PMC6305339_01
(A) Anteroposterior view of three-dimensional volume rendering of computed tomography angiography (CTA) showing a fistula (white arrow) located at the lever of craniocervical junction, with severe vascular distortion (blue arrow) at the beginning of left internal carotid artery (ICA). (B) Lateral view of three-dimensional volume rendering of CTA showing the dilatation of internal jugular vein (blue arrow). White arrow: the fistula. (C) CTA showing the size of fistula. (D) Digital subtraction angiography (DSA) showing the fistula (white arrow), dilatation of internal jugular vein (blue arrow) and the absence of blood flow from left ICA (black arrow) into the brain. (E) DSA of left external carotid artery (ECA) (white arrow) showing no obvious abnormality. (F) DSA showing right ICA supplying the left anterior cerebral artery and middle cerebral artery via the anterior communicating artery. (G) DSA showing vertebral basilar artery supplying contralateral cerebral via left posterior communicating artery (white arrow).
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F1
Computed tomography angiography (CTA) and DSA revealed a left high-flow internal carotid-jugular fistula at the first cervical level and twisted left internal carotid artery (ICA) (Figures 1A-D). Blood flow from the vertebrobasilar artery and right ICA via the circle of Willis supplied the left anterior cerebral artery and middle cerebral artery and drained backwards into the petrosal segment of left ICA (Figures 1E-G).
(A) DSA of left ICA showing the placement of the LVIS stent (white arrow) and the Echelon microcatheter. (B) DSA of right ICA showing the backward blood flow in the distal part of fistula that was reduced after coiling. White arrow: coils. (C) DSA of left ICA showing placement of one detachable balloon (blue arrow) to block the ICA near the proximal part of fistula. White arrow: coils. Black arrow: stent. (D) DSA of right ICA showing placement of one detachable balloon (blue arrow) to block the ICA near the proximal part of fistula.
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F2
One LVIS 5.5*30 mm stent, with its characteristic relatively compact mesh, was used to cover the distal part of fistula to avoid coils being pushed into internal jugular vein and heart (Figure 2A). Therefore, 10 coils were additionally used one by one, to block the fistula from the distal to proximal part through an Echelon-10 microcatheter (Figure 2B). We chose one detachable balloon to block the ICA near the proximal part of fistula to stop the forward blood flow, and the backward blood flow would be stopped in the second treatment (Figures 2C,D).
(A) DSA of left ICA showing the balloon (red arrow) in the ICA (black arrow) near the fistula and residual blood flow in the fistula (white arrow) from the left ICA. (B) DSA of right ICA showing backward blood flow from the right ICA. (C) Anteroposterior view of DSA showing the fistula embolization with Double-microcatheter techniques. Black arrow: ICA, white arrow: coils in the fistula. (D) Lateral view of DSA showing the fistula embolization with Double-microcatheter techniques. Black arrow: ICA, white arrow: coils in the fistula. (E) Anteroposterior view of DSA of left ICA showing obvious forward blood flow from the left ICA (black arrow) to fistula after embolization (white arrow). (F) Lateral view of DSA of left ICA showing obvious forward blood from the left ICA (black arrow) to fistula after embolization (white arrow). (G) DSA showing placement of two Balt detachable balloons (black arrows) in the proximal part of fistula to block the blood flow of left ICA. (H) DSA of right ICA showing the backward blood flow was reduced significantly after the fistula coiling.
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F3
ICA and premature balloon deflation (Figures 3A,B). It was fortunate that LVIS stent blocked the balloon into the internal jugular vein. An additional 13 coils were used to pack the fistula with double-microcatheter techniques, under the multi-angle DSA projection, to avoid the coil protruding into the internal jugular vein (Figures 3C-F). Afterwards, two detachable balloons were used to block the proximal part of left ICA again (Figure 3G). DSA revealed the forward blood flow disappeared, the low-flow backward blood from right ICA still supplied the fistula, and a normal ipsilateral jugular vein (Figure 3H).
(A) CT showing no abnormality in the brain. (B) CT showing a subcutaneous hematoma (*) in left occipitocervical region. (C) DSA of left vertebral artery showing little backward blood flow in the fistula from the posterior communicating artery, but no appearance of internal jugular vein in the proximal part of the fistula. (D) DSA of right ICA showing little backward blood flow in the fistula from the anterior communicating artery, but no appearance of internal jugular vein in the proximal part of the fistula (arrow). (E) DSA of right common carotid artery (CCA) showing fistula disappearance after placement of 3 coils and a 1.2 ml Onyx-18. (F) DSA of left vertebral artery showing no backward blood flow in the fistula (black arrow). White arrow: posterior communicating artery. (G) Six-month follow-up DSA of left CCA showing a totally occluded fistula, in 6-month follow-up. (H) DSA of right CCA showing a totally occluded fistula.
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F4
Emergent CT revealed a subcutaneous hematoma in left occipitocervical region, without abnormalities in brain (Figures 4A,B). The lower part of fistula was not shown, because the blood drained into the right internal jugular vein through the sigmoid and transverse sinus reversely (Figures 4C,D). DSA examination after this procedure revealed that the backward blood flow distal to the fistula disappeared (Figures 4E,F). A 6-month follow-up DSA demonstrated a totally occluded fistula allowing the patient to engage in light manual labor with normal neurological functioning after the operation (Figures 4G,H).