title: The use of a covered stent graft for obliteration of high-flow carotid cavernous fistula presenting with life-threatening epistaxis.
abstract: BACKGROUND
  We present a rare complication of trans-sphenoidal adenectomy (TSA) for pituitary macroadenoma: carotid cavernous fistula (CCF) that was treated with endovascular therapy. The incidence of internal carotid artery (ICA) injury following TSA is 1% and may spontaneously heal by packing and rarely manifest as symptomatic CCF/aneurysm. Treatment of post-TSA CCF may be challenging due to the breach of nasal floor and may be prone to recurrence.
  Uncontrolled intra-operative bleeding during a TSA led to an emergent angiogram to show slow-flow left CCF. Due to clinical deterioration with nasal bleeding, angiography was repeated after 4 h; the fistula had transformed into high flow with significant increase in size, and was therefore embolized using stent-assisted coiling. The fistula recanalized in a month with massive epistaxis and was re-treated using a covered stent graft.
  
  
  CONCLUSIONS
  This case represents several unique learning points: (1) CCF as a complication of TSA due to close anatomical proximity; (2) the role of endovascular management post-TSA complication; (3) stent-assisted coil embolization of high-flow fistula with moderate ICA laceration; (4) recanalization of CCF causing massive epistaxis; (5) rare use of covered stent graft stent in distal intracranial circulation maintaining integrity and patency of ICA; (6) long-term results after covered stent graft with no in-stent restenosis.
authors: Department of Neurology, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, Wisconsin, USA.
authors: J S
authors: JS
authors: Kalia
authors: T
authors: T
authors: Niu
authors: O O
authors: OO
authors: Zaidat
mesh_terms: D000208:Acute Disease; D000236:Adenoma / Q000601:surgery*; D020212:Carotid Artery Injuries / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy; D002343:Carotid Artery, Internal / Q000601:surgery; D020216:Carotid-Cavernous Sinus Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D020099:Coated Materials, Biocompatible; D004844:Epistaxis / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects; D010911:Pituitary Neoplasms / Q000601:surgery*; D011859:Radiography; D013100:Sphenoid Bone / Q000601:surgery; D015607:Stents
chemical_list: D020099:Coated Materials, Biocompatible