Detachable balloon embolization of carotid-cavernous fistula

The internal carotid artery wall of the cavernous sinus segment of the carotid-cavernous sinus or the branch of the segment ruptures, resulting in abnormal motor and vein communication with the cavernous sinus. The most common cause is skull base fracture caused by craniocerebral injury, damage to the internal carotid artery or its branch of the cavernous sinus segment; it can also be caused by spontaneous rupture of the internal carotid artery, the cavernous sinus segment of the internal carotid aneurysm, and inflammation. Curing disease: Indication Carotid-cavernous sinus detachable balloon embolization is suitable for: 1. Traumatic internal carotid artery - cavernous sinus fistula. 2. Indications for emergency treatment of carotid-cavernous sinus fistula: 1 major bleeding and nosebleeds; 2 due to sinus reversal of the contralateral internal carotid artery or vertebral artery system blood, secondary intracranial ischemic stroke; 3 occurs Intracranial subarachnoid hemorrhage; 4 abnormal venous drainage to the cortical vein increases the chance of cerebral hemorrhage and venous hypertension; 5 visual deterioration rapidly leads to blindness. 3. Due to surgery or embolization failure, the internal carotid artery of the proximal segment of the fistula is occluded, and the internal carotid artery is not closed in the distal part of the fistula. Because the intracranial blood is stolen, and the eye vein is the main reflow, the eye can be used. The upper venous approach is embolized; if the sinus is the upper sinus of the sinus, the transfemoral (or intracranial) venous approach can be used, and the sinus can be treated by embolization of the posterior sinus of the sinus. Contraindications 1. Patients who cannot tolerate surgery or those with severe heart, lung, liver or kidney dysfunction. 2. The cavernous sinus type of dural arteriovenous fistula, due to multiple neck and internal carotid artery blood supply, the fistula is small, the balloon can not enter the fistula or cavernous sinus. Preoperative preparation 1. The patient prepares 1 for conjunctival edema, congestion, and valgus, pay attention to protect the cornea from the eye and prevent the formation of corneal ulcer; 2 preoperative preparation for embolization with the same cerebral arteriovenous malformation. 2. Special equipment, medicine preparation, 116G or 18G needle; 2 diameter 0.89mm, length 40cm guide wire; 36F catheter sheath, 8F catheter sheath; 45F cerebral angiography catheter, 8F guide 1 tube; 5 with three-way soft connection tube; 6Y-shaped valve connector 2, two-way switch; 7 pressure infusion bag 4 sets; 8 coaxial catheter, 1 Magic-BD catheter; 9Balt with X-ray labeled balloon 1st, 2nd, and 3rd; 10 balloon sputum, ophthalmology direct sputum, 1 ophthalmic direct shear; ? non-ion isotonic contrast agent (180mg per liter of iodine) 10ml; 1 part of HEMA, 1 ml of 30% hydrogen peroxide; 3 pairs of 1 ml syringe. Surgical procedure Anesthesia and position 1. The patient is lying on the angiography table. 2. All patients who can cooperate with nerve anesthesia plus puncture site infiltration anesthesia, in order to observe the patient's state of consciousness, language function, limb movement and so on. General anesthesia with tracheal intubation for pediatric and special patients who cannot cooperate. 3. During the operation, the anesthesiologist is required to monitor the patient's vital signs and record. Transarterial approach Transfemoral puncture cannula is generally used. (1) The perineum and bilateral groin are routinely disinfected and sterile towels are placed. With 1% or 2% lidocaine in the right (or left) side of the inguinal ligament 2 ~ 3cm, the femoral artery pulsation is clearly layer by layer infiltration anesthesia, and the patient is neurologically anesthetized. The left femoral artery was inserted into the 6F catheter sheath and the right femoral artery was inserted into the 8F catheter sheath. (2) The 5F cerebral angiography catheter was inserted through the 6F tube sheath. Under the TV surveillance, selective left cerebral venous angiography was performed by inserting the left and right cervical and external arteries and the vertebral artery respectively, and the diagnosis and understanding of the cranial medial branch circulation were confirmed. Thereafter, the 5F contrast catheter is temporarily placed in the contralateral internal carotid artery or vertebral artery. (3) Insert the 8F guide tube through the 8F catheter sheath, and insert the affected internal carotid artery under the TV monitor to reach the C2 level. The end of the 8F guiding tube is connected with a "Y" shaped valve connector. The "Y" shaped valve side arm is connected with the arterial pressurized infusion tube with the three-way soft connecting tube. After the air in the tube is drained, the physiological saline is slowly dropped. . (4) Systemic heparinization before the insertion of microcatheter, intravenous injection at 1mg/kg, the first dose for adults is 50mg, after 2h, if continued treatment, add 0.5mg/kg body weight, adult 25mg intravenous injection And so on. . (5) According to the size of the fistula seen by cerebral angiography, select the appropriate balloon to be placed in the coaxial catheter or the end of the Magic-BD catheter. The steps are as follows: 1 Use scissors to cut off the excess part of the neck of the balloon; The latex strip of mm is cut to a length of 0.6 mm, and a short acupuncture needle is used to cut through a center of the latex strip to make a balloon valve; 3 the balloon valve is moved to the end of the coaxial catheter or the end of the Magic-BD catheter Teflon catheter 1/3 segment, and fill the catheter with 180 mg of non-ionic contrast agent per ml of iodine; 4 open the balloon neck with balloon sputum, insert the valved coaxial catheter or Magic-BD catheter into the balloon neck, Place the valve just in the middle of the balloon neck; 5 pull out the inner guide wire of the Magic-BD catheter, connect a 1ml syringe that sucks the non-ionic contrast agent to the tail, or connect a simple band at the end of the coaxial inner catheter. The valve connector was connected to a 1 ml syringe that aspirate the non-ionic contrast agent to test the expansion and retraction of the balloon to make the loading satisfactory. (6) The balloon or the Magic-BD catheter (inserted into the guide wire before use) through the Y-shaped valve connector, the valve arm is sent into the 8F guide tube, and slowly under the TV monitor Sending the internal carotid artery of the affected side, using the blood flow to bring the balloon into the cavernous sinus or the cavernous sinus cavity of the carotid artery. When the balloon suddenly changes direction when it is seen under the TV, it indicates that the balloon has entered the cavernous sinus. Oral cavity or sinus cavity. (7) using a non-ion isotonic contrast agent containing 180 mg of iodine per ml, slowly filling the balloon through the microcatheter (not exceeding the balloon volume), and confirming that the fistula is completely blocked when the contrast agent is injected through the guiding tube. Slowly pull the inner catheter or Magic-BD catheter to release the balloon and leave it in the lesion. If a balloon can't block the mouth, you can also put multiple balloons. After occlusion, the internal carotid artery angiography was repeated to find out whether the sputum occlusion was complete, whether the internal carotid artery was unobstructed, and whether the patient's intracranial squealing and auscultation of the eyelid murmur disappeared. (8) If the balloon cannot enter the fistula or the cavernous sinus cavity, and the internal carotid artery should be occluded at the same time, the internal carotid artery occlusion test must be performed first, and the contralateral carotid artery and vertebral artery angiography should be used to understand the anterior and posterior communicating artery. Whether the collateral circulation is good, whether the patient can tolerate the occlusion of the affected internal carotid artery. Only when the cranial medial branch circulation is proven and the patient can tolerate the occlusion of the affected internal carotid artery, the internal carotid artery can be occluded with a balloon. A second protective balloon or coil is placed in the neck of the internal carotid artery. It is also possible to place only one balloon in the mouth of the fistula, and at the same time to block the proximal and distal carotid arteries of the fistula, and the balloon is filled with a permanent embolic agent HEMA. (9) At the end of treatment, pull out the guiding tube and catheter sheath, neutralize heparin with protamine as appropriate, and press the puncture site for 15-20 min. Cover the sterile gauze without bleeding and compress the dressing. 2. Transsacral approach (1) Disinfection around the affected eyelid, inhalation anesthesia with 2% procaine as the puncture site. (2) Select the middle and inner 1/3 of the upper edge of the eyelid as the puncture point. Use the Seldinger method to directly puncture the supraorbital vein with the 18G puncture needle, and insert the 5F, 6F or 8F catheter sheath as appropriate. (3) If you want to embolize the cavernous sinus with NBCA, insert the 4F or 5F catheter into the cavernous sinus through the 5F catheter sheath, and inject 0.1% to 0.5ml of 66% NBCA mixture through the catheter by sandwich injection technique, and quickly pull out the catheter. (4) If you want to embolize the cavernous sinus with a spring coil, insert the 5F thin-walled catheter through the 6F catheter sheath, and insert the spring-loaded needle into the end of the 5F catheter. Then use a 0.96mm long guide wire to insert the end of the spring ring needle, push the spring ring into the catheter, and then push it out into the cavernous sinus by the 5F catheter under the TV surveillance. If a spring coil can not block the mouth, it can be sent again. The second and third spring coils are until the cymbal is completely blocked. (5) If the sinus fistula is to be embolized with a detachable balloon, insert the 8F guide tube through the 8F catheter sheath, and then insert the detachable balloon coaxial catheter or Magic-BD catheter through the 8F guide tube. (6) Using any of the above methods, embolization of the cavernous sinus fistula, and then cerebral angiography through the contralateral internal carotid artery or vertebral artery, through the anterior and posterior communicating arteries to understand whether the intracranial segment of the affected internal carotid artery is stolen. blood. (7) At the end of treatment, the catheter and catheter sheath were withdrawn and compressed for 15-20 min, and the gauze was wrapped. 3. Transfemoral or jugular vein approach (1) The patient was subjected to heparinization, and the femoral vein or internal jugular vein was inserted by Seldinger method, and the 8F catheter sheath was inserted. (2) Insert the 8F catheter lead through the 8F catheter sheath to reach the C2 plane of the affected side internal jugular vein. (3) Insert the Magic-BD catheter with detachable balloon through the 8F guiding tube, and send it into the cavernous sinus through the internal jugular vein and the upper (lower) sinus under the supervision of TV. The ionic contrast agent fills the balloon and is released. One balloon is not enough to be delivered to the second and third balloons until the angiography is occluded. (4) At the end of treatment, the catheter and catheter sheath were pulled out, partially compressed for 15-20 min, covered with sterile gauze, and pressure-wrapped. complication 1. Because the catheter and balloon damage the blood vessels during operation, or the balloon is released, the internal carotid artery or intracranial blood vessel occlusion may cause cerebral ischemia. Therefore, it should be noted that the operation is gentle and soft to prevent the balloon from falling off automatically. 2. Due to the premature overflow of the contrast agent in the balloon, the thrombus formation in the cavernous sinus is incomplete, causing recurrence or pseudoaneurysm formation. 3. In chronic high blood flow, due to severe stealing blood, the normal cerebral vascular autoregulation function is dysfunctional. After transient occlusion, hyperperfusion syndrome may occur, and controlled hypotension should be prevented during or after surgery. occur.