The Source for Neurovascular News and Education

March 29, 2024

 

Key Points:

- Study retrospectively examines using Willis covered stents for traumatic direct carotid-cavernous fistulae

- High rate of success, with recovery/improvement in all patients

 

A novel approach to the treatment of traumatic direct carotid-cavernous fistulae using a stent and technique developed in Shanghai, China, is highly successful, according to research published online by its pioneers on June 1, 2016, ahead of print in Neurosurgery.

Yong-Dong Li, MD, PhD, of the Shanghai Jiao Tong University Affiliated Sixth People’s Hospital (Shanghai, China), and colleagues evaluated the long-term efficacy of an endovascular treatment for these complex fistulae. The approach uses a Willis covered stent and focuses on reconstruction and preservation of the internal carotid artery.

The Willis stent was developed at the investigators’ institution in collaboration with MicroPort Medical (Shanghai, China). It consists of “a balloon-expandable endoprosthesis composed of a bare stent and an expandable polytetrafluoroethylene membrane,” the researchers report, adding. “The delivery system is a rapid-exchange balloon catheter system with a working length of 145 cm.”

After inserting a guiding catheter and microwire into a distal branch of the middle cerebral artery, the researchers “advanced a delivery system with the Willis covered stent over the microguidewire until the proximal and distal edges of the stent bridged the orifice of the pseudoaneurysm. Multiple control angiograms were obtained to confirm that the stent fully covered the pseudoaneurysm orifice. Under fluoroscopic control, the Willis covered stent was then inflated with 5 atm of pressure.”

Angiography was used to confirm correct stent placement and satisfactory occlusion of the aneurysm. Endoleaks were treated via redilation of the proximal edge of the covered stent by applying 5 to 6 atm of pressure.

Over the past 8 years, the investigators have treated 25 patients with 27 fistulae using 44 Willis covered stents. In all cases, initial attempts to treat the fistulae using detachable balloons had been unsuccessful.  

For this analysis, Li and colleagues assessed outcomes of 25 patients with 27 fistulae. Willis stent placement had been technically successful in 100% of attempted cases. Follow-up lasted 6 and 88 months (mean, 43.8 months).

In 17 fisulae (16 patients), complete exclusion was achieved immediately after stent placement. The other 10 fistulae had transient endoleaks: 6 were treated with redilation and 4 with additional stents.

Initial angiographic results demonstrated complete exclusion with preservation of the internal carotid artery in 26 fistulae (24 patients). One patient whose fistula initially showed immediate occlusion had a delayed endoleak that required an additional stent. Follow-up angiography performed after a mean of 30.3 months revealed complete exclusion in all 27 fistulae, with a patent internal carotid artery in 23 patients. Clinical follow-up demonstrated full recovery in 23 patients and improvement in 2 patients.


Unique but Effective Approach

“This is a unique treatment approach,” Dr. Li told Neurovascular Exchange in an email. Typically, the first-line approach for this condition is endovascular therapy with detachable balloon. “The use of Willis covered stents was confirmed [in this study] to be effective, safe, and a curative approach for endovascular treatment of complex [traumatic direct carotid-cavernous fistulae] and internal carotid artery reconstruction.”

The main drawback to the approach, he noted, is that because the stents are quite stiff, it can be difficult to navigate them into the cavernous segments of the internal carotid artery. A benefit of the approach, however, is that is preserves the artery via reconstruction of the wall.


Source:

  • Wang W, Li MH, Li YD, et al. Reconstruction of the internal carotid artery after treatment of complex traumatic direct carotid-cavernous fistulas with the Willis covered stent: a retrospective study with long-term follow-up. Neurosurgery. 2016;Epub ahead of print.

Disclosures:

  • Dr. Le reports no relevant conflicts of interest.