Abstract 1122‐000097: Recurrent Carotid Cavernous Fistula Requiring Complex Repair of Ruptured Cavernous Carotid Aneurysm: A Case Report

Introduction: There are no studies investigating the safety and efficacy of covered stent grafts, particularly the newly developed stents such as the PK Papyrus stent, for endovascular treatment of direct carotid cavernous fistulas (CCFs). Methods: We present a case of a 75‐year‐old female who presented to the hospital with a three‐week history of worsening left eye vision, chemosis, proptosis, and partial third nerve palsy. Patient was found to have left direct Type A CCF secondary to ruptured cavernous segment carotid aneurysm. Results: The CCF was treated with coil embolization and pipeline Shield stent embolization devices with immediate stagnation and improvement of symptoms. Patient had history of an aortic mechanical valve and thus was started on warfarin and ASA. After achieving INR level of 2.5‐3.5, patient started to have recurrent swelling of the left eye associated and decreased visual acuity. Repeated diagnostic cerebral angiogram revealed residual CCF. Onyx liquid embolization and a Surpass Evolve Flow Diverter were attempted to slow the fistulization with no success. Multiple attempts for direct percutaneous superior ophthalmic vein cannulation were also unsuccessful. At this point, two coronary graft‐covered PK Papyrus stents were implanted across the fistula pouch, which resulted in immediate resolution of the CCF with evidence of persistent normal flow within left ophthalmic artery. Patient’s visual acuity and left eye movement improved. Conclusions: This case report highlights the effectiveness and safety of covered stent grafts, particularly more flexible stents such as the PK Papyrus stent, in navigating the carotid vasculature and closing direct CCFs and may be used as a first‐line technique. More large‐scale studies are warranted to investigate the safety and efficacy of using such stent grafts to treat direct CCFs in the setting of antithrombotic agents and anticoagulation.