Iampreechakul P, Wangtanaphat K, Chuntaroj S, Wattanasen Y, Hangsapruek S, Lertbutsayanukul P, Puthkhao P, Siriwimonmas S. Pseudoaneurysm formation following transarterial embolization of traumatic carotid-cavernous fistula with detachable balloon: An institutional cohort long-term study. World J Radiol 2024; 16(4): 94-108 [PMID: 38690547 DOI: 10.4329/wjr.v16.i4.94]
Corresponding Author of This Article
Prasert Iampreechakul, MD, Staff Physician, Department of Neurosurgery, Neurological Institute of Thailand, Ratchawithi Road, Khwaeng Thung Phaya Thai, Bangkok 10400, Thailand. bangruad@hotmail.com
Research Domain of This Article
Neuroimaging
Article-Type of This Article
Observational Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Radiol. Apr 28, 2024; 16(4): 94-108 Published online Apr 28, 2024. doi: 10.4329/wjr.v16.i4.94
Pseudoaneurysm formation following transarterial embolization of traumatic carotid-cavernous fistula with detachable balloon: An institutional cohort long-term study
Prasert Iampreechakul, Korrapakc Wangtanaphat, Department of Neurosurgery, Neurological Institute of Thailand, Bangkok 10400, Thailand
Songpol Chuntaroj, Yodkhwan Wattanasen, Sunisa Hangsapruek, Punjama Lertbutsayanukul, Department of Neuroradiology, Neurological Institute of Thailand, Bangkok 10400, Thailand
Pimchanok Puthkhao, Department of Medical Services, Neurological Institute of Thailand, Bangkok 10400, Thailand
Somkiet Siriwimonmas, Department of Radiology, Bumrungrad International Hospital, Bangkok 10110, Thailand
Author contributions: Iampreechakul P proposed the study concept and design; Iampreechakul P and Siriwimonmas S contributed to the manuscript writing; Wangtanaphat K, Chuntaroj S, and Lertbutsayanukul P contributed to data acquisition; Wattanasen Y and Hangsapruek S contributed to data analysis and interpretation; Puthkhao P contributed to statistical analysis; Iampreechakul P and Puthkhao P contributed to manuscript revision.
Institutional review board statement: The study was approved by the Neurological Institute of Thailand Institutional Review Board (No. 54020).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymized clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: The authors declare having no conflicts of interest.
Data sharing statement: The data used to support the findings to this study are available from the corresponding author upon request.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Corresponding author: Prasert Iampreechakul, MD, Staff Physician, Department of Neurosurgery, Neurological Institute of Thailand, Ratchawithi Road, Khwaeng Thung Phaya Thai, Bangkok 10400, Thailand. bangruad@hotmail.com
Received: December 11, 2023 Revised: April 4, 2024 Accepted: April 16, 2024 Published online: April 28, 2024
Abstract
BACKGROUND
The goal of therapy for traumatic carotid-cavernous fistula (TCCF) is the elimination of fistula while maintaining patency of the parent artery. The treatment for TCCF has evolved from surgery to endovascular management using detachable balloons, coils, liquid embolic agents, covered stents, or flow-diverter stent through arterial or venous approaches. Despite the withdrawal of detachable balloons from the market in the United States since 2004, transarterial embolization with detachable balloons has currently remained the best initial treatment for TCCF in several countries. However, the pseudoaneurysm formation following transarterial detachable balloon embolization has rarely been observed in long-term follow-up.
AIM
To determine the occurrence and long-term follow-up of pseudoaneurysm after transarterial detachable balloon for TCCF.
METHODS
Between January 2009 and December 2019, 79 patients diagnosed with TCCF were treated using detachable latex balloons (GOLDBAL) of four sizes. Pseudoaneurysm sizes were stratified into five grades for analysis. Initial and follow-up assessments involved computed tomography angiography at 1 month, 6 month, 1 year, and longer intervals for significant cases. Clinical follow-ups occurred semi-annually for 2 years, then annually. Factors analyzed included sex, age, fistula size and location, and balloon size.
RESULTS
In our cohort of 79 patients treated for TCCF, pseudoaneurysms formed in 67.1%, with classifications ranging from grade 0 to grade 3; no grade 4 or giant pseudoaneurysms were observed. The majority of pseudoaneurysms did not progress in size, and some regressed spontaneously. Calcifications developed in most large pseudoaneurysms over 5-10 years. Parent artery occlusion occurred in 7.6% and recurrent fistulas in 16.5%. The primary risk factors for pseudoaneurysm formation were identified as the use of specific balloon sizes, with balloon SP and No. 6 significantly associated with its occurrence (P = 0.005 and P = 0.002, respectively), whereas sex, age, fistula size, location, and the number of balloons used were not significant predictors.
CONCLUSION
Pseudoaneurysm formation following detachable balloon embolization for TCCF is common, primarily influenced by the size of the balloon used. Despite this, all patients with pseudoaneurysms remained asymptomatic during long-term follow-up.
Core Tip: This study investigated the incidence and determinants of pseudoaneurysm formation following transarterial detachable balloon embolization in treating traumatic carotid-cavernous fistula over a decade. It highlighted balloon size as a significant risk factor, with larger balloons notably increasing pseudoaneurysm occurrence. Despite the high incidence of pseudoaneurysms, all affected patients remained asymptomatic through long-term follow-up, underscoring the procedure’s overall safety. These findings emphasize the critical role of selecting appropriate balloon sizes to mitigate risk and optimize outcomes, offering valuable insights for clinicians in managing this complex condition effectively.
