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Kaufmann JE, Mayer-Suess L, Seiffge D, Knoflach M, Engelter ST, Traenka C. Management of cervical artery dissection: new evidence and future directions. J Neurol 2025; 272:426. [PMID: 40423824 PMCID: PMC12116624 DOI: 10.1007/s00415-025-13166-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2025] [Revised: 05/06/2025] [Accepted: 05/07/2025] [Indexed: 05/28/2025]
Abstract
Cervical artery dissection (CeAD) is a leading cause of ischemic stroke in young adults. Although its pathogenesis remains incompletely understood, advancements in CeAD patient care have been made in recent years. This review provides an updated overview of the latest evidence on hyperacute and (sub-)acute management of CeAD, highlighting aspects that have received limited attention, including vascular risk factors and mental health. Furthermore, we aim to outline future research directions to enhance patient outcomes and deepen our understanding of the disease.
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Affiliation(s)
- Josefin E Kaufmann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.
- Department of Rehabilitation and Neurology, Department of Geriatric Medicine FELIX PLATTER, University, University of Basel, Basel, Switzerland.
| | - Lukas Mayer-Suess
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - David Seiffge
- Department of Neurology, Inselspital Bern, Bern, Switzerland
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Research Centre On Clinical Stroke Research, VASCage, Innsbruck, Austria
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Rehabilitation and Neurology, Department of Geriatric Medicine FELIX PLATTER, University, University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Rehabilitation and Neurology, Department of Geriatric Medicine FELIX PLATTER, University, University of Basel, Basel, Switzerland
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2
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Fierro AL, Lantis JC. Carotid Aneurysm Disease Review. Ann Vasc Surg 2025; 113:392-399. [PMID: 39362464 DOI: 10.1016/j.avsg.2024.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 08/22/2024] [Accepted: 08/23/2024] [Indexed: 10/05/2024]
Abstract
Carotid artery aneurysms are a rare pathology, accounting for less than 1% of all arterial aneurysms and 0.4 to 4% of all peripheral arterial aneurysms. Owing to their exceedingly rare nature, management guidelines remain far from being standardized; however, aneurysm morphology, etiology, size, location, and patient characteristics are critical factors dictating the most appropriate management approach. As these aneurysms represent a serious and life-threatening pathology, they mandate an expedient diagnosis and an individually tailored management plan and as such, understanding the various etiologies, indications for treatment, and potential risks of deterring intervention are of utmost importance.
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Affiliation(s)
- Allegra L Fierro
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Surgery, Mount Sinai West, New York, NY.
| | - John C Lantis
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Surgery, Mount Sinai West, New York, NY.
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3
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Wahlgren CM, Aylwin C, Davenport RA, Davidovic LB, DuBose JJ, Gaarder C, Heim C, Jongkind V, Jørgensen J, Kakkos SK, McGreevy DT, Ruffino MA, Vega de Ceniga M, Vikatmaa P, Ricco JB, Brohi K, Antoniou GA, Boyle JR, Coscas R, Dias NV, Mees BME, Trimarchi S, Twine CP, Van Herzeele I, Wanhainen A, Blair P, Civil IDS, Engelhardt M, Mitchell EL, Piffaretti G, Wipper S. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. Eur J Vasc Endovasc Surg 2025; 69:179-237. [PMID: 39809666 DOI: 10.1016/j.ejvs.2024.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2024] [Accepted: 12/09/2024] [Indexed: 01/16/2025]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy. METHODS The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence. RESULTS A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients' perspectives are discussed. CONCLUSION The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma.
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Feng Y, Zhu Z, Shao J, Li K, Xie Y, Xie L, Wang Y, Wang L, Dai H, Lai Z, Liu B. Comparative outcomes of surgical and conservative management in carotid artery dissection. Vascular 2024:17085381241289815. [PMID: 39368078 DOI: 10.1177/17085381241289815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2024]
Abstract
OBJECTIVES Carotid artery dissection (CAD) is a significant cause of strokes in young individuals, leading to severe complications and socioeconomic burdens. Despite antithrombotic therapy being the primary management strategy, optimal treatment for patients with recurrent or worsening symptoms remains undefined. This study aims to describe the characteristics and evaluate the outcomes of conservative versus surgical management in CAD patients. METHODS A total of 23 patients presenting with CAD from November 2014 to December 2021 were reviewed retrospectively. Patient demographics, vascular risk factors, symptoms, imaging results, treatment details, and follow-up information were collected and analyzed. Propensity score matching (PSM) was utilized to enhance comparability. RESULTS The mean age of the patients was 46.4 ± 9.4 years, with a median follow-up of 12 (range 3-90) months. Of the 23 patients reviewed, seven underwent endovascular treatment or open surgery due to unresponsiveness to conservative therapy, while 16 received conservative management. All patients showed regression of symptoms. Surgical patients showed a significant improvement with a 100% patency rate during the follow-up. PS matching adjusted for baseline differences, yielding comparable groups for analysis. No significant difference between treatment approaches was observed in stroke recurrence rates, although surgical intervention showed promising outcomes in symptom resolution and stroke prevention. CONCLUSION Both conservative and surgical management of CAD can lead to favorable outcomes. While conservative therapy remains the initial approach and proves effective, surgery appears beneficial and safe in certain cases unresponsive to conservative treatment. Further investigation through larger prospective and randomized trials is necessary to establish its safety and efficacy.
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Affiliation(s)
- Yuyao Feng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhan Zhu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Eight-year Program of Clinical Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiang Shao
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kang Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yiyun Xie
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lizhi Xie
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuru Wang
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Eight-year Program of Clinical Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lin Wang
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- 4+4 Medical Doctor Program, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Huanyu Dai
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Eight-year Program of Clinical Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhichao Lai
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bao Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Amatya B, Chitale AV, Mukherjee D. Neurovascular management of intracranial internal carotid artery dissection post-carotid endarterectomy: A case report of an innovative approach. Brain Circ 2024; 10:366-371. [PMID: 40012594 PMCID: PMC11850933 DOI: 10.4103/bc.bc_59_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 08/19/2024] [Accepted: 09/08/2024] [Indexed: 02/28/2025] Open
Abstract
Carotid endarterectomy (CEA) is an established method of stroke prevention in patients with severe carotid artery stenosis, especially in those with symptomatic disease. Complications of CEA include perioperative stroke, cranial nerve palsy, hemorrhage, and vascular dissection. We present an unusual case of a 66-year-old man who presented for elective right CEA for symptomatic 70% right internal carotid artery (ICA) stenosis due to ulcerated plaque. Following surgery, the patient developed fluctuating neurological deficits consistent with involvement of the right middle cerebral artery territory. Imaging revealed possible mild clamp-induced ICA dissection limited to the ICA in the neck. Despite initial successful anticoagulation management in the neurointensive care unit, the patient returned 2 days later with stroke symptoms, necessitating urgent endovascular intervention. Neurovascular interventions involved aspiration thrombectomy and multiple stenting extending distally into intracranial ICA, which successfully restored cerebral arterial perfusion and normal neurological function. This case highlights the first reported instance of extensive intracranial ICA dissection managed with full-length stenting. This article offers an effective endovascular procedure for preventing a devastating stroke from a complication of a procedure that was performed to prevent it.
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Affiliation(s)
- Bibhas Amatya
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ameet V. Chitale
- Department of Neurosurgery, Inova Fairfax Hospital, Falls Church, VA, USA
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6
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Zhou B, Hua Z, Li C, Jiao Z, Cao H, Xu P, Liu S, Li Z. Classification and management strategy of spontaneous carotid artery dissection. J Vasc Surg 2024:S0741-5214(24)01210-2. [PMID: 38777158 DOI: 10.1016/j.jvs.2024.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/02/2024] [Accepted: 05/12/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Spontaneous carotid artery dissections (sCADs) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 patients with sCAD and proposed a new classification for sCAD with prognostic and therapeutic significance. METHODS This is a retrospective review of prospectively collected data from June 2018 to June 2023 of patients with sCAD treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types: type Ⅰ, intramural hematoma or dissection with <70% luminal narrowing; type Ⅱ, intramural hematoma or dissection with ≥70% luminal narrowing; type Ⅲ, dissecting aneurysm; type ⅣA, extracranial carotid artery occlusion; and type ⅣB, tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCADs. RESULTS A total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 patients with sCAD was 49.5 years, 78% were male, and 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 type Ⅰ (28.4%), 50 type Ⅱ (25.4%), 60 type Ⅲ (30.5%), and 31 type Ⅳ (15.7%) dissections. During a mean hospitalization length of 11.4 ± 47.0 days, there were nine recurrent strokes (4.6%) after medical treatment, two type Ⅲ dissections (1.0%), seven type Ⅳ dissections (3.6%), all ipsilateral, and one death. Overall, there were seven (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent strokes and three (1.5%, all type Ⅲ dissections) recurrent transient ischemic attacks in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (range, 3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment (EVT) or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine type I dissections (51.8%) were completely recanalized after antithrombotic therapy. A total of 19 type II dissections (38%) and 44 type III dissections (73%) received EVT for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight type IVB dissections (33%) received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all P > .05). Favorable outcome was achieved in 168 patients (93.9%). CONCLUSIONS This study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcomes should undergo further research.
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Affiliation(s)
- Baoning Zhou
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhaohui Hua
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | - Zhouyang Jiao
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui Cao
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Xu
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shirui Liu
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Li
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Izutsu N, Nishizawa N, Nakajima S, Kanemura Y, Ozaki T, Asai K, Kidani T, Kobayashi K, Fujimi Y, Fujinaka T. Extracranial internal carotid artery-dissecting aneurysm having a re-entry tear and causing lower cranial nerve palsies treated with flow-diverting stent: A case report. Surg Neurol Int 2024; 15:126. [PMID: 38741991 PMCID: PMC11090541 DOI: 10.25259/sni_57_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/16/2024] [Indexed: 05/16/2024] Open
Abstract
Background Extracranial internal carotid artery (ICA)-dissecting aneurysms (DAs) rarely cause re-entry tears and lower cranial nerve palsies. The therapeutic strategies for these pathologies are not well established. This report presents a case of an extracranial ICA -DA with a re-entry tear that caused lower cranial nerve palsy. Case Description A 60-year-old man presented with left neck pain, hoarseness, and dysphagia. Physical examination and laryngoscopy determined palsies of the left cranial nerves IX, X, and XII. Digital subtraction angiography (DSA) revealed a DA in the left extracranial ICA, and three-dimensional DSA showed entry and re-entry tears in the intimal flap. Flow-diverting stents (FDSs) were placed on the lesion that covered the entry and re-entry tears because the symptoms did not improve after five weeks of conservative treatment. A post-procedural angiogram indicated flow stagnation in the DA. Symptoms improved remarkably immediately after the procedure, and the aneurysm was almost completely occluded six months later. Conclusion Herein, an extracranial ICA -DA with a re-entry tear that caused lower cranial nerve palsy did not improve after five weeks of conservative treatment. FDS placement promptly resolved the aneurysm and symptoms. Thus, FDS placement may be an effective treatment option for extracranial ICA-DAs with re-entry tears or lower cranial nerve palsies.
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Affiliation(s)
- Nobuyuki Izutsu
- Department of Neurosurgery Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
| | - Naoki Nishizawa
- Department of Neurosurgery Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
| | - Shin Nakajima
- Department of Neurosurgery Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
| | - Yonehiro Kanemura
- Department of Neurosurgery Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
- Department of Biomedical Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
| | - Tomohiko Ozaki
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsunori Asai
- Department of Neurosurgery Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
| | - Tomoki Kidani
- Department of Neurosurgery Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
| | - Koji Kobayashi
- Department of Neurosurgery Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
| | - Yosuke Fujimi
- Department of Neurosurgery Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
| | - Toshiyuki Fujinaka
- Department of Neurosurgery Research and Innovation, NHO Osaka National Hospital, Osaka, Japan
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Yaghi S, Engelter S, Del Brutto VJ, Field TS, Jadhav AP, Kicielinski K, Madsen TE, Mistry EA, Salehi Omran S, Pandey A, Raz E. Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association. Stroke 2024; 55:e91-e106. [PMID: 38299330 DOI: 10.1161/str.0000000000000457] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.
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Arzola LH, Mani K, Zuccon G, Ekberg T, Wanhainen A. Viabahn™-assisted sutureless anastomosis (VASA) repair of a complex internal carotid artery aneurysm. J Vasc Surg Cases Innov Tech 2023; 9:101161. [PMID: 37152913 PMCID: PMC10160778 DOI: 10.1016/j.jvscit.2023.101161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/21/2023] [Indexed: 03/22/2023] Open
Abstract
Extracranial carotid artery aneurysms (CAAs) are extremely rare and often require surgical intervention to avoid complications such as local compression symptoms and thrombo-embolization. We present the case of a 63-year-old man with a history of hypertension, meningioma, and an incidental finding of a right saccular internal carotid artery aneurysm at the base of the skull. He underwent open surgical repair; nonetheless, end-to-end anastomosis was not feasible. As bailout, the internal carotid artery was successfully reconstructed with a novel Viabahn-assisted sutureless anastomosis technique (GORE, Viabahn). Postoperative clinical assessment revealed no complications, postoperative computed tomography angiography revealed a patent reconstruction, and the patient was discharged home uneventfully with 1-year clinical and computed tomography angiography follow-up without remarks. Hybrid procedure is a viable option for technically challenging carotid anastomoses near the skull base.
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Affiliation(s)
- Luis H. Arzola
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Gianmarco Zuccon
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Tomas Ekberg
- Department of Otorhinolaryngology-Head and Neck Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Correspondence: Anders Wanhainen, MD, PhD, Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala SE 75185, Sweden
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10
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Oldham B. An unusual case of bilateral internal carotid artery occlusion—A case report. SONOGRAPHY 2022. [DOI: 10.1002/sono.12332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Beryl Oldham
- Medical Imaging The Prince Charles Hospital Brisbane Queensland Australia
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11
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Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J 2021; 6:XXXIX-LXXXVIII. [PMID: 34746432 PMCID: PMC8564160 DOI: 10.1177/23969873211046475] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/26/2021] [Indexed: 11/15/2022] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.
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Affiliation(s)
- Stephanie Debette
- Bordeaux Population Health research
center, INSERM U1219, University of Bordeaux, Bordeaux, France
- Department of Neurology and
Institute for Neurodegenerative Diseases, Bordeaux University
Hospital, France
| | - Mikael Mazighi
- Department of Neurology, Hopital Lariboisière, Paris, France
- Interventional Neuroradiology
Department, Hôpital Fondation Ophtalmologique
Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- FHU NeuroVasc, Paris, France
- Laboratory of Vascular Translational
Science, INSERM U1148, Paris, France
| | - Philippe Bijlenga
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and
Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Masatoshi Koga
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - Anna Bersano
- Fondazione IRCCS Istituto Neurologico
'Carlo Besta', Milano
| | - Janika Kõrv
- Department of Neurology and
Neurosurgery, University of Tartu, Tartu, Estonia
- Department of Neurology, Tartu University
Hospital, Tartu, Estonia
| | - Julien Haemmerli
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | | | - Piotr Tekiela
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Kaori Miwa
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - David J Seiffge
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Sabrina Schilling
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Avtar Lal
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Marcel Arnold
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Hugh S Markus
- Department of Clinical
Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan T Engelter
- Department of Neurology and
Stroke Center, University Hospital and University of
Basel, Basel, Switzerland
- Neurology and
Neurorehabilitation, University Department of Geriatric
Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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Retinal emboli after cervicopetrous junction internal carotid artery pseudoaneurysm stenting. Am J Ophthalmol Case Rep 2021; 23:101164. [PMID: 34296045 PMCID: PMC8282970 DOI: 10.1016/j.ajoc.2021.101164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 05/01/2021] [Accepted: 07/05/2021] [Indexed: 01/10/2023] Open
Abstract
Purpose To describe acute and chronic retinal ischemic changes following an internal carotid artery pseudoaneurysm stenting procedure, and to review current evidence for risk factors and management of post-procedural retinal ischemic events. Observation A 50-year-old man presented with a 3-month history of pulsatile tinnitus, headache, and intermittent blurry vision. A CT angiogram of head and neck showed bilateral cervicopetrous internal carotid artery (ICA) pseudoaneurysms. The patient underwent successful repair with angioplasty and stenting of the flow-limiting high-grade (>95%) stenosis of his left high cervical ICA. On post-operative day 1, the patient reported monocular vision loss with a large central scotoma. He was found to have a central macular area of retinal whitening and multiple areas of perivascular retinal whitening on exam, concerning for retinal artery occlusions secondary to peri-procedural emboli. Dual antiplatelet therapy was started and a stroke evaluation was performed. Two months later, his visual acuity in the affected eye was counting fingers and his left eye fundus examination was notable for multiple areas of scattered hemorrhages, microaneurysms, and retinal exudates in the distribution of prior retinal ischemia. OCT imaging revealed atrophic changes in the left macula. Subsequently, the patient completed stage-2 repair of the left ICA pseudoaneurysm followed by uncomplicated repair of the right ICA. Four months later, his left eye visual acuity and retinal findings remained stable. Conclusions and Importance Post-procedure retinal emboli and ischemia are important, vision threatening possible ocular complications for patients undergoing carotid vascular and endovascular procedures.
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Martins de Souza N, Vikatmaa P, Tulamo R, Venermo M. Etiology and treatment patterns of ruptured extracranial carotid artery aneurysm. J Vasc Surg 2021; 74:2097-2103.e7. [PMID: 34245848 DOI: 10.1016/j.jvs.2021.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 06/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Rupture of an extracranial carotid artery aneurysm (ECAA) is a very rare and life-threatening condition. To obtain a comprehensive view of previous and current management of ruptured ECAAs (rECAAs), we analyzed all cases reported since 1940 and two of our own cases. METHODS We performed a comprehensive literature review of reports from the MEDLINE database on rECAAs and included two patients treated in our department. RESULTS A total 58 reports of 74 rECAAs in 74 patients were analyzed. Their mean age was 50 years, and the male/female ratio was 2.2:1. Infection was the most common reported etiology (19 of 74; 26%), followed by connective tissue disorder (13 of 74; 18%), atherosclerosis (9 of 74; 12%), and previous trauma (5 of 74; 7%). For 28 patients (38%), information on the etiology was not available. Of the 74 patients, 24 (32%) had undergone reconstructive surgery, 10 (14%) had undergone endovascular treatment, 17 (23%) had undergone ligation, 2 (3%) had been treated conservatively, and 1 (1%) had died before receiving definite treatment. For 20 patients (27%), information on the treatment received was not available. The complications after reconstruction included carotid blowout (3 of 24 patients; 13%) and cranial nerve deficit (3 of 24 patients; 13%). Two patients (8%) had died of unrelated ECAA causes during long-term follow-up, and one patient (4%) had died of an ECAA-related cause within 30 days. After an endovascular approach, 1 of the 10 patients had developed a cranial nerve deficit. After ligation, five patients (29%) had experienced stroke, three of which were fatal. One conservatively treated patient had experienced no complications and one had died of an ECAA-related cause. CONCLUSIONS The most common reported etiology for rECAA was infection. Reconstructive surgery was the most common approach and was safer than ligation, which carried a high risk of stroke. Endovascular treatment showed promising results, especially for distally located aneurysms; however, the number of patients has remained low.
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Affiliation(s)
- Nicole Martins de Souza
- Department of Vascular Surgery, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Pirkka Vikatmaa
- Department of Vascular Surgery, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riikka Tulamo
- Department of Vascular Surgery, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Kalashnikova L, Danilova M, Gubanova M, Dobrynina L, Dreval M, Krotenkova M. Aneurysms and pathological tortuosity of the internal carotid and vertebral arteries in patients with dissection of these vessels: a results of long-term study. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:7-12. [DOI: 10.17116/jnevro20211211217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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15
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Fate of distal false aneurysms after carotid dissection. J Vasc Surg 2020; 71:2183. [PMID: 32446520 DOI: 10.1016/j.jvs.2019.11.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/23/2019] [Indexed: 11/21/2022]
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16
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Lurie F, Abbas JT. Reply. J Vasc Surg 2020; 71:2183-2184. [PMID: 32446521 DOI: 10.1016/j.jvs.2020.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 01/11/2020] [Indexed: 11/17/2022]
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17
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Saal-Zapata G, Durand W, Valer D, Rodríguez R. Internal Carotid Artery Dissection Treated with C-Guard Stent. Int J Angiol 2020; 31:61-66. [PMID: 35221855 DOI: 10.1055/s-0040-1708839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Internal carotid dissection is the most common cause of stroke in the young population. Stroke, the presence of a pseudoaneurysm, and decreased artery lumen with cerebral flow impairment are indications for treatment. Medical therapy with antithrombotic drugs and endovascular therapy with stenting are the main available options. The C-Guard stent is an open cell mesh-covered dual layer stent that has been mainly used in cases of internal carotid artery stenosis with a post-operative reduction in stroke incidence. Thus, we present two cases of internal carotid artery dissections of the cervical segment treated with the open cell dual-layer C-Guard stent without complications.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru
| | - Walter Durand
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru
| | - Dante Valer
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru
| | - Rodolfo Rodríguez
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru
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Hodjati H, Ghoddusi Johari H, Khademi B, Rahmanian A, Vahidi A, Dehghankhalili M. Aneurysm of the Internal Carotid Artery Misdiagnosed as Cervical Paraganglioma; A Case Report and Literature Review. Bull Emerg Trauma 2019; 7:420-423. [PMID: 31858007 PMCID: PMC6911723 DOI: 10.29252/beat-070413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aneurysms of the extracranial segment of the internal carotid artery are not common and are associated with severe neurologic deficits. They could be misdiagnosed with several lesion of the cervical region. We herein report a case of internal carotid artery aneurysm misdiagnosed as paraganglioma. A 23-year-old man presented with progressive growing mass in right enlarging mass in the upper part of the neck below the angle of the mandible. The patient underwent surgery by the ear, nose, throat (ENT) surgeon through submandibular approach with impression of paraganglioma but severe pulsatile bleeding was encountered intraoperatively. Two vascular clamps were applied and the patient was transferred to the vascular ward. Computerized tomography (CT) angiogram revealed a huge aneurysm of the internal carotid artery in the extracranial segment with injured wall. After 2 days of medical therapy the patient was transferred to the operating room and the aneurysm was repaired using Dacrons. The patient had an uneventful hospital course and was asymptomatic after 1 year of follow-up. Precise preoperative assessment and evaluation with different modalities should be performed to avoid fatal complications. Surgery is a safe and effective method in experienced hands for repair of such aneurysms.
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Affiliation(s)
- Hossein Hodjati
- Department of General Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Bijan Khademi
- Department of Otolaryngology, Otolaryngology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Abtin Vahidi
- Department of General Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
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Kasprzak D, Bojakowski K, Nowicki M, Zawadzki M, Andziak P. False Aneurysms Complicating Internal Carotid Artery Dissection. Vasc Endovascular Surg 2019; 53:259-263. [PMID: 30630394 DOI: 10.1177/1538574418823381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pseudoaneurysm formation is a rare but dangerous complication of carotid artery dissection. It can result from trauma, spontaneous artery dissection, or iatrogenic causes. Presence of symptoms and ineffective medical therapy are one of the indications for invasive treatment. We present the case of 3 symptomatic patients with dissecting pseudoaneurysms-2 traumatic and 1 spontaneous. They were treated with 3 different endovascular procedures: the use of covered stentgraft, trans-stent coil embolization, and carotid stenting. After invasive and dual antiplatelet therapy, complete resolution of symptoms was achieved in all patients.
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Affiliation(s)
- Dominika Kasprzak
- 1 Student's Scientific Group "Lusoria" at the Second Department of Vascular Surgery and Angiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Internal Affairs Warsaw, Warsaw, Poland
| | - Krzysztof Bojakowski
- 2 Second Department of Vascular Surgery and Angiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Internal Affairs, Warsaw, Poland
| | - Mirosław Nowicki
- 3 Department of Diagnostic and Interventional Radiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Internal Affairs, Warsaw, Poland
| | - Michał Zawadzki
- 3 Department of Diagnostic and Interventional Radiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Internal Affairs, Warsaw, Poland
| | - Piotr Andziak
- 2 Second Department of Vascular Surgery and Angiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Internal Affairs, Warsaw, Poland
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Pourier VEC, Welleweerd JC, Kappelle LJ, Rinkel GJE, Ruigrok YM, Worp HB, Lo TH, Bots ML, Moll FL, de Borst GJ. Experience of a single center in the conservative approach of 20 consecutive cases of asymptomatic extracranial carotid artery aneurysms. Eur J Neurol 2018; 25:1285-1289. [DOI: 10.1111/ene.13720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- V. E. C. Pourier
- Department of Vascular Surgery University Medical Center Utrecht Utrecht
| | - J. C. Welleweerd
- Department of Vascular Surgery University Medical Center Utrecht Utrecht
| | - L. J. Kappelle
- Brain Center Rudolf Magnus Department of Neurology and Neurosurgery University Medical Center Utrecht Utrecht
| | - G. J. E. Rinkel
- Brain Center Rudolf Magnus Department of Neurology and Neurosurgery University Medical Center Utrecht Utrecht
| | - Y. M. Ruigrok
- Brain Center Rudolf Magnus Department of Neurology and Neurosurgery University Medical Center Utrecht Utrecht
| | - H. B. Worp
- Brain Center Rudolf Magnus Department of Neurology and Neurosurgery University Medical Center Utrecht Utrecht
| | - T. H. Lo
- Department of Radiology University Medical Center Utrecht Utrecht
| | - M. L. Bots
- Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht The Netherlands
| | - F. L. Moll
- Department of Vascular Surgery University Medical Center Utrecht Utrecht
| | - G. J. de Borst
- Department of Vascular Surgery University Medical Center Utrecht Utrecht
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Pourier VEC, de Borst GJ. Re. "Fate of the Distal False Aneurysms Complicating Internal Carotid Artery Dissection: Systematic Review". Eur J Vasc Endovasc Surg 2016; 53:302. [PMID: 27993455 DOI: 10.1016/j.ejvs.2016.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/11/2016] [Indexed: 11/17/2022]
Affiliation(s)
- V E C Pourier
- Department of Vascular Surgery G04.129, University Medical Center Utrecht, PO Box 85500, 3508GA Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery G04.129, University Medical Center Utrecht, PO Box 85500, 3508GA Utrecht, The Netherlands.
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