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Advances in the endovascular treatment of direct carotid
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Advances in the endovascular treatment of direct carotid cavernous fistulas. The treatment of these lesions has changed many The clinical manifestations are delayed appearing after. times over the last few years especially due to the intro venous hypertension has reached a critical level which. duction of new materials The objective of the present ar may take weeks to happen 22 In addition the exuberance. ticle is to review the current techniques for treatment of of the clinical condition is more related to the venous. direct CCFs with special emphasis on the endovascular drainage standard than to the size of the fistula 4 There. treatment options currently available may be compromised cranial nerves III IV V and VI caus. ing extraocular motility paralysis and diplopia in addi. Methods tion to the appearance of headache retro ocular pain vi. A review of the literature was conducted searching the sion loss and even intracranial hemorrhage 22 Deteriorated. MEDLINE database using as keywords carotid cavern vision occurs due to the combination of the reduction in. ous fistula The papers that were located were analyzed arterial perfusion and venous hypertension accompa. focusing mainly on those related to the treatment of di nied by glaucoma and the worsening of the retina perfu. rect CCFs especially the largest published series sion 1 4 A condition of cerebral ischemia related to the. The search results were presented in the format of this phenomenon of vascular theft seems to be exception. paper aiming at making a comprehensive review with em ally rare and occurs only in patients with variations in. phasis on the current endovascular treatment of direct CCFs the Willis polygon 4 There are also reports of subarach. noid hemorrhage caused by direct CCF 23 This aspect is. Discussion related to the transmission of venous hypertension to the. Epidemiology cortical veins adjacent to the lesion. Direct post traumatic CCFs are a rare condition occurring A direct CCF is formed by the blood overflow from. in only 0 17 1 01 of the traumatic brain injuries the ICA to the CS In this manner there is a blood flow. TBI 6 11 14 15 They can occur as a consequence both of closed from a compartment of high pressure to a compartment. and open TBI the latter of which may present a direct ICA of low pressure This abnormal communication leads to. lesion 2 6 7 14 15 However most direct CCFs result from a increase in pressure in the CS and consequent compres. closed cranial lesion associated with a skull base frac sion of its contents including the cranial nerves III IV V. ture 13 16 17 The direct CCFs are more common in young and VI 3 5 24 The involvement of these nerves results in. male patients which is the group most commonly affect ophthalmoplegia alterations in face sensitivity ptosis. ed by TBI 4 Nevertheless cranial traumas in persons of any and photophobia 4 24 In addition the occurrence of oph. age can result in the appearance of a direct CCF 4 thalmoplegia is facilitated by edema in intraorbital and. The ICA is fixed between the lacerum foramen and the periocular structures4 Figure 1 Venous hypertension. anterior clinoid process with dural ligaments When a leads to engorgement of the ophthalmic veins causing. TBI occurs the stretching forces sometimes accompa the classic triad of direct CCF ocular bruit chemosis and. nied by penetrating bone spicules can cause a lesion in pulsatile exophthalmos 1 4 24 In addition the intracavern. the ICA between its fixation points 4 Most of the time the ous pressure can be transmitted to the contralateral CS. laceration is single and unilateral More rarely this lesion through the intercavernous sinuses resulting in bilater. can be multiple and bilateral 4 11 12 al ocular deficits 4 22. Despite classically being of traumatic etiology the The symptoms usually improve significantly follow. direct CCF can result from iatrogenic lesions such as ing treatment many times achieving resolution in hours. trans sphenoidal or endovascular surgeries 4 14 15 18 19 col or days Total recovery however can take weeks or months 4. lagen deficiencies as in the Ehlers Danlos syndrome rup Thus the duration of the symptoms seems to be an impor. tured intracavernous aneurysms 4 12 13 20 21 dissections os tant prognostic factor being that those patients with pro. teogenesis imperfecta or even fibromuscular dysplasia 4 longed symptomatology take longer to achieve a satisfac. tory recuperation 4,Clinical presentation, The clinical presentation of direct CCFs can be varied Diagnosis. many times being similar to the presentation of neuro The diagnosis of direct CCF is based on its clinical pre. logical diseases such as multiple sclerosis cerebral tu sentation as well as on neuroimaging exams 22 Comput. mors or even encephalic vascular accidents 22 erized tomography CT of the skull without contrast can. Despite the fact that direct CCFs occur as acute events show ocular proptosis engorgement and tortuosity of. the symptoms can be insidious and potentially grave 4 22 the superior ophthalmic vein as well as the enlargement. Rev Assoc Med Bras 2016 62 1 78 84 79,Aguiar GB et al. FIGURE 1 Photograph of a patient with a direct carotid ca. vernous fistula demonstrating intense conjunctival edema and. ocular hyperemia, of the CS involved 22 Magnetic resonance imaging MRI Thus by definition every direct CCF must be readi. of the brain shows similar findings to those of the CT ly treated In the past before the development of endo. but with better definition being also particularly useful vascular techniques the treatment of this type of lesion. in the classification of the CCFs 22 CT and MRI are also was to perform the ligature or trapping of the ICA often. important in evaluating the encephalic parenchyma for with severe sequelae and persistence of fistula 2 4 26 Current. the identification of possible traumatic lesions or even ly endovascular treatment is the procedure of choice for. associated ischemia 4 In addition CT in coronal view is these lesions 2 4 5 8 9 Once the lesion is treated the CS pres. widely used in the evaluation of possible bone lesions at sure is normalized allowing symptoms to subside 22 Drug. the skull base 4 treatment must be promptly instituted in the form of lo. The best exam for the diagnosis and classification of cal care provided to the eyes for as long as it takes to re. the CCFs is cerebral angiography Figure 2 4 7 It is per verse the clinical condition 4 Some authors affirm that. formed with the objective of identifying location and size there should be a one to two week delay following the. of the fistula as well as its venous drainage 4 In addition onset of the symptoms to perform the endovascular treat. by this method it is possible to identify associated vascu ment 12 They state that due to the recent cranial trauma. lar lesions such as pseudoaneurysms or varicose veins in the ICA could present a strong reaction to the endovas. the CS which also require treatment 4 As this is a high cular navigation which would cause greater risk of endo. flow lesion it is often difficult to visualize the morphol thelial lesion 12 However some cases need treatment in. ogy of the fistula orifice To obtain a more detailed im the acute phase generally due to the imminent risk of in. age the Allcock maneuver can be utilized which consists tracranial hemorrhage caused by venous hypertension 12. of ICA compression ipsilateral to the fistula with the in or to the rapid deterioration of the vision 22. jection of a contrast in the vertebral artery or even in the The ideal treatment for a direct CCF is the exclusion. contralateral ICA Figure 3 4 of the fistula from the circulation preserving the paten. cy of the ICA 4 6 9 12 14 15 From the 1970s on this began to. Treatment be successfully achieved using detachable balloons 4 11 27. Direct CCFs are high flow lesions that can be related to Currently a variety of new materials and different strat. intracranial bleeding visual loss corneal exposure or egies have been used in the treatment of direct CCFs 4 11. even fatal epistaxis4 22 and therefore their treatment is In this manner direct CCFs can be managed successful. always recommended Treatment must be provided as ly both via artery or vein or even transorbitally through. soon as possible and to reinforce this Halbach et al 25 the superior ophthalmic vein 4. identified some high risk situations which require ur The gold standard for treatment is the transarterial. gent treatment These include the onset of intracranial route with occlusion of the fistula and preservation of. hemorrhage epistaxis increase in the intraocular pres the blood flow through the ICA This is achieved with the. sure reduction of visual acuity and rapidly progressive positioning of a latex balloon in the CS occluding the. proptosis fistula orifice 4 6 8 14 15 20 28 Nevertheless in some countries. 80 Rev Assoc Med Bras 2016 62 1 78 84, Advances in the endovascular treatment of direct carotid cavernous fistulas. FIGURE 2 Left carotid angiography before A and B, and after C F endovascular treatment of the direct CCF.
A and B early opacification of the left cavernous sinus. with cerebral blood flow deviation C and D normal, opacification of the left cerebral hemisphere E and F. carotid angiography showing the positioning of the balloon. arrow in the left cavernous sinus A C E frontal,incidence B D F lateral incidence. FIGURE 3 Left vertebral angiography with left carotid. compression demonstrating the opacification of the left. CCF double arrow by means of the flow inversion in the. posterior communicating artery arrow in the Allcock. Rev Assoc Med Bras 2016 62 1 78 84 81,Aguiar GB et al. such as the United States detachable balloons are not As the ICA flow is almost exclusively directed to the. used 11 making another type of approach necessary In fistula it is not necessary to perform the ICA occlusion. addition the failure rate for selective occlusion of the fis test before sacrificing it 4 Nevertheless in patients who. tula with a balloon is as high as 10 4 29 31 Frequently the present with good opacification in the cerebral parenchy. failure of this technique occurs because of the small size ma distal to the fistula the ICA occlusion test is recom. of the fistula orifice making it impossible for the balloon mended before proceeding with the therapeutic occlu. to pass through or even the small size of the CS which sion of this artery If the patient does not tolerate the. makes it impossible to adequately inflate the balloon 4 occlusion another method of treatment should be ad. The navigation of the microcatheter to reach the fistula opted 4 such as vascular bypass for example. may also be a limiting factor in this option especially if Although the standard treatment for a direct CCF is. the fistula is located in the segment C4 of the cavernous most frequently performed via the artery by means of se. ICA due to a very acute entrance angle to the ICA 4 The lective occlusion of the fistula and preservation of the. presence of bone spicules may lead to perforation of the ICA patency with a balloon the embolization of the af. balloon during inflation 32 which also constitutes a lim fected CS using platinum coils and accessing the region. itation to this technique by the transvenous route has been used currently main. Another negative aspect of occluding the fistula with ly due to safety of its execution and the high rate of suc. a balloon technique is the appearance of thromboem cess obtained 12 28 33. bolic complications related to the procedure generally Access through the ipsilateral jugular vein and infe. caused by the manipulation of the balloon with an ad rior petrosal sinus IPS is the venous route most often. jacent endothelial lesion 4 In patients with complex CCFs used for access to the affected CS 4 8 12 35 After positioning. it has been observed that associated with this technique the microcatheter in this CS the occlusion of the sinus. is the presence of residual CCFs or even recurrent ones and consequently of the fistula can be performed using. as well as the formation of pseudoaneurysms This as a detachable balloon detachable coils tissue adhesives. pect is associated with an incomplete occlusion of the or Onyx or even a combination of these 4 36 During the. orifice 14 15 procedure a catheter should be positioned in the ICA for. Although not so widely known there is also the pos injection of contrast at this site and subsequent pinpoint. sibility of selective occlusion of the CS preserving the ing of the fistula and the CS as well as to confirm the oc. patency of the ICA using detachable platinum coils clusion of the fistula In cases in which it is impossible to. which are released in a controlled manner into the inte use the ipsilateral IPS other venous routes can be used. rior of the CS 4 11 33 This technique can be enhanced by such as the contralateral IPS the pterygoid plexus veins. the use of adhesive liquids cyanoacrylates or Onyx in the superior ophthalmic vein and even the cortical veins. an attempt to obtain occlusion of the fistula 4 34 Despite through the sphenoparietal sinus 4. having greater chances for success with this association This transvenous route although anatomically favor. it must be remembered that there is a possibility of liq able is not exempt from complications 4 12 Protrusion of. uid agent reflux into the ICA with consequent distal em coils to the ICA can occur especially in large fistulas 12. bolization of the carotid territory and possible ischemic but this complication can be minimized by using a bal. sequelae 4 loon for protection positioned in the ICA during the re. Even though the treatment s objective is to preserve lease of the coils There is the possibility of subarachnoid. the ICA flow 4 12 14 15 this is not always possible In situa hemorrhage especially by lesions in the petrosal sinuses. tions in which it is not possible to achieve selective occlu or cortical veins during the manipulation of the cathe. sion of the fistula either with a balloon or with detach ters 4 12 also due to the hemodynamic alteration caused. able platinum coils there is the option of definitive by the change in the venous drainage pattern which oc. occlusion of the ICA to close the fistula 4 11 performed curs with the use of embolic agents 4 There is a risk of. through the transarterial route as well In this manner transitory paralysis in the oculomotor and abducent nerves. when it is performed with balloons these should be po due to the compressive effect caused in the CS 12. sitioned so as to occlude the fistula orifice interrupting Another possibility of access to the compromised CS. its flow 4 11 When it is performed with platinum coils these is through the orbit by means of direct puncturing of. should be released into the CS but also occluding the the superior ophthalmic vein 4 In CCF cases this vein is. ICA so as to prevent its distal migration and to guaran generally congested facilitating the access to that com. tee the occlusion of the ICA partment for the occlusion of the lesion. 82 Rev Assoc Med Bras 2016 62 1 78 84, Advances in the endovascular treatment of direct carotid cavernous fistulas. The most recent advance in the endovascular treat the loss of self regulation with an increase in the local. ment of direct CCFs is the utilization of covered stents flow associated with edema in the adjacent structures 11. which provide the occlusion of the fistula and preserva Numerous accounts have associated the theory of reper. tion of the ICA flow 4 11 14 15 37 This transarterial technique fusion with the onset of intracranial hemorrhages follow. not only preserves the ICA but also remodels it and aims ing diverse revascularization techniques including carot. to simplify the endovascular procedure reducing both id endarterectomies and bypass There are other factors. procedure time and the costs involved in the treatment involved in the genesis of this phenomenon such as the. of CCFs 14 15 An expandable polytetrafluoroethylene possible release of free radicals with endothelial lesion. PTFE teflon prosthesis is used making it possible to or local sympathetic response 11. obtain a higher rate of complete fistula occlusion as well. as to reduce the incidence of recurrences and the form Conclusion. ing of pseudoaneurysms with the objective of complete Direct CCF constitutes a rare disease occurring general. ly covering the fistula orifice 14 15 37 There are also reports ly after a closed TBI Its treatment involves the utiliza. on the successful use of flow diverter stents in the treat tion of diverse endovascular techniques usually success. ment of the traumatic CCF 38 ful in the outcome The use of a detachable balloon with. When comparing traditional embolization with coils fistula occlusion and ICA flow preservation still repre. techniques Wang et al 14 pointed out some advantages sents the most widely accepted treatment for this condi. in the utilization of the covered stent over the latter the tion However the use of covered stents arose as a viable. positioning of the stent is a simple and rapid procedure alternative which makes the treatment of the great ma. it does not have the risk of herniation or coil migration jority of the cases of direct CCF possible especially in. it promotes the disappearance of the mass effect and lo young patients who have favorable vascular anatomies. cal compression and it is not accompanied by the forma Nevertheless new studies and a longer follow up of these. tion of pseudoaneurysms Also according to the same au patients are necessary in order to come to definitive con. thors the use of stents in the management of direct CCFs clusions. instead of using coils or balloons provides a substantial. increase in the fistula occlusion rate and anatomical cure Resumo. eliminating the possibilities of recanalization and reduc. ing the costs of eventual retreatment for recurrent lesions Avan os no tratamento endovascular de f stulas caroti. For Yin et al 39 in a non randomized prospective study docavernosas diretas. published in 2012 the angiographic and clinical results. obtained with the utilization of covered stents are supe As f stulas carotidocavernosas FCC s o comunica es. rior to those obtained with the use of detachable balloons anormais entre a art ria car tida e o seio cavernoso Elas. However there are some disadvantages in using these s o consideradas diretas quando h uma comunica o. stents to treat CCFs 4 11 14 15 There is a risk of late stent direta entre a art ria car tida interna e o seio cavernoso. thrombosis but this can be minimized by instituting the Nesses casos s o geralmente traum ticas As FCC dire. correct anticoagulant antiplatelet therapy 4 11 14 15 37 The tas s o les es de alto fluxo podendo estar relacionadas a. disadvantage is that this therapy cannot be used in pa sangramento intracraniano perda visual exposi o cor. tients in the acute phase of the trauma Difficulty in nav neana ou at mesmo a epistaxe fatal Seu tratamento. igation and the release of stents into small caliber and sempre indicado O tratamento ideal da FCC direta a. generally tortuous vessels is the major limitation to this exclus o da f stula da circula o com preserva o do flu. technique but which has been increasingly overcome with xo carot deo Isso pode ser obtido por meio de t cnicas. the use of new materials that were specially developed for endovasculares diversas O objetivo do presente artigo. intracranial vessels 11 realizar uma revis o sobre as FCC diretas com especial. Cho et al 11 report the occurrence of cerebral hemor enfoque nas op es de tratamento endovascular dispo. rhage following the utilization of a covered stent This n veis na atualidade. aspect can stem from the reperfusion mechanism The. theory of reperfusion was described by Spetzler as a pos Palavras chave traumatismo craniocerebral les es das. sible cause of intracranial hemorrhage following the re art rias car tidas f stula carotidocavernosa procedimen. section of cerebral arteriovenous malformations due to tos endovasculares emboliza o terap utica. Rev Assoc Med Bras 2016 62 1 78 84 83,Aguiar GB et al.
References 21 Do an S Salman MC Deren O Geyik S Carotid cavernous fistula in term. pregnancy due to spontaneous rupture of carotid cavernous aneurysm. Obstet Gynaecol Res 2012 38 2 427 30, 1 Grumann AJ Boivin Faure L Chapot R Adenis JP Robert PY Ophthalmologic 22 Kaplan JB Bodhit AN Falgiani ML Communicating carotid cavernous. outcome of direct and indirect carotid cavernous fistulas Int Ophthalmol sinus fistula following minor head trauma Intl J Emerg Med 2012 5 10. 2012 32 2 153 9 23 Asano T Houkin K Moriwaki T Niiya Y Mabuchi S Case of direct carotid. 2 Ellis JA Goldstein H Connolly ES Jr Meyers PM Carotid cavernous fistulas cavernous fistula presenting with subarachnoid hemorrhage No Shinkei. Neurosurg Focus 2012 32 5 E9 Geka 2012 40 3 235 9, 3 Kim JW Kim SJ Kim MR Traumatic carotid cavernous sinus fistula 24 Kocer N Kizilkilie O Albayram S Adaletli I Kantarci F Islak C Treatment. accompanying abducens nerve VI palsy in blowout fractures missed of iatrogenic internal carotid artery laceration and carotid cavernous fistula. diagnosis of white eyed shunt Int J Oral Maxillofac Surg 2013 pii S0901 with endovascular stent graft placement AJNR Am J Neuroradiol 2002. 5027 13 00026 X 23 3 442 6, 4 Kanamalla US Jungreis CA Kochan JP Direct carotid cavernous fistula In 25 Halbach VV Hieshima GB Higashida RT Reicher M Carotidcavernous. Hurst RW Rosenwasser RH eds Interventional neuroradiology 1 ed New fistulae indications for urgent therapy AJR Am J Roentgenol 1987. York Informa Healthcare USA 2008 p 231 8 149 3 587 93. 5 Ducruet AF Albuquerque FC Crowley RW McDougall CG The evolution 26 Sanders MD Hoyt WF Hypoxic ocular sequelae of carotid cavernous fistulae. of endovascular treatment of carotid cavernous fistulas a single center Study of the causes of visual failure before and after neurosurgical treatment. experience World Neurosurg 2013 pii S1878 8750 13 00298 2 in a series of 25 cases Br J Ophthalmol 1969 53 82 97. 6 Malan J Lefeuvre D Mngomezulu V Taylor A Angioarchitecture and 27 Lewis A Tomsick TA Tew JJ Management of 100 consecutive direct carotid. treatment modalities in posttraumatic carotid cavernous fistulae Interv cavernous fistulas results of treatment with detachable balloons. Neuroradiol 2012 18 2 178 86 Neurosurgery 1995 36 239 44. 7 Aissa A Arous A Alouini R Taktak J Allani M Ballistic trauma resulting 28 Gonzalez LF Chalouhi N Tjoumakaris S Jabbour P Dumont AS. in carotid cavernous fistula J Fr Ophtalmol 2012 35 9 722 Rosenwasser RH Treatment of carotid cavernous fistulas using intraarterial. 8 Pang PF Jiang ZB Zhou B Li ZR Huang MS Zhu KS et al Diagnosis and balloon assistance case series and technical note Neurosurg Focus 2012. treatment of carotid cavernous fistula analysis of 28 patients Zhonghua 32 5 E14. Yi Xue Za Zhi 2012 92 21 1458 62 29 Halbach VV Higashida RT Barnwell SL Dowd CF Hieshima GB. 9 Gemmete JJ Ansari SA Gandhi DM Endovascular techniques for treatment Transarterial platinum coil embolization of carotid cavernous fistula AJNR. of carotid cavernous fistula J Neuroophthalmol 2009 29 1 62 71 Am J Neuroradiol 1991 12 3 429 33. 10 Uehara T Tabuchi M Kawaguchi T Mori E Spontaneous dural ca rotid 30 Halbach VV Higashida RT Hieshima GB Hardin CW Yang PJ Transvenous. cavernous sinus fistula presenting isolated ophthalmoplegia evaluation embolization of direct carotid cavernous fistulas AJNR Am J Neuroradiol. with MR angiography Neurology 1998 50 814 6 1988 9 4 741 7. 11 Cho KC Seo DH Choe IS Park SC Cerebral hemorrhage after endovascular 31 Moron FE Klucznik RP Mawad ME Strother CM Endovascular treatment. treatment of bilateral traumatic carotid cavernous fistulae with covered of high flow carotid cavernous fistulas by stentassisted coil placement AJNR. stents J Korean Neurosurg Soc 2011 50 126 9 Am J Neuroradiol 2005 26 6 1399 404. 12 Mercado GB Irie K Negoro M Moriya S Tanaka T Ohmura M et al 32 Horton JA Jungreis CA Stratemeier PH Sharp vascular calcifications and. Transvenous embolization in spontaneous direct carotid cavernous fistula acute balloon rupture during embolization AJNR Am J Neuroradiol 1991. in childhood Asian J Neurosurg 2011 6 1 45 8 12 1070 3. 13 Barrow DL Spector RH Braun IF Classification and treatment of spontaneous 33 Luo CB Teng MM Chang FC Lin CJ Guo WY Chang CY Transarterial. carotid cavernous sinus fistulas J Neurosurg 1985 62 248 56 detachable coil embolization of direct carotid cavernous fistula immediate. 14 Wang YL Ma J Ding PX Li YD Han XW Wu G Treatment of post traumatic and long term outcomes J Chin Med Assoc 2013 76 1 31 6. carotid cavernous fistulas with the Willis covered stent A preliminary 34 Yu Y Huang Q Xu Y Hong B Zhao W Deng B et al Use of onyx for. prospective study Interv Neuroradiol 2012 18 2 172 7 transarterial balloon assisted embolization of traumatic carotid cavernous. 15 Wang YL Ma J Li YD Ding PX Han XW Wu G Application of the Willis fistulas a report of 23 cases AJNR Am J Neuroradiol 2012 33 7 1305 9. covered stent for the management of posttraumatic carotid cavernous 35 Bing F Albrieux M Vinh Moreau Gaudry V Vasdev A Cavernous sinus. fistulas an initial clinical study Neurol India 2012 60 2 180 4 fistula treated through the transvenous approach report of four cases J. 16 Newton TH Hoyt WF Dural arteriovenous shunts in the region of the Neuroradiol 2009 157 1 5. cavernous sinus Neuroradiology 1970 1 71 81 36 Zenteno M Santos Franco J Rodr guez Parra V Balderrama J Aburto. 17 Debrun GM Vinuela F Fox AJ Davis KR Ahn HS Indications for treatment Murrieta Y Vega Montesinos S et al Management of direct carotid cavernous. and classification of 132 carotid cavernous fistulas Neurosurgery 1988 sinus fistulas with the use of ethylene vinyl alcohol Onyx only preliminary. 22 2 285 9 results J Neurosurg 2010 112 3 595 02, 18 Kwon HJ Jin SC Spontaneous healing of iatrogenic direct carotid cavernous 37 Kalyanpur TM Narsinghpura K Yadav M Mehta P Paul K Cherian M. fistula Interv Neuroradiol 2012 18 2 187 90 Covered coronary stent grafts as a treatment option for carotid cavernous. 19 Conti MLM Aguiar GB Veiga JCE Santos ARL Lazarini PR Jory M et al fistulas our initial experience Neurol India 2011 59 6 895 8. Endovascular treatment of iatrogenic pseudoaneurysm and delayed carotid 38 Nadarajah M Power M Barry B Wenderoth J Treatment of a traumatic. cavernous fistula following transsphenoidal surgery Rev Chil Neurocirug a carotid cavernous fistula by the sole use of a flow diverting stent J Neurointerv. 2012 38 2 147 50 Surg 2012 4 3 e1, 20 Wang Q Chen G Endovascular treatment of bilateral multiple carotid 39 Yin B Sheng HS Wei RL Lin J Zhou H Zhang N Comparison of covered.
cavernous fistulas in a patient with Ehlers Danlos syndrome J Neurol Surg stents with detachable balloons for treatment of posttraumatic carotid. A Cent Eur Neurosurg 2013 74 Suppl 1 e41 4 cavernous fistulas J Clin Neurosci 2013 20 3 367 2.

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