Radial Artery Graft Bypass with Endovascular Trapping of the Internal Carotid Artery for Recurrent Carotid Cavernous Fistula: Different Surgical Fields, Different Surgical Considerations

Abstract

Background: Venous infarction in the brainstem caused by venous congestion is an extremely rare complication of traumatic carotid cavernous fistulas (CCFs). This condition requires immediate treatment and a multimodal treatment strategy is needed to prevent recurrence.

Case description: A 24-year-old man presented with exophthalmos and chemosis after a bicycle accident. Cerebral angiography showed an engorged right superior ophthalmic vein and a right carotid cavernous fistula. Transvenous coil embolization was successfully performed without severe complications. Two months later, a decline in mental status occurred. Follow-up angiography showed recanalization of the CCF. The patient underwent radial artery graft bypass surgery combined with endovascular trapping of the internal carotid artery. Sylvian veins and other cortical veins became intraoperatively arterialized and we observed marked brain edema after high-flow CCF. After surgery, the patient's mental status recovered and angiography showed good patency of the bypass graft and complete obliteration of the recurrent CCF.

Conclusions: To ensure prevention of recurrent CCF, internal carotid artery trapping combined with high-flow bypass surgery can be a good salvage treatment for urgent cases in which an endovascular approach already failed.

Keywords: High-flow bypass; Traumatic carotid cavernous fistula; Venous infarction.