Avoiding intraarterial balloon detachment in the treatment of posttraumatic carotid-cavernous fistulae with detachable balloons.

Since the introduction by Serbinenko [1] of the concept of using detachable balloons to occlude arteriovenous fistulae and the development of the latex detachable balloon system by Debrun et al. [2] , detachable balloons have become the treatment of choice in the management of posttraumatic carotid-cavernous fistulae [3, 4]. Using this method, the fistula can be occluded with preservation of flow through the internal carotid artery (ICA) in most patients [3-5]. Complications of the technique are infrequent, particularly when routine sterile precautions and systemic heparinization are used [3, 6, 7]. Intraarterial detachment or migration of a balloon may rarely occur [8, 9]. The potential for serious consequences is obvious, particularly if the balloon occludes not only the ICA but also the collateral pathways via the posterior communicating and anterior cerebral arteries [8] . Although the aim of the embolization is to occlude the fistula while preserving internal carotid flow, angiographic demonstration of fistula occlusion with a patent carotid artery does not necessarily mean that the balloon can be detached safely. Two patients in whom the potential for intraarterial balloon embolization was recognized are described to illustrate this principle. Analysis of the balloon position, the size of the fistula, and the size of the adjacent cavernous sinus can be used to prevent intraarterial balloon detachment. Similar cases and the principles to be learned from them have not been reported previously.