Direct Carotid-Cavernous Fistula Coil-Pipeline reconstruction

Case courtesy Drs. Erez Nossek and Eytan Raz

Superlative cavernous sinus / venous anatomy! And a (generally) excellent method of carotid reconstruction

Trauma

CTA — look at differential opacification of cavernous region and SSS if its a question of timing

Retrograde flow thru PCOM and distal right ICA towards the fistula

Excellent ACOM. Carotid can be sacrificed if necessary.  More retrograde fistula flow

Right ICA injection.  Over 25 venous structures can be identified in total!  No key here — if you want an exercise, name them and email answers to neuroangio@neuroangio.org

Stereos

DYNA CT — same numbers

A super DYNA / VR video.  Pause it to scroll through structures

Bilateral ICA injections

ECA —  see what the ophthalmic is doing?

Right ILT — just a lucky shot.  Nice connection via rotundum branch to IMAX and superior division of ascending pharyngeal artery — just some anatomy here…

More anatomy — notice all kinds of linear structures in the left cavernous sinus.  Are they septations?  Vessels? Both?

Treatment — two 18-type catheters in the cavernous sinus — one front, one back. Third phenom 027 for Pipeline — PED-supported coiling.

Final post — dorsal ophthalmic?  Not really?

Learning points?

Great anatomy.  If dual antiplatelets are OK, Shield and coils are a great option — better than any stent

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