Keywords
carotid-cavernous fistula - Brazilian unified health system - health care
Palavras-chave
fístula carotídeo-cavernosa - sistema único de saúde - assistência à saúde
Introduction
Carotid-cavernous fistula (CCF) is an abnormal communication between the carotid system
and the cavernous sinus.[1] It is classified according to the etiology as traumatic or spontaneous; according
to hemodynamic characteristics, it is classified as high- or low-flow; and depending
on the angioarchitecture, it is classified as direct or indirect.[2] In most cases, spontaneous fistulas occur by rupture of intracavernous aneurysms
of the internal carotid artery. Traumatic fistulas occur in ∼ 0.2% of cranioencephalic
traumas, and 75% of all CCFs are caused by penetrating traumas or automobile accidents.[3]
[4]
The signs and symptoms often associated with CCFs vary in installation speed and severity.[5]
[6] They are: pulsatile exophthalmos, pulsatile proptosis, Dandy triad, which consists
of blowing and venular dilation with chemosis, diplopia, and dysfunctions of cranial
nerve pairs III and V; and, in 85% of the cases, dysfunction of cranial nerve pair
IV.[7]
For the initial imaging diagnosis when there is suspicion of CCF, computed tomography
(CT), magnetic resonance imaging (MRI), angiography by CT, angiography by MRI, or
Doppler are requested.[8]
[9] However, cerebral angiography is presented as a gold standard for the diagnosis,
classification and definitive planning of the endovascular intervention due to the
identification of the type, location and size of the connection, as well as the analysis
of the arteriovenous environment and the presence of coexistent deviations, mainly
ischemic repercussions on the cortex. The differential diagnosis encompasses a vast
field of pathologies, including intraorbital lesions such as osteoma, hemangioma,
fibrous dysplasia, frontal sinus mucocele and ocular neoplasms.[10]
The management of the patient with CCF depends on the risks, and can be performed
conservatively, consisting of drug treatment and manual compression therapy, surgical
treatment, stereotactic radiosurgery, and transarterial or transvenous endovascular
repair.[11] The surgical approaches are limited because of the associated morbidity of cranial
nerve deficits and residual fistulae communications, but are indicated when the proximal
arterial access is compromised, preventing endovascular repair, or when failures occur
by this method.[12] The approaches may be: ligature of the common carotid artery, surgical segmental
isolation of the fistula, and surgical transvenous tamponade. Currently, endovascular
therapy is the procedure of choice for CCFs.[13] Some authors advocate treatment at an early stage, especially with the emergence
of intracranial hemorrhage, epistaxis, increased intraocular pressure, reduction of
visual acuity or progressive proptosis. Carotid-cavernous fistulas may evolve to complications
such as amaurosis, intracerebral hemorrhage, hypertension, cranial nerve palsy, and
subarachnoid hemorrhage.[14]
[15]
Objective
The goal of the present study is to identify epidemiological data regarding the number
of annual procedures, hospital expenses, length of stay and number of deaths of patients
admitted by the Brazilian Unified Health System (SUS, in Portuguese) in the period
from 2007 to 2017 using the surgical code of surgical treatment for CCF.
Methods
This is an ecological study, whose data were obtained by consulting the database provided
by the Department of Computer Sciences of the SUS (Datasus) (http://www.datasus.gov.br), which was accessed from October to December 2017. The study sample consisted of
all cases of patients undergoing surgical treatment for CCF (code 0403070090) from
January 2007 to October 2017. New tables were made based on the data obtained through
the Datasus using the Microsoft Word (Microsoft Corporation, Redmond, WA, US) software.
Since a public domain bank was used to obtain the data, submission of the project
to the Research Ethics Committee was not necessary.
Results
[Table 1] presents the data referring to the surgical treatment of CCF from January 2007 to
October 2017. Out of 85 surgeries, 16 occurred in 2008, the year that had the highest
number of cases, representing 18.82% of the total. Comparing the years 2007 and 2017,
a decrease of 10 procedures was observed.
Table 1
Total distribution of the number of surgeries for the treatment of carotid-cavernous
fistula from 2007 to 2017 in the Unified Health System
|
Processed year
|
Total AHs
|
%
|
|
2007
|
14
|
16.47
|
|
2008
|
16
|
18.82
|
|
2009
|
6
|
7.06
|
|
2010
|
9
|
10.59
|
|
2011
|
4
|
4.71
|
|
2012
|
10
|
11.76
|
|
2013
|
2
|
2.35
|
|
2014
|
11
|
12.94
|
|
2015
|
3
|
3.53
|
|
2016
|
6
|
7.06
|
|
2017
|
4
|
4.71
|
|
Total
|
85
|
100
|
Abbreviation: AHs, authorizations for hospitalization.
Note: Source: Ministério da Saúde - Sistema de Informações Hospitalares do Sistema
Único de Saúde (SIH/SUS).
In a comparative analysis between the number of procedures in this same period and
the Brazilian population, it was possible to notice that, even with the population
increase, the annual incidence of patients undergoing this surgical treatment remained
low: 1 case for each 13,135,714 in 2007, and 1 case for each 51,925,000 in 2017, as
represented in [Table 2].
Table 2
Annual Incidence of patients who underwent surgical treatment for carotid-cavernous
fistula from 2007 to 2017 in the Unified Health System
|
Processed year
|
Total AHs
|
Brazilian population (millions)
|
Incidence
|
|
2007
|
14
|
183.9
|
1: 13,135,714
|
|
2008
|
16
|
189.6
|
1: 11,850,000
|
|
2009
|
6
|
190.7
|
1: 31,783,333
|
|
2010
|
9
|
191.4
|
1: 21,266,666
|
|
2011
|
4
|
192.3
|
1: 48,075,000
|
|
2012
|
10
|
193.9
|
1: 19,390,000
|
|
2013
|
2
|
201.1
|
1: 19,390,000
|
|
2014
|
11
|
202.7
|
1: 18,427,272
|
|
2015
|
3
|
204.4
|
1: 68,133,333
|
|
2016
|
6
|
206.0
|
1: 34,333,333
|
|
2017
|
4
|
207.7
|
1: 51,925,000
|
Abbreviation: AHs, authorizations for hospitalization.
Note: Source: Ministério da Saúde - Sistema de Informações Hospitalares do Sistema
Único de Saúde (SIH/SUS).
Regarding the analysis by region, quantitatively, most surgeries occurred in the Southeastern
region of Brazil. There were 33 procedures, representing 44.71% of the total. As observed
in [Table 3], the Northern region presented the smallest number of surgeries in the period, with
1 procedure, totaling 1.18%.
Table 3
Distribution by region of the number of surgeries for the treatment of carotid-cavernous
fistula from 2007 to 2017 in the Unified Health System
|
Region
|
Number
|
%
|
|
Northern
|
1
|
1.18
|
|
Northeastern
|
16
|
18.82
|
|
Southern
|
16
|
18.82
|
|
Southeastern
|
38
|
44.71
|
|
Midwestern
|
14
|
16.47
|
|
Total
|
85
|
100
|
Note: Source: Ministério da Saúde - Sistema de Informações Hospitalares do Sistema
Único de Saúde (SIH/SUS).
As evidenced in [Table 4], the mean value of the procedure in 2007 was R$3,078.32, and R$2,463.61 in 2017,
representing a decrease of 19.9%. In the same period, the value of hospital and professional
services suffered a reduction in expenses of 25.43% and 58.77% respectively.
Table 4
Distribution of costs in reais (R$) resulting from surgeries for the treatment of carotid-cavernous fistulas from
2007 to 2017 in the Unified Health System
|
Processed year
|
Total value (R$)
|
Mean value (R$)
|
Value of hospital services (R$)
|
Value of professional services (R$)
|
|
2007
|
43,096.48
|
3,078.32
|
23,116.00
|
6,760.84
|
|
2008
|
47,783.37
|
2,986.46
|
37,318.15
|
10,465.22
|
|
2009
|
21,628.94
|
3,604.82
|
17,097.56
|
4,531.38
|
|
2010
|
21,768.00
|
2,418.67
|
15,273.93
|
6,494.07
|
|
2011
|
12,587.41
|
3,146.85
|
8,880.99
|
3,706.42
|
|
2012
|
38,547.97
|
3,854.80
|
27,847.95
|
10,700.02
|
|
2013
|
6,189.88
|
3,094.94
|
4,222.48
|
1,967.40
|
|
2014
|
33,170.38
|
3,015.49
|
22,707.86
|
10,462.52
|
|
2015
|
7,641.86
|
2,547.29
|
4,811.61
|
2,830.25
|
|
2016
|
28,954.33
|
4,825.72
|
22,022.78
|
6,931.55
|
|
2017
|
9,854.46
|
2,463.61
|
5,880.63
|
3,973.83
|
Note: Source: Ministério da Saúde - Sistema de Informações Hospitalares do Sistema
Único de Saúde (SIH/SUS).
In turn, [Table 5] highlights the data regarding the average length of stay in the hospital, as well
as the number of deaths. The year with the highest average length of stay was 2014,
and there was a variation of 9.8 days between 2007 and 2017. In relation to the number
of deaths, they were only reported in 2008, 2012 and 2016.
Table 5
Average distribution of days of hospital stay and number of deaths related to surgeries
for the treatment of carotid-cavernous fistula from 2007 to 2017 in the Unified Health
System
|
Processed year
|
Mean stay (days)
|
Deaths
|
|
2007
|
14.3
|
–
|
|
2008
|
13.6
|
1
|
|
2009
|
11.7
|
–
|
|
2010
|
5.2
|
–
|
|
2011
|
8.3
|
–
|
|
2012
|
10.4
|
1
|
|
2013
|
7.0
|
–
|
|
2014
|
18.3
|
–
|
|
2015
|
18.0
|
–
|
|
2016
|
12.0
|
1
|
|
2017
|
4.5
|
–
|
Note: Source: Ministério da Saúde - Sistema de Informações Hospitalares do Sistema
Único de Saúde (SIH/SUS).
Discussion
In total, 85 surgical procedures were performed for the treatment of CCF from January
2007 to October 2017 through the SUS, and there was a 71.42% reduction in the number
of procedures performed in this period. The endovascular emergency treatment of CCF
is reserved for some specific situations, such as in the presence of pseudoaneurysms
and increased intracranial pressure. The neuroendovascular treatment is reserved for
cases in which the conservative management is ineffective, or before ocular surgical
procedures.[16]
[17] The endovascular (arterial or venous) approach is the current procedure of choice.
The annual incidence of patients undergoing this surgical treatment during the observed
period remained low: 1 case for each 1.3135.714 in 2007, and 1 case for each 51,925,000
in 2017. Although it is not a common pathology in the clinical practice, CCF is a
diagnostic hypothesis that should be mandatorily proposed when the clinical picture
suggestive of it, since it can develop with important complications, such as intracranial
hypertension and cerebral hemorrhage.[18]
[19]
In a quantitative analysis according to the Brazilian geographic regions, most surgeries
occurred in the Southeastern region, with a total of 44.71%. The Northern region presented
the smallest number of surgeries, with a total of 1.18%. The population density, the
type of work activity, the patient's access to health services, and the ability of
the health professional to recognize the pathology are some of the factors responsible
for the differences observed among the Brazilian regions, which have socioeconomic
characteristics that distinguish the reality of health care.[20]
Comparatively, between 2007 and 2017, there was a reduction in expenditure in SUS
services. There was a decrease of 19.9% in the mean value, and a reduction in expenses
with hospital services and professionals of 25.43% and 58.77% respectively. The surgical
correction of arteriovenous fistulas frequently required large procedures, such as
occipital or temporal craniotomy in cases of involvement of the carotid and vertebral
arteries. However, with the recent development of catheters and balloons for the treatment
of CCFs, the surgeries had their size reduced. Large surgeries are costly for health
services, and there is a high probability of fluid and blood loss.[21] With the expansion of the use of new technologies for CCF treatment, the length
of hospitalization was minimized, decreasing the treatment costs when compared with
open interventions as well as the resulting complications, which also explains the
reduction in the number of days in the average length of stay.
Regarding the number of deaths, which was null in most years, the data evidenced that
the additional information arising from the evolution and solvability of neuroimaging
techniques increase the accuracy and anticipation of the topographic diagnosis and
facilitate the therapeutic access, resulting in greater success in the treatment approach.[22]
Conclusion
Despite the low annual incidence of surgical treatment of CCFs performed by the SUS
in Brazil in the period from 2007 to 2017, the data obtained on the mean length of
stay and expenses regarding hospital services evidenced the need for a health planning
suitable for the Brazilian regions that have the poorest health care indicators regarding
this issue, since early diagnosis and neurosurgical intervention in a timely manner
promote the reduction of morbidity and mortality.
