Balloon-Assisted Roadmap Technique to Enable Flow Diversion of a High-Flow Direct Carotid-Cavernous Fistula

Background: The use of flow diverters as a first-line treatment for direct carotid cavernous fistula (CCF) is a relatively new approach in the neurointerventional field which allows obliteration of the fistula with less mass effect from coils in the cavernous sinus. Safe and successful deployment of a flow diverter requires adequate imaging of the parent vessel, which may be challenging in the setting of high-flow CCF without antegrade flow. Objective: To facilitate adequate parent vessel imaging in the setting of high-flow CCF to enable the safe development of a flow diverter device. Methods: Here we present the case of a patient with delayed presentation of post-traumatic direct CCF after a motor vehicle accident, with no antegrade flow past the fistulous connection. We used temporary balloon occlusion of the fistulous connection to enable road-map imaging of the parent vessel and flow-diverter placement. “Drag and drop” device opening in the middle cerebral artery facilitated better deployment of the flow-diverter against retrograde cavernous flow through the fistula. Results: Temporary balloon occlusion of the fistulous connection was used to acquire a roadmap to facilitate safe deployment of a flow diverter and subsequent treatment of the CCF with transvenous coil embolization, with complete resolution of symptoms. Conclusion: Balloon-assisted roadmap use is a novel means of visualizing the parent vessel in direct CCF to facilitate safe flow diverter deployment.