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Carotid-Cavernous Fistula Complicating Thromboendarterectomy for an Occluded Internal Carotid Artery

Thromboendarterectomy for revascularization of the totally occluded in ternal carotid artery is becoming more prevalent. New studies have attested to its efficacy in properly selected patients; however, the procedure has a potential for significant morbidity if improperly executed. One particularly rare complication of this opertion is the creation of an internal carotid artery to cavernous sinus fistula. Atherosclerotic changes in the arterial walls and the natural convolutions of the intracranial carotid arteries predispose to this iatrogenic rupture, especially with the rather stiff Fogarty catheter used to remove thrombi. In a recent case of iatrogenic carotid-cavernous fistula following an internal carotid thromboendarterectomy, the fistula proved difficult to close. Initial ligation of the common carotid appeared to resolve the defect, but collateral circulation had been established so that the fistula was fed by retrograde flow via the vertebral and external carotid arteries. A second ligation proce dure on both the internal and external carotid branches was necessary to successfully close the fistula. This case report exemplifies not only a complication of thromboendarter ectomy in the totally occluded internal carotid artery but also the types of problems which can arise when dealing with an intracranial fistula.