral infarction and resolution of proptosis (Fig. 4A), and MRA confirmed the disappearance of the aneurysm and the d-CCF (Fig. 4B). Serial photographs taken preoperatively, immediately postoperatively, and on postoperative day 6 demonstrated progressive improvement in conjunctival injection and proptosis (Fig. 4C). There were no complications, and she was discharged 1 week later.

Fig. 4 Post-treatment imaging and clinical photographs demonstrating resolution of ocular symptoms and elimination of the d-CCF. (A) Axial FLAIR MRI performed after treatment showing the resolution of right-sided proptosis. (B) Postoperative MRA confirming the disappearance of the aneurysm and the d-CCF. (C) Serial photographs of the right eye: preoperative (left), immediately postoperative (center), and 6 days postoperatively (right), showing progressive improvement in conjunctival injection and proptosis. d-CCF, direct carotid-cavernous fistula

Discussion

d-CCFs are abnormal arteriovenous shunts between the intracavernous portion of the ICA and the cavernous sinus. Barrow et al. classified d-CCF lesions into 4 types, with Type A representing direct, high-flow shunts typically caused by trauma or rupture of an intracavernous ICA aneurysm.¹⁾ Although the majority of d-CCFs are traumatic in origin and frequently associated with closed head injuries and skull base fractures, nontraumatic causes account for approximately 25% of cases.²⁾ These include ruptured intracavernous aneurysms, iatrogenic injuries from procedures such as trans-sphenoidal or endovascular procedures, and connective tissue disorders, such as Ehlers–Danlos syndrome, fibromuscular dysplasia, and osteogenesis imperfecta.^2,3)

High-flow arteriovenous shunting usually presents with characteristic symptoms, such as pulsatile exophthalmos, chemosis, and orbital bruit, which support clinical suspicion and warrant urgent intervention.⁴⁾ Our patient presented with a rare and challenging constellation of clinical and anatomical factors—including advanced age (95 years), a wide-neck ruptured aneurysm, and severely limited vascular access due to residual aortic dissection—requiring a highly individualized and carefully planned endovascular approach. These anatomical and clinical challenges made conventional transfemoral or transradial access unfeasible. In such circumstances, direct puncture of the CCA has been reported as a viable alternative. Although the use of direct CCA puncture has been described in other neuroendovascular contexts—such as aneurysm coiling⁵⁾ and mechanical thrombectomy for acute ischemic stroke⁶⁾—its application to d-CCFs remains relatively rare. Chi et al.⁷⁾ classified angiographic patterns of traumatic d-CCFs and described a case successfully treated via transcervical direct CCA puncture. Moreover, Tsai et al.⁸⁾ reported a challenging case of recurrent d-CCF treated by direct puncture of a previously trapped ICA. These reports demonstrate the feasibility of direct carotid access in selected cases where conventional routes are not viable. Compared with these previous reports, our case is distinctive in that it involved an extremely old patient (aged 95 years) with residual aortic dissection and a ruptured wide-neck aneurysm. The combination of multiple anatomical and clinical challenges makes this an exceptionally rare and instructive case. Our successful treatment outcome highlights the viability of direct CCA puncture as a valuable rescue technique for d-CCF, even in highly complex scenarios. In the present case, balloon-assisted coil embolization was chosen over other adjunctive techniques for several reasons. In the acute phase of aneurysmal rupture, the use of stent-assisted coiling or flow diverters is generally avoided due to the off-label nature of these devices in ruptured cases and the associated risk of hemorrhagic complications, especially in older patients.⁹⁾ These techniques often require dual antiplatelet therapy, which carries significant bleeding risks in nonagenarians. In contrast, balloon-assisted coiling may avoid the need for dual antiplatelet therapy and allow for safe and controlled embolization of the aneurysm and fistulous point. In our case, aspirin (100 mg daily) was continued perioperatively as part of the patient’s baseline regimen, which was considered acceptable given the absence of major hemorrhagic risk and the limited invasiveness of the procedure.

The embolization procedure in this study was performed using a trans-fistulous approach, navigating through the shunt into the cavernous sinus and subsequently into the aneurysmal sac. This strategy allowed for efficient packing of the cavernous sinus and aneurysm while preserving the antegrade ICA flow. Similar approaches have been described as effective in managing anatomically complex d-CCFs.^10–12)

Furthermore, the 3D rotational DSA was crucial for identifying the exact location of the fistulous connection and delineating venous drainage patterns. This modality provides superior spatial resolution compared with conventional 2D imaging and significantly facilitates procedural planning and microcatheter navigation.¹³⁾

Conclusion

d-CCFs can be effectively treated with careful planning, alternative access methods, and appropriate embolization techniques. The direct CCA puncture technique is a feasible, safe, and effective endovascular access route for such conditions. Even in extremely old patients with high-risk vascular profiles and anatomically complex lesions—including residual aortic dissection and wide-neck aneurysms—safe and effective endovascular treatment is feasible through tailored strategies such as direct carotid puncture and balloon-assisted coiling.

Disclosure Statement

The authors declare that they have no conflicts of interest.

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