2.3 Therapeutic Measures

2.3

Therapeutic Measures

When Travers was a demonstrator of anatomy at Guys Hospital in London in 1811, he ligated successfully the left common carotid artery for a carotid cavernous sinus fistula. Thus he became not only the first to describe the condition but also the first to describe its therapy even before the discovery of anesthesia.

France of Guys Hospital, in 1853 was the first to describe spontaneous thrombosis of the fistula (France 1855) without digital compression or ligation.

Gioppi (1858) of Padua suggested intermittent digital compression of the carotid artery in 1856, and he is credited with being the first to use it successfully. Vanzetti (1858) very shortly afterward described this method in more detail.

Brainard, Professor of Surgery at Rush Medical School in Chicago in 1852 attempted as one of the first to cure an “erectile tumor of the orbit” by injecting “lactate of iron” and “puncture with hot needles” in a 35-year-old patient (Brainard 1853) in whom ligation a year earlier had failed (Kosary et al. 1968). Similar attempts were made at the same time in Europe by Giraldes (1853-1854) and Pravez et al. (1853), who used “perchloride of iron” for injection, which was, however, followed by gangrene. These attempts represented a different therapeutic approach, namely ignoring the inflow tracts and attempting to obliterate the outflow tract of a carotid cavernous complex.

Petrequin(1846),Bourguet(1855),andCiniselli

(1868) suggested electropuncture using acupuncture needles made of platinum with an iron tip.

Lansdown (1875), surgeon at Bristol General Hospital, attempted to cure a traumatic case with ligation and removal of the varicose ophthalmic veins. This technique was also performed and advocated by Sattler (1880, 1905) (Fig. 2.6).

In Berlin, Zeller (1911) questioned ligation of the carotid artery as a suitable treatment and opposed to the “dangerous” bilateral ligation in cases of retrograde filling of the fistula via collateral vessels through the circle of Willis or the external carotid system. He suggested a new approach namely the “voellige Ausschaltung des Arterienstueckes in dem das Loch sitzt, aus dem arteriellen Kreislauf durch proximale and distale Ligatur”, the trapping of the fistulous carotid by proximal ligation in the

neck and distal ligation proximal or immediately distal to the origin of the ophthalmic artery. After studies in cadavers he was able to demonstrate in 1908 that this procedure was effective. Even though his patient died due to intraoperative rupture of the ICA caused by an unfortunate mistake of his assistant, this approach was adopted later by Hamby and Gardner (1933), Dandy (1937) and others (Toennis 1937).

Locke (1924) described an apparatus for external compression of the large vessels in the neck, consisting of a wooden frame and a rubber band (Fig. 2.7).

Brooks (1931), in discussing a paper by Noland and Taylor before the Southern Surgical Association, reported a unique method for obliteration of CCF: He opened the carotid and packed a strip of muscle between the clamps. The incision of the artery was then closed and the clamps removed so that the blood stream would force the muscle piece downstream into the fistula site. The patient lost vision but otherwise recovered. This procedure, although never really proven, has since been considered the first successful arterial embolization. Whether or not the muscle piece in fact plugged the fistula or just occluded the carotid remains unknown. Brooks himself discussed critically in his original description: “Owing to the marked curvature of the bony canal through which the carotid artery enters the intracranial cavity, it is of course, difficult to be sure that our attempt to obliterate the artery at the site of fistulous opening was successful. We believe however this was accomplished.”

The procedure was modified by Gardner (Hamby and Gardner 1933) on May 15, 1931 who used a piece of muscle the size of a pea (5 mm) and attached a silver clip for radiographic localization. The idea here was to make the embolus small enough to enter the venous component (sinus) of the fistula where “it would be an active nucleus for the rapid production of thrombus that would close the opening”. The bruit immediately ceased and proptosis improved until it reoccurred 8 days later and the patient underwent ligation.

In 1934, Dandy occluded the intracranial ICA with a silver clip (Dandy 1937), followed by Walker and Allegre (1956), Adson (1942) and Toennis et al. (1937).

Gurdjian (1938) reported a case in which external and internal carotid arteries were ligated and 2×0.25 cm muscle plugs were introduced to remove the carotid opening at the site of the lesion. This re-

sulted in improvement of proptosis, ophthalmoplegia and vision.

Jaeger (1949) reported the successful combination of intracranial clipping of the internal carotid, muscle embolus and ligation of the carotid in the neck in a 12-year-old boy 7 years earlier. He was able to control the position of the embolus using X-ray identification of the silver clip at the carotid cavernous opening. The patient was immediately and completely cured when seen again for a 7-years follow-up. In 1959 he reported on six cases being successfully treated using the same technique.

Parkinson (1963a,b) devised the direct surgical approach to the cavernous sinus using hyperthermia and cardiac arrest. Although his first patient died due to pulmonary complications, this new approach opened the door for microsurgical techniques in

the treatment of carotid cavernous fistulas, some of which are employed until today in intractable cases.

2.4 Embolization

On September, 25th in 1963, Lang and Bucy (1965) were able to successfully treat a case with free embolization of a muscle piece with silver clip and referred to several additional previous reports in the literature. While all of those had to undergo intracranial ligation because of persisting symptoms, the case of Lang and Bucy was cured by embolism

Fig. 2.7. Instrument employed to compress the common carotid artery against the transverse process of the cervical vertebrae, from Locke (1924): Intracranial arteriovenous aneurysm or pulsating exophthalmos. The frame was placed around the neck and the rubber band was then stretched over the screw

alone. The control angiogram confirmed complete thrombosis of the ipsilateral internal carotid while good cross flow was preserved from the contralateral territory. Kosary et al. (1968) reported the successful embolization of a CCF using porcelain beads.

To avoid distal migration of the embolus, Arutiunov et al. (1968) had developed a particular technique, consisting of a clipped muscle embolus attached to a nylon string. This allowed controlling of the embolus to the fistula site under X-ray, and securing it in place by anchoring it to the ICA ligation. This technique was performed in 13 patients with 100% success and can be considered the precursor of detachable balloons introduced a few years later. Prolo and Hanbery performed in October 1969 an occlusion of a CCF using a nylon balloon catheter through an arteriotomy in the common carotid artery achieving complete cure.

Isamat et al. (1970) ingeniously embolized the fistula and preserved the patency of the carotid artery using a previously magnetized metal clip on a muscle embolus. The authors thought of guiding the embolus by an electromagnet over the skin covering the superior-anterior part of the cavernous sinus of

the left zygoma, which was however not necessary because the pressure and flow was such as to conduct the embolus properly into the fistulous opening in its venous side without interfering the patency of the carotid.

In 1973, Black et al. followed this concept of “flow-directed” muscle embolization and were able to maintain the patency of the carotid artery.

Serbinenko (1971) published an article about the use of detachable balloons for occlusion of cerebral vessels. This first and quite significant contribution was published only in the Russian literature and was initially missed by most Westerners. It was after his second report, this time published in the English literature (Serbinenko 1974), that colleagues like Chermet et al. (1977) followed in his footsteps.

Peterson et al. (1969) deserves credit for the first retrograde venous passage through the SOV using a copper wire and positive current for electrocoagulation of a CCF.

Kerber et al. (1979) pioneered the use cyanoacrylate to occlude a carotid cavernous fistula with preservation of the carotid artery flow. He used a particular calibrated leak balloon microcatheter in three patients and was able to occlude the fistula but with persistent neurological complication in one.

These and other pioneering efforts opened the door to a new era of therapeutic management of carotid cavernous fistulas: endovascular treatment using arterial embolization. Minimal invasive management has been firmly established since, has continuously advanced over the following years, and has eventually been augmented by transvenous occlusion (TVO) techniques in the 1990s (more in Chap. 8).

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