A recent study published in the Journal of Neuro-Ophthalmology has concluded that employing the patch technique with progressively expanding flow diverters is a practical solo approach for treating direct carotid-cavernous fistulas symptoms, achieving immediate CVR resolution, and preserving cavernous sinus anatomy.
Previously, the employment of flow diverters (FDs) in managing high-flow Type-A carotid-cavernous fistulas (CCFs) has primarily been documented as an adjunctive method to conventional endovascular approaches rather than a standalone treatment option.

In the present study, researchers retrospectively evaluated their experience with FDs as the solo nonadjunctive treatment of Type A CCF with severe cortical venous reflux (CVR).
A retrospective analysis was conducted on patients with Type A cerebral cavernous malformations (CCFs) treated using the FDs' patch technique (PT). The patients' demographic information, clinical details, and preoperative and postoperative eye examinations were documented. The procedure technique, the diameter of the Pipeline Embolization Device (PED), and immediate and long-term procedure results were summarized.
This case series included three patients with a history of trauma who presented with decreased visual acuity, cranial nerve II deficit, limited extraocular muscles' movement, and increased intraocular pressure (IOP). Diagnostic angiography confirmed high-flow Type A CCF, and endovascular treatment was performed through distal radial (2 patients) and femoral access (1 patient) by deploying four sequentially enlarging PEDs with immediate resolution of ocular symptoms. Follow-up angiography showed complete resolution in two patients. In contrast, the third patient who lost to follow-up had residual small CCF demonstrated by angiogram at four months with significant improvement from postprocedure angiogram.
The patch technique with sequentially enlarging FDs can be considered a suitable solo technique for addressing symptoms of CCF and lead to the immediate resolution of CVR without causing harm to the cavernous sinus's anatomy. The technique preserves the anatomy of cavernous sinus.
Reference:
Al-Smadi et al. Patch Technique for Primary Treatment of Type A Carotid Cavernous Fistula: A Case Series and Technical Notes. Journal of Neuro-Ophthalmology 43(4):p 541-546, December 2023.