A traumatic carotid-jugular fistula with or without apseudoaneurysm is rare, and generally occurs after apenetrating trauma rather than after blunt trauma. A by-pass graft and sacrifice of the involved carotid arterywas originally the treatment of choice until the adventof endovascular method. Currently, a traumatic carotid-jugular fistula can be treated using endovascular meth-ods such as ballooning, coiling, stent-graft deploymentand stent assisted coil embolization. The authors presenttwo cases of traumatic carotid - jugular fistula that weretreated using endovascular methods.

Case Report

Case 1

A 6-year-old boy was admitted to our hospital with the

chief complain of progressive headache, pulsating mass,and a hard thrill immediately below the right mandibleangle for a 3 month duration. He had suffered a deeppenetrating neck injury 9 months earlier. 3D CTA andDSA revealed an arteriovenous fistula between the rightfacial artery to the right retromandibular vein, whichdrained to the right internal jugular vein (Figs. 1A, B).Endovascular treatment was planned because thismethod is less invasive than surgery. Among the en-dovascular methods including coil embolization and bal-loon occlusion, common carotid-jugular fistula coil em-bolization was chosen. The fistula could not be locatedprecisely using external carotid angiography due to thehigh flow arteriovenous shunt. Therefore, the plan wasto occlude the fistula through the venous route using aGugelielmi detachable coil (GDC; Boston Scientific,Natick, MA). Microcatheters (Prowler 14; CordisNeurovascular systems, Miami, FL) were inserted intothe dilated retromandibular vein through the internaland external jugular vein. Two-dimensional, 20 mm×30 cm sized, GDC was used to make the coil frame.Subsequently, two GDCs (16 mm×30 cm, 12 mm×30cm) were inserted until a dense coil packing was made.

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Endovascular Treatment of Traumatic Carotid- JugularFistula: Report of Two Cases1

Han Won Jang, M.D., Woo Mok Byun, M.D., Jae Woon Kim, M.D., Chul Hoon Chang, M.D.2

1Department of Diagnostic Radiology, Yeungnam University College ofMedicine

2Department of Neurosurgery, Yeungnam University College of MedicineReceived June 20, 2006 ; Accepted November 14, 2006Address reprint requests to : Woo Mok Byun, M.D., Department ofDiagnostic Radiology, College of Medicine Yeungnam UniversityHospital, 317-1, Daemyungdong, Namgu, Daegu 705-717, South KoreaTel. 82-53-620-3046 Fax. 82-53-653-5484E-mail: wmbyun@med.yu.ac.kr

We report 2 patients with a traumatic carotid- jugular fistula. The first patient suf-fered a deep neck penetrating injury. The external carotid-jugular fistula was demon-strated by 3-dimension CT angiography (3D CTA) and digital subtraction angiography(DSA). The patient was treated with coil embolization. The second patient suffered agun shot injury to the neck. 3D CTA and DSA revealed a common carotid-jugular fistu-la and a pseudoaneurysm. The common carotid-jugular fistula was treated with coilembolization in the fistula and the pseudoaneurysm was treated with stent assistedcoil embolization .

Index words : Fistula, arteriovenousNeck, injuriesCarotid arteries, interventional procedures

After the blood flow through the fistula had decreased, atotal of eleven Tornado platinum coils (A Cook GroupCompany, Bloomington, IN) were deployed. The totallength of the inserted coils was 120 cm. After emboliza-tion, a small amount of the blood flow through the arte-riovenous shunt was remained but the right intracere-bral vascular structures were well visualized (Fig. 1C).Embolization was stopped due to the expected sponta-neous regression of the fistula. After 3 months, the rightcarotid angiogram revealed an increased arteriovenousshunt from the right facial artery to the internal jugularvein (Fig. 1D). Therefore, an attempt was made to em-

bolize the arteriovenous fistula through the arterial ap-proach. The microcatheter was inserted into the dilatedfistula through the facial artery and embolized withGDCs (18 mm×30 cm, 20 mm×30 cm) and Tornadoplatinum coils (Total length 54 cm) until the abnormalvenous drainage had disappeared (Fig. 1E). There wasno evidence of a fistula during the 12-month follow up.

Case 2

A 22-year-old man was admitted due to neck swellingfrom a gun shot injury. He had no neurologic deficits.3D CTA and DSA revealed a high flow fistula between

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A B C

D E

Fig. 1. Case 1. A, B. 3D CTA (A) and DSA (B) show a fis-tula between the dilated retromandibularvein (white arrows), which drained to theinternal jugular vein (IJV) and facial artery(black arrows). C. DSA after embolization of the fistula.Early venous drainage (arrow) throughthe arteriovenous fistula (arrow head) stillremained between the facial artery andinternal jugular vein. D. DSA of 3 months follow up. ECA an-giography shows a more aggravated shuntbetween the facial artery and the IJV. E. Complete resolution of the fistula wasachieved by obliterating the facial arterywith additional coil embolization (arrow).

the distal common carotid artery and the internal jugu-lar vein (Figs. 2A, B) and a pseudoaneurysm in the distalcommon carotid artery immediately above the fistulasite (Fig. 2C). The plan was to embolize the fistula andthen perform surgery. Using the venous approach, thefistula was treated successfully with four GDCs (Totallength 115 cm). However, the surgery failed due to se-vere adhesion adjacent to the common carotid artery.Stent assisted coil embolization was then performed in-stead of a graft stent due to the uncertain long-term pa-tency and freedom from a restenosis of the graft stent.

First, a microcatheter was placed in the pseudoa-neurysm and then 8 mm×3 cm sized Easy Wallstent(Boston Scientific/Schneider, Minneapolis, MN) was de-ployed. A total of four GDCs (Total length 35 cm) wereinserted into the pseudoaneurysm through the micro-catheter until dense coil packing had been achieved (Fig.2D). After the procedure, the pseudoaneurysm and fis-tula disappeared and the left internal carotid artery flowwas well preserved until the 12-month follow up.

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A B

Fig. 2. Case 2. A, B. 3D CTA (A) andDSA (B) reveal a fistula (arrows) be-tween the distal common carotidartery and IJV. C. DSA after coil embolization of fistu-la. The fistula was obliterated by coilembolization (arrow), but the pseudoa-neurysm still remained (arrowhead). D. DSA after the stent assisted coil em-bolization shows complete obliterationof the pseudoaneurysm.

C D

Discussion

Penetrating objects such as a bullet or knife passingthrough or near the neurovascular bundles of the neckcan easily damage the blood vessels (1). These injuriescan cause acute hemorrhage, complete major vessel ob-struction and the formation of a traumatic aneurysm orarteriovenous fistula (2). If left untreated, the pseudoa-neurysm can cause compressive symptoms and embolicphenomena, and a carotid-jugular fistula usually en-larges and causes severe high output heart failure andobstructive symptoms (3). Conventional angiography istraditionally used to diagnose the injured vessel.However, a rapid and noninvasive diagnosis of majorvessel injuries can be made using helical CT angiogra-phy with a high sensitivity and specificity (4). The aimof a carotid-jugular fistula including a pseudoaneurysmis to occlude the fistula and pseudoaneurysm whilst pre-serving the parent artery. Traditionally, surgery by anexcision of the fistula with vascular reconstruction wasthe treatment of choice for carotid-jugular fistula andpseudoaneurysm. Recently, the development of new de-vices and techniques has enabled the use of endovascu-lar treatments for surgery. These endovascular methodsinclude balloon occlusion (5) and coil embolization for afistula (6), stent assisted coil embolization for a pseudoa-neurysm and stent-graft insertion either for a fistula andpseudoaneurysm (3, 7-10). These methods have theirown advantages and disadvantages. Surgery is a definitemethod for achieving proximal vascular control of thecommon carotid artery by isolating the parent arteryfrom the fistula or pseudoaneurysm. However, the pro-cedure carries potential risks, such as cranial nerve in-jury and sternostomy (10). Stent assisted coil emboliza-tion for the treatment of a pseudoaneurysm allows agood packing density compared with simple coiling be-cause the stent prevents the migration or bulging of coilsinto the parent vessel lumen. On the other hand, there ispotential risk of recanalization of the sac due to incom-plete exclusion by the vessel lumen (10). In the case of acarotid-jugular fistula combined with a pseudoa-neurysm, a stent-graft is a promising technology forobliterating a fistula and pseudoaneurysm, and preserv-ing the parent artery with relatively safely (8). However,the long term patency and freedom from a restenosis of

the stent-graft are still unknown. Hence, close observa-tion is needed (9). In the case of an external carotid-jugu-lar fistula, the treatment options are limited to surgery,simple coiling and ballooning. In our case, the externalcarotid-jugular fistula was treated successfully using de-tachable coils and multiple fibered coils. In our case of acommon carotid-jugular fistula combined with apseudoaneurysm, the common-carotid jugular fistulawas obliterated using detachable coils and then thepseudoaneurysm was excluded by stent assisted coilembolization. Both patients suffered no recurrence dur-ing a 12 months follow up.

In conclusion, coil embolization or stent assisted coilembolization can be considered the first line treatmentfor a traumatic carotid -jugular fistula with or without apseudoaneurysm.

References

1. Amirjamshidi A, Abbassioun K, Rahmat H. Traumatic aneurysmand arteriovenous fistulas of the extracranial vessels in war in-juries. Surg Neurol 2000;53:136-145

2. Tew JM Jr, Johnson JK, Tomsick TA. Traumatic lesions of thecarotid artery. In Smith RR, ed. Stroke and the extracranial vessels.New York, NY: Raben Press; 1984;307-319

3. Self ML, Mangram A, Jefferson H, Slonim S, Dunn E, KollmeyerK. Percutaneous stent-graft repair of a traumatic common carotid-internal jugular fistula and pseudoaneurysm in a patient with cer-vical spine fractures. J Trauma 2004;57:1331-1334

4. Munera F, Soto JA, Palacio D, Velez SM, Medina E. Diagnosis ofarterial injuries caused by penetrating trauma to the neck: compar-ison of helical CT angiography and conventional angiography.Radiology 2000;216:356-362

5. Gobin YP, Garcia de la Fuente JA, Herbreteau D, Houdart E,Merland JJ. Endovascular treatment of external carotid-jugular fis-tula in the parotid region. Neurosurgery 1993;33:812-816

6. Jansen O, Dorfler A, Forsting M, Hartmann M, von Kummer R,Tronnier V, et al. Endovascular therapy of arteriovenous fistulawith electrolytically detachable coils. Neuroradiology 1999;41:951-957

7. Ramsay DW, McAuliffe W. Traumatic pseudoaneurysm and highflow arteriorvenous fistula involving internal jugular vein andcommon carotid artery. Treatment with covered stent and em-bolization. Australas Radiol 2003;47:177-180

8. Ahn JY, Chung YS, Lee BH, Choi SW, Kim OJ. Stent-graft place-ment in a traumatic internal carotid-internal jugular fistula andpseudoaneurysm. J Clin Neurosci 2004;11:636-639

9. Wyers MC, Powell RJ. Management of carotid injuries in a hostileneck using endovascular grafts. J Vasc Surg 2004;39:1335-1339

10. Patel JV, Rossbach MM, Cleveland TJ, Gaines PA, Beard JD.Endovascular stent-graft repair of traumatic carotid arterypseudoaneurysm. Clin Radio 2002;57:308-311

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대한영상의학회지 2007;56:109-113

외상성 경동맥-경정맥 누공의 혈관 내 치료: 2 증례 보고1

1영남대학교 의과대학 진단방사선과학교실2영남대학교 의과대학 신경외과학교실

장한원·변우목·김재운·장철훈2

혈관 내 치료를 시행한 외상성 경동맥 - 경정맥 누공환자 두 증례를 보고하고자 한다. 첫 번째 환자는 경부 심

부 관통상을 가졌으며 삼차원 전산화단층혈관조영술과 디지털감산혈관조영술에서 외경동맥 - 목정맥 누공이 보였

고 코일 색전술로 치료하였다. 두 번째 환자는 경부 총상환자로 삼차원 전산화단층혈관조영술과 디지털감산혈관조

영술에서 총경동맥 - 목정맥 누공과 가성동맥류가 동반되었으며 누공은 코일 색전술로 치료하였고 가성동맥류는

스텐트 보조 코일색전술을 시행하였다.