Management of a complex CCF case

• Presented with proptosis of the left eye of insidious onset, complete ptosis, conjunctival congestion and double vision for one month
• No previous h/o trauma or neurosurgery

Pre-procedure MRI

No CCF filling

Cross flow  / LT ICA LAT PRE

LT ICA PRE LAT

LT ICA TOWNE PRE

LT ICA  Pre Towne

How to proceed?

a) Occlusion of the parent artery
b) Covered stent
c) Stent / FD (arterial side) assisted by coiling + onyx (venous approach)

Micro for FD and coiling

FD partial deployment

FD deployment + micro in CCF

Post complete FD deployment

Post-coiling RT IPS 

SS RT IPS LAT

SS IPS TOWNE

Post-coiling

ONYX EMBOLIZATION

via right IPS

Post- IPS partial coiling 

LT ICA LAT

Coiling from left SPS

 SPS coiling

ICA protection (balloon occlusion)

Onyx embolization

Right SPS

Onyx cast

Final AP 

Final lateral

• Bruit and chemosis subsided by POD 1
• Pain subsided at discharge D4.
• Follow-up after a week: partial ptosis and moderate restriction of EOM in all directions.

Learning points

Principles for managing high-speed direct CCFs

Spontaneous direct CCFs are reported

Identification of the precise site of the fistula (fast images per second with cross compression or balloon)

Cross flow from Acomm or Pcomm

Venous flow (vascular access planning) (obstruction at sigmoid VMI junction)

Obstruction (occlusion) or preservation (stent / FD / coiling /onyx)

Bottlenecks in this case

Direct high flow CCF

Dysplastic ICA (FD endothelializes the ICA and allows for coil entrapment)

Collapsed FD at the elbow (opened with balloon angioplasty)

Ipsilateral IPS not seen (venous approach i.e. IPS - inter cavernous connection)

Large fistula and difficult to occlude with coiling from IPS access alone (Ipsilateral SPS used to occlude posterior part of fistula)

The coils fail to occlude the CCF (Onyx to occlude small tributaries)