Carotid cavernous fistula: direct repair with preservation of carotid.

Abstract

The standard treatment of carotid cavernous fistulas has been trapping or a combination of trapping and embolization. In either case the carotid is sacrificed and a certain percentage of fistulas persist in spite of complete trapping and embolization. Several years ago we began to devise a method of repairing the fistula and preserving the carotid. The first step involved finding the normal collateral vessels serving these persistent fistulas of the carotid, which is classically drawn in the anatomy texts as a nonbranching artery traversing a trabeculated venous cavern. The second problem involved finding an anatomically safe approach past the cranial nerves to the cavernous carotid and its branches. The third problem involved provision of periods of complete circulatory arrest in order that such an approach might be used and a repair effected. The significant arterial, venous, and neural anatomical findings are illustrated. The techniques are descri.bed as used in 1 1 fistula repairs with preservation of the carotid utilizing hyopthermia and circulatory arrest in increments up to 55 minutes. The operating microscope has greatly enhanced the technical feasibility.