title: Use of Pipeline Embolization Devices for treatment of a direct carotid-cavernous fistula.
abstract: BACKGROUND
  The use of minimally porous endoluminal devices (MPEDs) such as the Pipeline Embolization Device (PED) has been described for the treatment of brain aneurysms. The benefit of using MPEDs to assist embolization of a direct high-flow carotid cavernous fistula resulting from a ruptured cavernous carotid artery aneurysm is not well documented.
  
  
  METHODS
  We describe our experience with deploying a tailored multidevice PED construct across the cavernous internal carotid artery (ICA) wall defect in combination with transarterial coil embolization using the "jailed microcatheter" technique.
  
  
  RESULTS
  A 59-year-old woman presented with acute left-sided ophthalmoplegia. Diagnostic cerebral angiography demonstrated a ruptured giant cavernous carotid aneurysm with fistulous outflow via the ipsilateral left superior ophthalmic vein and into the pterygoid venous plexi bilaterally. Via the Marksman microcatheter, a total of three PEDs measuring 4.5 mm × 18 mm, 4.5 mm × 20 mm, and 4.75 mm × 16 mm were telescoped within the ICA across the aneurysm neck. Coiling of the aneurysm fundus and cavernous sinus via the "jailed" Rapidtransit microcatheter was subsequently achieved. A 2-year follow-up digital subtraction angiography (DSA) demonstrated stable obliteration of the aneurysm and the fistula, coincident with complete resolution of the patient's symptoms.
  
  
  CONCLUSIONS
  Based on our long-term clinical and angiographic results, we advocate that the presented method be a valid treatment option for selected cases.
authors.affiliation: Department of Neurological Surgery, New York University School of Medicine, New York, NY, USA.
authors.forename: E
authors.initials: E
authors.lastname: Nossek
authors.forename: D
authors.initials: D
authors.lastname: Zumofen
authors.forename: E
authors.initials: E
authors.lastname: Nelson
authors.forename: E
authors.initials: E
authors.lastname: Raz
authors.forename: M B
authors.initials: MB
authors.lastname: Potts
authors.forename: K G
authors.initials: KG
authors.lastname: Desousa
authors.forename: O
authors.initials: O
authors.lastname: Tanweer
authors.forename: M
authors.initials: M
authors.lastname: Shapiro
authors.forename: T
authors.initials: T
authors.lastname: Becske
authors.forename: Howard A
authors.initials: HA
authors.lastname: Riina
mesh_terms: D017542:Aneurysm, Ruptured / Q000150:complications / Q000601:surgery; D001807:Blood Vessel Prosthesis; D020216:Carotid-Cavernous Sinus Fistula / Q000209:etiology / Q000601:surgery*; D004621:Embolization, Therapeutic / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D008875:Middle Aged; D062666:Vascular Access Devices