title: Direct carotid cavernous sinus fistulae: vessel reconstruction using flow-diverting implants.
abstract: OBJECTIVE
  Retrospective evaluation of our experience with the use of flow diverters (FD) for the endovascular treatment of direct carotid-cavernous sinus fistulae (diCCF).
  
  
  METHODS
  Between 2011 and 2015, 14 consecutive patients with 14 diCCF were treated with FD alone or in combination with other implants in a single institution.
  
  
  RESULTS
  A total of 21 sessions were performed in 14 patients. FD placement was technically successful in all cases without an adverse event. Patients were treated with FD alone (n = 5), FD and covered stents (n = 2), FD and coils (n = 7). A total of 59 FD (24 Pipeline Embolization Device, Medtronic; 35 p64 Flow Modulation Device, phenox), 291 coils, and 3 stent grafts were used. Three of 14 diCCF were completely occluded after the 1stsession, a minor residual shunt was found in 7/14, and in the remaining 4/14 patients, the shunt volume was reduced significantly. The mean follow-up period encompassed 20 months. Additional treatment included transvenous coil occlusion (n = 3) and/or further FD deployment (n = 5). An asymptomatic internal carotid artery (ICA) occlusion was encountered in 2 patients, related to an interruption of antiaggregation. At the last follow-up, 10/14 patients were free from ocular symptoms (71 %), 2 had residual exophthalmos, and no patient had clinical deterioration.
  
  
  CONCLUSIONS
  The usage of FD for the treatment of diCCF is straightforward. Injury of the cranial nerves can be avoided. In most cases, ocular symptoms improve. Several FD layers and/or an adjunctive venous coil occlusion are required. Complete occlusion of a diCCF may take weeks or months and long-term antiaggregation is required. In the future, a flexible stent graft might be a better solution.
authors.affiliation: Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany. christina.wendl@ukr.de.|Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Universitätsklinikum Regensburg, Regensburg, Germany. christina.wendl@ukr.de.
authors.forename: C M
authors.initials: CM
authors.lastname: Wendl
authors.affiliation: Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.|Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Henkes
authors.affiliation: Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
authors.forename: R
authors.initials: R
authors.lastname: Martinez Moreno
authors.affiliation: Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
authors.forename: O
authors.initials: O
authors.lastname: Ganslandt
authors.affiliation: Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Bäzner
authors.affiliation: Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Aguilar Pérez
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002343:Carotid Artery, Internal; D020216:Carotid-Cavernous Sinus Fistula / Q000628:therapy*; D002426:Cavernous Sinus; D002533:Cerebral Angiography; D004621:Embolization, Therapeutic; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome; D055815:Young Adult
keywords: CCF; Endovascular; Flow diverter; Pipeline; p64