Abstract 362: Papyrus Stent for Primary and Rescue Therapy in Direct Carotid‐Cavernous Fistula Cases

IntroductionDirect carotid‐cavernous fistulas (CCFs) are high‐flow connections between the internal carotid artery (ICA) and the cavernous sinus. Traditional repair methods, such as transvenous or transarterial embolization with coils, liquid embolic agents, flow diversion, and ICA deconstruction, are well documented.1,2 This case series explores the use of PK Papyrus covered stent in repair of direct CCFs.Materials/MethodsWe selected four patients who presented with direct CCFs due to trauma or dissection reasons at a single comprehensive stroke center between July 2023 and April 2024 and were treated with the PK Papyrus stent (Biotronik, Inc., Lake Oswego, Oregon, USA) as either primary or rescue therapy after transvenous coiling. IRB consent for off‐label use was discussed with each patient.ResultsAges of patients ranged from 25 to 53 years, with median age of 41.5 years [IQR: 32.5‐48 years]. Two patients presented due to penetrating injury, were started on tirofiban drip and aspirin pre‐procedurally, repaired successfully with Papyrus as primary therapy, and transitioned to aspirin and ticagrelor post‐procedure with plans to continue for 6‐12 months. One of these patients had mild extraocular weakness, left V1 numbness, and dilated pupil on follow‐up while the other had no deficits. One patient presented due to blunt head injury, was loaded with ticagrelor and aspirin pre‐procedurally, treated with stent as primary therapy as well, continued on dual therapy for 5 months before transition to sole aspirin therapy, and had angiographic and symptomatic resolution on follow up. Our last patient presented spontaneously with dissection leading to CCF and was treated with Papyrus as rescue therapy after failure with transvenous coiling. She was loaded with aspirin and ticagrelor prior to stent placement, with plans to continue 1‐year post‐procedure, and had angiographic and symptomatic resolution on follow‐up. Average follow‐up time for all patients was 9.5 weeks. All stents placed were 15 mm in length, with outer diameter ranging from 3.5 to 5 mm. No patients were recorded to have adverse periprocedural events, including ischemic or hemorrhagic stroke. Procedural time ranged from 100 to 220 minutes.ConclusionPK Papyrus can successfully be used as primary or rescue therapy for treating diffuse cavernous ICA injury leading to direct CCF, with no adverse patient outcomes, although long‐term follow‐up is needed to ensure the durability of these stents in our pati