Outcome of Detachable Balloon Embolization in Traumatic Carotid Cavernous Fistula

Abstract

Objective This article evaluates the outcomes and efficacy of detachable balloon embolization by single balloon delivery catheter, while identifying factors associated with successful embolization in traumatic carotid cavernous fistula (TCCF) patients.

Materials and Methods We retrospectively collected data of TCCF patients who underwent detachable balloon embolization during March 2020 to April 2024. All cases utilized a single balloon delivery catheter for detachable balloon deployment (GOLDBAL, BALT Extrusion, France). We analyzed demographic, clinical, imaging, and angiographic data, including outcomes, complications, and factors associated with successful embolization.

Results Thirty patients were treated with detachable balloon embolization. The mean age of the patients was 41.1 years (range 17–65 years). The median duration of symptom was 2.0 months (range 0.25–60 months). The most common mechanism of injury is motorcycle accident (83.3%). Nearly all patients had eye redness and proptosis. Angiographic data indicated 29 patients (96.7%) had drainage to the inferior petrosal sinus, 28 (93.3%) had drainage to the superior ophthalmic vein, and 8 (26.7%) had drainage to the superior petrosal sinus. Five cases (16.7%) were classified as small-sized fistula, 19 (63.3%) as medium-sized, and 6 (20%) as large-sized. Regarding the location of the fistula, 8 cases (26.7%) were found in the horizontal segment, while 22 cases (73.3%) were located in the ascending or genu segment of the cavernous internal carotid artery (ICA). Among the 24 patients (80%) who underwent successful embolization, the ICA was preserved in 23 out of 24 patients (95.8%). The remaining patient had ICA occlusion but exhibited no clinical symptoms. Residual cavernous aneurysm was found in two patients, one patient had persistent cranial nerve deficit, while the other was asymptomatic. Statistical analysis demonstrated a significant difference was associated with the fistula location at the ascending or genu segment of the cavernous ICA in relation to successful embolization

Conclusion Despite the availability of several endovascular treatment options for TCCF, using detachable balloon embolization is a relatively straightforward procedure. When combined with a thorough understanding of cavernous sinus anatomy, this approach can significantly enhance the occlusion rate and preserve ICA patency while minimizing complications, particularly when the fistula is located at the ascending or genu segment of the cavernous ICA.

Keywords

direct carotid cavernous fistula - traumatic neurovascular injury - detachable balloon - balloon embolization - traumatic carotid cavernous fistula

Introduction

Traumatic carotid cavernous fistula (TCCF) is a direct shunt between the cavernous segment of the internal carotid artery (ICA) and the cavernous sinus (CS). Prior to the advent of the endovascular era, TCCF was mainly treated with surgery.[1] [2] The first recorded case of endovascular treatment of TCCF using a detachable balloon was reported by Serbinenko in 1974.[3] Since then, various embolization materials including detachable balloons,[4] [5] coils,[6] [7] [8] [9] covered stents,[10] [11] [12] or flow diverter stent[13] [14] [15] have been employed to occlude TCCF. Detachable balloon embolization is a simple and cost-effective procedure, making it suitable for use in developing countries. We have adopted it as a first-line treatment in our institution. The purpose of this study was to evaluate the outcomes and efficacy of detachable balloon embolization by single balloon delivery catheter while identifying factors associated with successful embolization. Additionally, the study proposes techniques to enhance the rate of successful embolization.

Materials and Methods

Patient Population

We retrospectively collected data of TCCF patients who were treated with detachable balloon embolization at Rajavithi Hospital in Bangkok, Thailand, between March 2020 and April 2024. All cases were managed using transarterial balloon embolization with single balloon delivery catheter during the initial treatment session. Clinical follow-up was conducted at a minimum of 3 months postprocedure. This study was approved by the Institutional Review Board of Rajavithi Hospital (approval no. 66140). Informed consent was waived due to the retrospective nature of the data collection. Of the total 31 patients and 31 fistulas treated with detachable balloon embolization, one patient was excluded from the study due to suspected spontaneous rupture cavernous ICA aneurysm. Relevant information was recorded, including age, sex, clinical presentation, duration of symptoms, mechanism of injury, imaging finding, angiographic finding, fistula location, and fistula size. Fistula size was classified into three groups—small, medium, and large—based on the angiographic features.[16] The angiograms showing the presence of the anterior cerebral artery (ACA) and middle cerebral artery (MCA) were classified as small-sized fistulas, the presence of either the ACA or MCA was categorized as medium-sized fistulas, while the absence of the ACA and MCA was classified as large-sized fistulas. Based on the cavernous ICA segmentation,[5] [17] the classification included C1 (anterior ascending), C2 (anterior genu), C3 (horizontal), C4 (posterior genu), and C5 (posterior ascending) ([Fig. 1]). The fistula locations were categorized into two groups: ascending or genu (C1, C2, C4, C5) and horizontal (C3) segments. Successful embolization was evaluated on immediate angiographic findings and clinical follow-up of at least 3 months. Recurrent fistula, complication of embolization included balloon dislodgement, thromboembolism, permanent cerebral infarction, and residual cavernous aneurysm were recorded.

Fig. 1 Location of the fistula. The segments of cavernous internal carotid artery, which are divided into five segments including: C₁, anterior ascending segment; C₂, anterior genu segment; C₃, horizontal segment; C₄ posterior genu segment; and C₅, posterior ascending segment. OphthA, ophthalmic artery; PcomA, posterior communicating artery.

Procedure Details

All procedures were performed via standard transfemoral approach using an 8-Fr introducer sheath. Most cases received local anesthesia. Pretreatment control cerebral angiography demonstrated location of fistula, side, and size of fistula as well as the pattern of venous drainage. We used a single balloon delivery catheter for the deployment of the detachable balloon (GOLDBAL4, BALT Extrusion, France), which was inflated with a mixture of Visipaque (20 mL) and sterile water (5 mL). The balloon-mounted catheter was navigated through the fistula site using flow guidance. Once the balloon passes the fistula site, it was gradually inflated until complete embolization was achieved while preserving the ICA. The balloon was detached using manual traction. Postoperatively, all patients were maintained on absolute bed rest for up to 24 hours. Plain head X-rays were taken 1 day after the procedure.

Follow-Up

All patients were followed-up for a minimum of 3 months, during which clinical evaluation and plain head X-rays were conducted. Repeat angiography was conducted in the absence of clinical improvement, the presence of worsening neurological deficits, or if a recurrent fistula was suspected.

Statistical Analysis

Categorical variables were expressed as numbers and percentages, while continuous variables were presented as means, median, standard deviation, and ranges. For comparisons between groups, Pearson's chi-square test (or Fisher's exact test) and independent t-test were performed. Binary logistic regression model was used to evaluate factors that were associated with successful embolization. A p-value of less than 0.05 was considered statistically significant.

Results

Clinical Presentation and Imaging Data

A total of 30 patients were included in this study. The mean age of the patients was 41.1 years (range 17–65 years). There were 17 females (56.7%) and 13 males (43.3%). The median duration of symptom was 2.0 months (range 0.25–60 months); 26 cases (86.7%) presented with a duration of less than 6 months. Mechanism of injury was from motorcycle accident in 25 patients (83.3%), car accident in 2 (6.7%), and 3 (10%) were fall from height and body assault. We identified associated injuries, including traumatic brain injury in 14 patients (46.7%) and maxillofacial injuries in 6 patients (20%). Almost all patients exhibited eye redness and proptosis; 27 (87.1%) had orbital bruit, 23 (76.7%) had cranial nerve deficit, and 9 (30%) experienced visual impairment. Computed tomography image revealed CS enhancement in all patients, 29 (96.7%) had dilated superior ophthalmic vein (SOV) and 3 (10%) showed dilatation of the cortical veins. Angiographic finding demonstrated right side fistula in 18 cases (60%). Notably, 29 patients (96.7%) had drainage into the inferior petrosal sinus, 28 (93.3%) had drainage to the SOV, 8 (26.7%) into the superior petrosal sinus, 7 (23.3%) into the cortical vein, and 6 (20%) into the posterior fossa. Five cases (16.7%) were classified as small-sized fistula, 19 (63.3%) as medium-sized, and 6 (20%) as large-sized. Regarding the location of the fistula, 8 cases (26.7%) were found in the horizontal segment, while 22 cases (73.3%) were located at the ascending or genu segment of the cavernous ICA. Twenty-six patients (86.7%) were successfully (immediate) treated with balloon embolization during the first procedure. Among these cases, 24 out of 26 (92.3%) required only one balloon, while 2 out of 26 (7.7%) required two balloons. Four cases failed during the initial procedure; three of these patients underwent coiling embolization, while the remaining patient was treated with a covered stent (Graftmaster Coronary Stent Graft System, Abbott Vascular, Germany). Recurrent fistulas developed in three patients (10%), all of them had minimal residual fistula following balloon detachment. During the second procedures, these patients received repeated detachable balloon embolization and coiling embolization. Unfortunately, one patient passed away due to respiratory failure before the second procedure could be performed. Finally, the successful rate of detachable balloon embolization was 80% (24 out of 30), nearly all patients had ICA preservation ([Table 1]). A summary of 30 cases of TCCF treated with detachable balloon embolization as an initial intervention is presented, including subsequent treatment methods, outcomes, complications, and final follow-up results ([Table 2]). Residual cavernous aneurysms were identified in two patients, one had persistent cranial nerve deficit and was subsequently treated with transarterial coiling embolization, while the other remained asymptomatic and showed spontaneous resolution.

Table 1 Baseline demographic, clinical, and angiographic data

Baseline characteristic	No. of patients (%)
Age (y), mean ± SD	41.1 ± 14.17
Duration (mo), median (range)	2.0 (0.25–60.0)
Female sex, n (%)	17 (56.7)
Clinical presentation, n (%)
Eye redness and proptosis	29 (96.7)
Orbital bruit	27 (87.1)
Cranial nerve deficit	23 (76.7)
Mechanism of injury, n (%)
Motorcycle accident	25 (83.3)
Car accident	2 (6.7)
Others (fall from height, body assault)	3 (10)
Venous drainage, n (%)
Inferior petrosal sinus (IPS)	29 (96.7)
Superior ophthalmic vein (SOV)	28 (93.3)
Superior petrosal sinus (SPS)	8 (26.7)
Fistula size
- Small	5 (16.7)
- Medium	19 (63.3)
- Large	6 (20)
Fistula location
- Ascending and genu segment (C1, C2, C4, C5)	22 (73.3)
- Horizontal segment (C3)	8 (26.7)
Successful embolization	24 (80)
Recurrent fistula	3 (10)

Abbreviation: SD, standard deviation.

Table 2 Summary of 30 TCCF cases treated by detachable balloon embolization

Patient no.	No. of balloon	First angiography result	Second treatment	Second angiography result	ICA preservation	Recurrence or complication	Last follow-up result
1	One	Fistula occlusion	None	None	Yes	None	Cure
2	One	Fistula occlusion	None	None	Yes	None	Cure
3	One	Fistula occlusion	None	None	Yes	None	Cure
4	One	Fistula occlusion	None	None	Yes	Recurrence	Death
5	Two	Fistula occlusion	Coiling	Aneurysm occlusion	Yes	Residual cavernous aneurysm	Cure
6	One	Fistula occlusion	None	None	Yes	None	Cure
7	One	Fistula occlusion	None	None	Yes	None	Cure
8	One	Fistula occlusion	None	None	Yes	None	Cure
9	One	Fistula occlusion	None	None	Yes	None	Cure
10	—	No occlusion	Covered stent	Fistula occlusion	Yes	None	Cure
11	One	Fistula occlusion	None	None	Yes	None	Cure
12	—	No occlusion	Coiling	Fistula occlusion	Yes	None	Cure
13	One	Fistula occlusion	Balloon	Fistula occlusion	Yes	Recurrence	Cure
14	One	Fistula occlusion	None	None	Yes	None	Cure
15	One	Fistula occlusion	None	None	Yes	None	Cure
16	One	Fistula occlusion	None	None	Yes	None	Cure
17	Two	Fistula occlusion	None	None	Yes	None	Cure
18	One	Fistula occlusion	Coiling	Fistula occlusion	Yes	Recurrence	Cure
19	One	Fistula occlusion	None	None	Yes	Residual cavernous aneurysm	Cure
20	—	No occlusion	Coiling	Fistula occlusion	Yes	None	Cure
21	One	Fistula occlusion	None	None	Yes	None	Cure
22	One	Fistula occlusion	None	None	Yes	None	Cure
23	One	Fistula occlusion	None	None	No	None	Cure
24	One	Fistula occlusion	None	None	Yes	None	Cure
25	—	No occlusion	Coiling	Fistula occlusion	Yes	None	Cure
26	One	Fistula occlusion	None	None	Yes	None	Cure
27	One	Fistula occlusion	None	None	Yes	None	Cure
28	One	Fistula occlusion	None	None	Yes	None	Cure
29	One	Fistula occlusion	None	None	Yes	None	Cure
30	One	Fistula occlusion	None	None	Yes	None	Cure

Abbreviations: Balloon, detachable balloon (GOLDBAL4, BALT Extrusion, France); ICA, internal carotid artery; TCCF, traumatic carotid cavernous fistula.

Note: Successful cases are indicated in a white row, while failure cases are represented in a gray row.

Among the 24 patients who had successful embolization, classified into the success group, the ICA was preserved in 23 out of 24 patients (95.8%). The remaining patient had ICA occlusion but exhibited no clinical symptoms. The six patients who experienced embolization failure were classified into the failure group, which exhibited variable fistula sizes; however, only one case involved a fistula located in the ascending or genu segment of the cavernous ICA. A comparison between the two groups was conducted to identify factors associated with successful embolization. Age, sex, duration of symptom, and mechanism of injury were similar except for fistula size (p = 0.015) and fistula location (0.002), which were statistically significant ([Table 3]).

Table 3 Factor associated successful embolization

Factor	Success(n = 24)	Failure(n = 6)	p-Value
Age, y, mean ± SD	40.79 ± 14.27	42.33 ± 14.99	0.826
Female sex, n (%)	12 (70.6)	5 (29.4)	0.196
Duration, mo, n (%)
≤ 6 mo	22 (84.6)	4 (15.4)	0.169
> 6 mo	2 (50)	2 (50)
Mechanism of injury, n(%)
Motorcycle accident	21 (84)	4 (16)	0.254
Car accident	1 (50)	1 (50)
Others	2 (66.7)	1 (33.3)
Fistula size, n (%)
- Small	2 (40)	3 (60)	0.015[a]
- Medium	18 (94.7)	1 (5.3)
- Large	4 (66.7)	2 (33.3)
Fistula location, n (%)
- Ascending and genu segment (C1, C2, C4, C5)	21 (95.5)	1 (4.5)	0.002[a]
- Horizontal segment (C3)	3 (37.5)	5 (62.5)

Abbreviation: SD, standard deviation.

^a Indicates a significant difference for factor associated with successful embolization.

In the multivariable logistic regression analysis, the location of the fistula at the ascending or genu segment of the cavernous ICA maintained its significant association (p = 0.018). In contrast, the medium-sized fistula trended in the same direction but lost statistical significance (p = 0.088) ([Table 4]).

Table 4 Multivariate analysis of the factors associated with successful embolization

Factor associated successful embolization	Univariable			Multivariable
	Odd ratio	95% CI	p-Value	Odd ratio	95% CI	p-Value
Fistula size
- Medium	27.00	1.83–399.24	0.016[a]	18.96	0.65–557.18	0.088
- Large	3.00	0.26–35.33	0.383	–	–	–
- Small	1.00	–	–	–	–	–
Fistula location
- Ascending and genu segment	35.00	2.98–411.47	0.005[a]	30.14	1.79–506.74	0.018[a]
- Horizontal segment	1.00	–	–	–	–	–

Abbreviation: CI, confidence interval.

^a Indicates a significant difference for factor associated with successful embolization.

Discussion

Direct carotid cavernous fistula or TCCF is characterized by a direct shunt between the cavernous part of the ICA and the CS. The most common clinical presentations include eye redness, proptosis, and orbital bruit, which result from the engorgement of the draining vein and orbital venous congestion due to a high-pressure gradient. The goal of treatment is to achieve complete closure of the fistula while preserving the patency of the ICA. Due to the high-pressure gradient, a minimally inflated balloon can be easily navigated through the fistula, with repeated inflations and deflations until the balloon is in the proper position and then inflate the balloon until complete closure of the fistula.[3] [4] [5] This technique is relatively simple, does not require the use of antiplatelet agents, and the cost of device is lower compared with coiling embolization,[6] [7] [8] [9] covered stent,[10] [11] [12] or flow diverter stent.[13] [14] [15] However, there are some limitations to this approach: (1) for small-sized fistula, the size of the fistula hole should ideally be larger than that of the deflated balloon,[16] [18] [19] [20] (2) in case of a large tear in the ICA, while balloon can be easily navigated through the fistula, inflated balloon may lead to occlusion of the ICA,[16] [18] [19] and (3) sharp osseous fragments may cause balloon rupture during inflation.[18] [19] According to the literature reviewed, the rate of successful detachable balloon embolization alone is approximately 85 to 94%,[16] [18] [20] [21] [22] while the rate of ICA preservation ranges from 70 to 90.4%.[16] [18] [20] [22] Various techniques have been developed to enhance the success rate of embolization such as double balloon technique[20] and bracing balloon-assisted detachable balloon.[23] At our center, transarterial detachable balloon embolization by single balloon delivery catheter has been the first-line treatment for most TCCF patients. All patients utilized balloons of the same size (GOLDBAL4, BALT Extrusion). In the present study, we achieved successful embolization in 24 out of 30 fistulas (80%), which is comparable to previous reports. Remarkably, ICA preservation occurred in nearly all cases, with 23 patients (95.8%) maintaining patency. However, detachable balloon embolization failed in six cases. In one case, navigation through CS was impossible due to a very small fistula size. Subsequently, transarterial coiling embolization was performed in a second procedure. For the remaining five cases, which three of them had small-sized fistula also, although navigation through the CS was successful, the proper positioning for balloon placement could not be identified. Among these five patients, two experienced recurrent fistulas. One patient did not receive treatment due to death from respiratory failure, while the other underwent retreatment with transvenous coiling embolization. The other three cases included two treated with transvenous coiling embolization and one with covered stent. These findings suggest the primary limitations from small size or shallow space of CS.[20] [23] In addition to fistula size and adequate space of CS, we observed that fistula location in the ascending or genu segment of the cavernous ICA allowed for easier navigation of detachable balloon via flow guidance through the fistula point, in contrast to fistula located in the horizontal segment. In our analysis, we identified factors associated with successful embolization. From the multivariable logistic regression model, we found that the location of the fistula at the ascending or genu segment of the cavernous ICA exhibited an independent significant difference in outcomes. In contrast, the medium-sized fistula trended in the same direction; however, due to the small sample size, it did not reach statistical significance.

Due to the high-flow characteristics lesion, the size of the fistula may exceed the deflated size of the balloon. Therefore, we selected a moderate-sized balloon (GOLDBAL4) in each case. We did not employ a three-dimensional angiogram to accurately assess the fistula's location; instead, we utilized flow guidance to navigate the balloon through the fistula, allowing us to observe the balloon's movement, which indicated the location of the fistula. In this study, we found that, in nearly all cases, the size of the fistula was larger than the deflated balloon. After the balloon was passed through the fistula to the cavernous pouch, it was inflated until complete closure was achieved. These balloons can be reshaped to conform to the dimensions of the CS, thereby eliminating the need for pretreatment volumetric measurements of the CS. In the successful group, we utilized a single balloon (GOLDBAL4) in 22 out of 24 cases and employed two balloons in two cases. This supports the conclusion that detachable balloon embolization is a simple and cost-effective procedure in comparison to other methods. One cause of failure was the small size or shallow space of the CS, which led to improper balloon placement and resulted in recurrent fistulas or ICA sacrifice ([Fig. 2]). To improve the success rate of embolization, Teng et al[23] and Niu et al[20] employed the bracing balloon to position it over the fistula orifice in the ICA facilitating the detachable balloon's ability to adapt to the limited space within the CS, thus allowing it to remain inside the CS while preserving the ICA. In this circumstance, we recommend deflating the balloon and advancing it deeper into the second cavernous pouch or into a suitable region of the CS, which may be larger than the proximal cavernous pouch. Inflating the balloon until it fits the space ensuring no residual fistula remains ([Fig. 3]). Notably, we did not encounter complications such as balloon dislodge, thromboembolism, or groin complication during this study. While detachable balloon embolization is a simple and effective procedure, treatment protocols may evolve based on the expertise of neurointerventionists and the potential discontinuation of detachable balloons. Future strategies may involve transarterial or transvenous coiling embolization, either in conjunction with a stent or employing a covered stent alone.

Fig. 2 A 42-year-old woman. (A) Cerebral angiography of the right internal carotid artery (ICA) showed a traumatic carotid cavernous fistula (TCCF) with medium-sized fistula, fistula location at the genu segment of the cavernous ICA that drained into superior ophthalmic vein and inferior petrosal sinus. (B) After the balloon was navigated through the fistula point, it was inflated minimally and then the angiogram showed the ICA was occluded. (C) Illustrative picture showed improper position of balloon placement.

Fig. 3 (A) We deflated the balloon and advanced it deeper to find the appropriate space. After positioning the balloon correctly, we inflated it until a lobulated shape was observed. The angiogram confirmed successful embolization while preserving the internal carotid artery (ICA). (B) Illustrative picture showed proper position of the balloon. (C) Plain head X-ray in the lateral view confirmed that the lobulated balloon fit properly within appropriate space.

The limitations of this study include its retrospective design, single-center nature, and the fact that the outcomes of most cases were assessed solely based on clinical symptoms.

Conclusion

Despite the availability of several endovascular treatment options for TCCF, using detachable balloon embolization is a relatively straightforward procedure. When combined with a thorough understanding of the CS anatomy, this approach can significantly enhance the occlusion rate and preserve ICA patency while minimizing complications, particularly when the fistula is located at the ascending or genu segment of the cavernous ICA.

Conflict of Interest

None declared.

Ethical Approval

Reviewed and approved by the Intuitional Review board of Rajavithi Hospital; Approval No. 66140/2566.

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Publication History

Article published online:
18 March 2025