Transvenous coil embolization for cavernous sinus internal carotid artery ruptured aneurysm after flow diverter placement

Abstract

Direct carotid-cavernous fistula (CCF) is a rare complication due to treatment of internal carotid artery (ICA) aneurysms with Pipeline Flex embolization device (PED) placement. We present the case where we were able to treat this condition via transvenous coil embolization. A 69-year-old woman was treated with PED placement for a left ICA aneurysm. Three weeks later, she suffered from severe tinnitus due to direct CCF because of delayed aneurysm rupture. Our initial treatment failed as we could not access the aneurysm through the fistula via venous rout and the patient suffered from left oculomotor nerve palsy one month later. We re-attempted the transvenous coil embolization by reducing the arterial flow from the ICA using a balloon catheter and determining the rupture point by evaluating multiplanar reconstruction (MPR) derived from three-dimensional rotational angiography (3DRA). The procedure enabled us to perform transvenous coil embolization, alleviating the patient’s symptoms. MPR of 3DRA and arterial flow reduction seemed to be a useful technique for transvenous coil embolization in CCF treatment.