Willis覆膜支架治疗难治性外伤性颈动脉海绵窦瘘

Endovascular treatment of complex traumatic direct carotid-cavernous fistulas by using Willis covered stent

目的评价Willis覆膜支架血管内治疗难治性外伤性颈动脉海绵窦瘘(TCCF)的疗效,强调保留和重建颈内动脉(ICA)的重要性。方法回顾性分析最近6年使用Willis覆膜支架治疗的12例外伤性TCCF,其中1例双侧瘘口。所有病例经可脱球囊治疗失败,术后1～60个月脑血管造影和临床随访评价其疗效。结果 小瘘口3个,多发瘘口2个,大的海绵窦腔和瘘口8个。其中完全盗血3例,存在骨折碎片2例,合并夹层2例。Willis覆膜支架成功治疗了所有难治性TCCF,11例保留ICA,其中3例重建了海绵窦段ICA,另1例闭塞了单侧ICA和瘘口。术中无一例患者血管破裂,未出现远端脑栓塞和新发神经系统症状等并发症。术后6个月随访造影,10例瘘口完全闭塞、ICA通畅,支架内无明显狭窄,1例ICA闭塞。除外2例患者失明外,术后1 d～3个月其他病例症状均逐步改善,并最终消失。结论 Willis覆膜支架治疗难治性TCCF有效、安全,可以作为TCCF的一种重要的治疗方法。

Objective The purpose of this study is to evaluate the efficacy of Willis covered stent for endovascular treatment of complex traumatic carotid-cavernous fistulas（TCCFs）,focusing on preservation and reconstruction of the internal carotid artery（ICA）.Methods Endovascular treatment with Willis covered stent was employed in twelve patients with traumatic direct carotid-cavernous fistulas who failed to respond the treatment with detached balloon.The clinical data were retrospectively reviewed and analyzed.Bilateral fistulas was seen in one patient.The patency and stability of the stent were evaluated with angiographic study in all patients and a clinical follow-up for 1-60 months was made.Results Of the total 13 fistulas detected on angiography,small fistula was found in 3,multiple fistulas in 2 and enlarged cavernous sinus together with fistula in eight.Completely blood-stealing fistula was confirmed in 3 cases,coexisting sharp osseous fragments was seen in 2 cases and complicating with dissection was observed in two cases.All complex TCCFs were successfully treated with Willis covered stent.ICA was preserved in 11 cases,reconstruction of the carotid-cavernous segment of the ICA was carried out in 3 cases,and ICA was sacrificed in only one patient.No procedural complications such as vessel rupture,distal embolization and any new neurological deficits,occurred.The fistulas in 10 patients were completely occluded the ICAs were preserved and no in-stent stenosis occurred during a follow-up of 6 months after endovascular treatment.The clinical symptoms related to the TCCFs were improved gradually from the first day after treatment to 3 months,with the exception of two patients who suffered from ipsilateral blindness.Conclusion Willis covered stents can be used as a safe and effective tool to treat complex TCCFs with preservation or reconstruction of ICA,this technique can be regarded as an important therapeutic option for the case of TCCFs.