title: Treatment of carotid-cavernous fistulas using intraarterial balloon assistance: case series and technical note.
abstract: OBJECTIVE
  Multiple approaches have been used to treat carotid-cavernous fistulas (CCFs). The transvenous approach has become a popular and effective route. Onyx is a valuable tool in today's endovascular armamentarium. The authors describe the use of a balloon-assisted technique in the treatment of CCFs with Onyx and assess its feasibility, utility, and safety.
  
  
  METHODS
  The authors searched their prospectively maintained database for CCFs embolized using Onyx with the assistance of a compliant balloon placed in the internal carotid artery (ICA).
  
  
  RESULTS
  Five patients were treated between July 2009 and July 2011 at the authors' institution. A balloon helped to identify the fistulous point, served as a buttress for coils, protected from inadvertent arterial embolizations, and prevented Onyx and coils from obscuring the ICA during the course of embolization. No balloon-related complications were noted in any of the 5 cases. All 5 fistulas were completely obliterated at the end of the procedure. Four patients had available clinical follow-ups, and all 4 showed reversal of nerve palsies.
  
  
  CONCLUSIONS
  Balloon-assisted Onyx embolization of CCFs offers a powerful combination that prevents inadvertent migration of the embolic material into the arterial system, facilitates visualization of the ICA, and serves as a buttress for coils deployed in the cavernous sinus through the fistulous point. Despite adding another layer of technical complexity, an intraarterial balloon can provide valuable assistance in the treatment of CCFs.
authors.affiliation: Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania 19107, USA. fernando.gonzalez@jefferson.edu
authors.forename: L Fernando
authors.initials: LF
authors.lastname: Gonzalez
authors.forename: Nohra
authors.initials: N
authors.lastname: Chalouhi
authors.forename: Stavropoula
authors.initials: S
authors.lastname: Tjoumakaris
authors.forename: Pascal
authors.initials: P
authors.lastname: Jabbour
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Dumont
authors.forename: Robert H
authors.initials: RH
authors.lastname: Rosenwasser
mesh_terms: D000328:Adult; D000368:Aged; D021721:Balloon Occlusion / Q000379:methods*; D002343:Carotid Artery, Internal; D020216:Carotid-Cavernous Sinus Fistula / Q000628:therapy*; D017023:Coronary Angiography; D004121:Dimethyl Sulfoxide / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D007269:Injections, Intra-Arterial / Q000379:methods; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D004121:Dimethyl Sulfoxide