title: High-flow carotid cavernous fistula and the use of a microvascular plug system: initial experience.
abstract: OBJECTIVE
  We report our initial experience using a detachable microvascular plug system to occlude the internal carotid artery during endovascular treatment of high-flow carotid cavernous fistula.
  An 87-year-old patient was admitted for acute-onset double vision with associated right-eye ptosis. Exam revealed a pupil-sparing, partial right third cranial nerve palsy. MRI showed a carotid cavernous fistula with high-flow drainage. Digital subtraction angiography showed a high-flow, right-sided, direct carotid cavernous fistula with flow from the proximal right internal carotid artery. The ophthalmic artery, posterior communicating artery and anterior communicating arteries supplied retrograde flow to the fistula through the internal carotid artery. Obliteration of the fistula was achieved through coil embolization in combination with proximal and distal microvascular plugs (Reverse Medical, Irvine, Calif., USA).
  
  
  CONCLUSIONS
  The microvascular plug is a new addition to current endovascular embolization devices for the treatment of high-flow, direct carotid cavernous fistulas. This technique offers easy navigability through tortuous arteries, precise localization and immediate occlusion, which may allow shorter procedure and fluoroscopy times and increased cost-effectiveness. Larger case series are needed to support our observation.
authors.affiliation: Department of Neurology at Mount Sinai Beth Israel Medical Center, New York, N.Y., USA.
authors.forename: Yamin
authors.initials: Y
authors.lastname: Shwe
authors.affiliation: Hyman-Newman Institute of Neurology and Neurosurgery, Mount Sinai Hospital, New York, N.Y., USA.
authors.forename: Srinivasan
authors.initials: S
authors.lastname: Paramasivam
authors.affiliation: Hyman-Newman Institute of Neurology and Neurosurgery, Mount Sinai Hospital, New York, N.Y., USA.
authors.forename: Santiago
authors.initials: S
authors.lastname: Ortega-Gutierrez
authors.affiliation: Hyman-Newman Institute of Neurology and Neurosurgery, Mount Sinai Hospital, New York, N.Y., USA.
authors.forename: David
authors.initials: D
authors.lastname: Altschul
authors.affiliation: Hyman-Newman Institute of Neurology and Neurosurgery, Mount Sinai Hospital, New York, N.Y., USA.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Berenstein
authors.affiliation: Hyman-Newman Institute of Neurology and Neurosurgery, Mount Sinai Hospital, New York, N.Y., USA.
authors.forename: Johanna T
authors.initials: JT
authors.lastname: Fifi
keywords: Carotid cavernous fistula; High flow; Microvascular plug