Case report: treatment of a carotid artery pseudoaneurism with a polyester covered nitinol stent

Posttraumatic Pseudoaneurysm of Stenotic Internal Carotid Artery Repair by Stent Graft

The authors report an intravascular treatment in the case of posttraumatic pseudoaneurysm of a stenotic internal carotid artery, using a stent graft.

Traumatic Carotid Artery Dissection and Pseudoaneurysm Treated with Endovascular Coils and Stent

Purpose:

To report a case of post-traumatic internal carotid artery dissection and pseudoaneurysm formation at the C-1 level successfully treated by a percutaneous endovascular technique.

Methods and Results:

A 20-year-old female presented 72 hours after a motor vehicle accident with incomplete occulosympathetic paresis (Horner's syndrome), carotidynia, and left-sided weakness. Arteriography confirmed the diagnosis of carotid dissection and an associated 1.5-cm × 2.5-cm pseudoaneurysm at the C-1 level. Neuroradiologists embolized the pseudoaneurysm with Guglielmi detachable coils and controlled the dissection with placement of a Wallstent.

Conclusions:

This report illustrates successful percutaneous endovascular treatment of a carotid dissection and pseudoaneurysm near the base of the skull.

Endovascular treatment of carotid artery blowout syndrome caused by oropharyngeal carcinoma

A 64-year-old man was admitted with massive hemoptysis caused by oropharyngeal carcinoma. Angiography revealed active extravasation from the left carotid bulb. Covered stent-graft placement resolved the bleeding, but the patient presented with recurrent hemorrhage two hours later and was treated with another stent-graft.

Endovascular implantation of covered stents in the extracranial carotid and vertebral arteries: Case series and review of the literature

Background:

Covered stents are used endovascularly to seal arterial wall defects while preserving vessel patency. This report describes our experience with the use of covered stents to treat cervical pathology, and a review of the literature in regards to this topic is presented.

Case Description:

Two patients presenting with the carotid blowout syndrome and one patient with a vertebrojugular fistula were treated with covered stents. This allowed for preservation of the vessel and was a treatment alternative to cerebral bypass.

Conclusion:

Covered stents provide a viable means of preserving the cervical vessels in selected patients; however, long-term follow-up is necessary to determine stent patency and permanency of hemostasis.

Diagnosis and Management of Traumatic Pseudoaneurysm of the Carotid Artery: Case Report and Review of the Literature

Injury to the carotid artery can occur in the setting of blunt and penetrating trauma. Such injury can result in pseudoaneurysm formation. We present a case of posttraumatic common carotid pseudoaneurysm (PTCP) that was diagnosed and treated 2 months after a motor vehicle accident and review the literature on the presentation, diagnosis, and management of PTCP.

Stent-Graft Treatment of Extracranial Carotid and Vertebral Arterial Lesions

Five patients with pseudoaneurysms of the carotid artery (n = 4) and an arteriovenous fistula of the vertebral artery (n = 1) were treated with stent-grafts. Commercially made devices were used in all but one of the patients. In four of the five patients, the pathology was successfully excluded. One patient had a small type-I endoleak. There were no immediate procedure-related complications or neurologic sequalae. All experienced immediate resolution of symptoms. One patient was lost to follow-up after discharge and another died 2 weeks after intervention. The remaining patients remained asymptomatic with patent stent-grafts after follow-up periods of 14, 16, and 46 months, respectively.

Endovascular-covered stent treatment of posttraumatic cervical carotid artery pseudoaneurysms

Pseudoaneurysm involving the cervical portion of the carotid artery can result from prior trauma or dissection. Two patients are reported with posttraumatic carotid artery pseudoaneurysms. In both cases, endovascular-covered stents were placed across the diseased portion of the artery resulting in thrombosis of the aneurysm and preservation of the parent artery without any significant complication. It is therefore concluded that covered stent placement is an alternative approach in treating carotid artery pseudoaneurysms.

Occlusion of Experimental Aneurysms with Heparin-loaded, Microporous Stent Grafts

OBJECTIVE

An embolization technique using a stent graft has been developed to replace the conventional type of direct surgery or neurointervention with platinum coils and/or bare stents. The utility of a commercially available metal stent wrapped with a microporous elastomeric film coated with a thin, heparin-loaded, photocured gelatinous layer for the treatment of experimental carotid artery sidewall aneurysms in dogs was evaluated.

METHODS

The stent graft was used for embolization of experimental carotid artery aneurysms in dogs. The aneurysms were prepared bilaterally in canine carotid arteries with branching of an external jugular vein patch.

RESULTS

The entries into all of the aneurysms were occluded immediately after placement of the stent grafts, and the aneurysms were embolized by thrombus formation even 1 week after deployment. All of the parent carotid arteries in which stent grafts were placed were patent, without severe stenosis, immediately (n = 2), 1 week (n = 4), 1 month (n = 3), and 3 months (n = 4) after placement. Scanning electron microscopy demonstrated that the luminal surfaces of the stent grafts were entirely endothelialized as soon as 1 week after placement, via transmural tissue ingrowth through the micropores formed in the covering film.

CONCLUSION

The stent graft we have developed seems to be highly promising for the treatment of aneurysms, especially with respect to immediate termination of blood inflow for aneurysm occlusion and rapid endothelialization in the aneurysm neck.

Covered stent-graft repair of the brachiocephalic arteries: technical note

OBJECTIVE

The use of a covered stent-graft to repair disruptions of the cervical carotid and vertebral arteries is described. This device maintains vessel patency while effectively excluding pseudoaneurysms, arteriovenous fistulae, and other breaches in the integrity of the arterial wall.

METHODS

Patient 1 bled from a large rent in the proximal common carotid artery as a result of tumor invasion. Patient 2 developed a vertebral arteriovenous fistula after a stab injury to the neck. Patient 3 developed cerebral infarction and an enlarging pseudoaneurysm of the internal carotid artery, also after a stab wound to the neck.

RESULTS

All three patients were treated with the Wallgraft endoprosthesis (Boston Scientific, Watertown, MA). In each case, the vessel wall defect was repaired while antegrade flow through the artery was preserved or restored. No neurological complications occurred as a result of stent-graft deployment.

CONCLUSION

Covered stent-grafts offer an alternative to endovascular occlusion of the parent vessel, thereby expanding the therapeutic options for patients with extracranial cerebrovascular disease. These three cases highlight the usefulness and versatility of these devices for endoluminal reconstruction of the brachiocephalic vasculature.

Treatment of an iatrogenic petrous carotid artery pseudoaneurysm with a Symbiot covered stent: technical case report

OBJECTIVE AND IMPORTANCE

Surgery involving the middle ear or the temporal bone may cause an injury to the petrous carotid artery resulting in a pseudoaneurysm. Conventional treatment of such pseudoaneurysms has ranged from carotid occlusion to conservative management. The use of a balloon-expandable stent and/or Guglielmi detachable coils may be effective in a partially healed pseudoaneurysm. This report details the case of an acute petrous carotid pseudoaneurysm after a myringotomy procedure that was effectively treated with an expanded polytetrafluoroethylene-covered stent.

CLINICAL PRESENTATION

During a right myringotomy procedure, pulsatile blood was encountered in a 42-year-old woman with a history of repeated ear infections and bilateral middle ear ventilation tube placement. The blood was adequately tamponaded with gauze packing. Computed tomography of the temporal bone demonstrated a dehiscent carotid artery, and cerebral angiography revealed a 6-mm right petrous carotid pseudoaneurysm.

INTERVENTION/TECHNIQUE

An 8-French guide catheter was positioned via a transfemoral approach into the cervical right internal carotid artery, and the patient was systemically heparinized. A 4- x 31-mm Symbiot covered stent (Boston Scientific/Scimed, Maple Grove, MN) was passed over a Choice PT exchange wire (Boston Scientific/Scimed) to cover the neck of the pseudoaneurysm, obliterating the pseudoaneurysm. The patient was given aspirin and clopidogrel after stenting, and ear exploration was possible later the same day. Follow-up computed tomographic angiography performed 6 weeks later verified patency of the stent.

CONCLUSION

The use of an expanded polytetrafluoroethylene-covered stent may effectively treat intracranial internal carotid artery pseudoaneurysms in an acute setting. This treatment allows preservation of the parent artery and immediate treatment by reconstruction of the incompetent arterial wall to prevent potentially life-threatening hemorrhagic complications.

Endoluminal stent placement and coil embolization for the management of carotid artery pseudoaneurysms

PURPOSE

To present a series of carotid artery pseudoaneurysms treated successfully using an endovascular approach.

METHODS

From April 1995 to November 1999, 5 patients with neurological symptoms not explained by computed tomography of the head were identified by carotid angiography as having internal carotid artery (ICA) pseudoaneurysms. Three patients had sustained blunt trauma, and 2 had previous elective carotid endarterectomies for atherosclerotic disease. The time between injury and treatment ranged from 3 days to 10 years. The patients were treated with endovascular stent placement for exclusion of the pseudoaneurysm, followed by filling of the cavity with multiple detachable coils. Patients were maintained on oral antiplatelet agents or anticoagulant therapy after the procedure.

RESULTS

Primary technical success was 100%. No patient suffered permanent neurological sequelae. Postprocedure angiography demonstrated a patent ICA in all cases, with complete obliteration of the pseudoaneurysm. At a mean 8.4-month follow-up (range 2-21), all patients remained symptom free; angiograms in 3 patients at a mean 11.7 months demonstrated continued ICA patency. One patient had a 60% focal narrowing of the distal common carotid artery, which was treated successfully with balloon dilation and stenting.

CONCLUSIONS

Endovascular treatment of carotid artery pseudoaneurysms is a useful alternative to standard surgical repair. This modality avoids the necessity for surgical exposure at the skull base with its inherent morbidity.

The use of stents in the management of neurovascular disease: a review of historical and present status

In the mid-1960s, radiologists began experimenting with stents for use in the peripheral vasculature in the hope of treating vascular insufficiency resulting from vessel stenosis in a nonsurgical manner. The 1990s saw stents move into the neurovascular arena for the management of a variety of disease processes, including arterial and venous sinus stenosis, arterial dissection, arterial aneurysms, and arteriovenous fistulae. This article reviews the current status of stenting in regard to the management of neurovascular maladies.

Stent-graft treatment of a common carotid artery pseudoaneurysm

PURPOSE

To report a case demonstrating successful endovascular treatment of a right common carotid artery pseudoaneurysm using a commercially prepared balloon-expandable covered stent.

METHODS AND RESULTS

A 50-year-old man was evaluated for syncopal episodes. He had a history of severe trauma sustained in a motor vehicle accident 3 years before symptom onset. Doppler ultrasound scanning detected a pseudoaneurysm at the origin of the right common carotid artery. The defect measured 25 mm x 20 mm with a 22-mm-long neck on angiography and computed tomography; there was no evidence of carotid stenosis or associated vascular pathology. Via a percutaneous femoral access, 2 Jostent peripheral stent-grafts were placed at the level of the aneurysm, safely achieving complete repair of the arterial wall defect. The patient was asymptomatic at his 12-month evaluation. Color flow duplex scans showed continued exclusion of the pseudoaneurysm.

CONCLUSIONS

Wide-necked aneurysms in the extracranial carotid arteries may be treated with stent-grafts, which can achieve complete and permanent reconstruction of the arterial wall by excluding the aneurysm.

Treatment of symptomatic cervical carotid dissections with endovascular stents

OBJECTIVE

Symptomatic dissections of the cervical carotid artery (CCA) can be spontaneous or secondary to trauma and may be associated with pseudoaneurysms. Surgical treatment is often difficult or unavailable. We report the successful use of endovascular stents in the treatment of symptomatic dissection of the CCA.

METHODS

Five consecutive patients with symptomatic CCA dissection were seen at our institution. There were four female patients and one male patient, ranging in age from 19 to 56 years. One dissection was spontaneous. The others were secondary to a gunshot wound (one patient), blunt neck trauma (two patients), and endovascular treatment of atherosclerotic carotid bifurcation disease (one patient). Balloon-expandable and self-expanding stents were placed via a transfemoral approach.

RESULTS

Success in restoring the carotid lumen with two to five stents in each patient was angiographically demonstrated. There were no procedure-related complications. All patients experienced significant clinical improvement within the first 24 hours and complete long-term recovery.

CONCLUSION

Symptomatic dissections of the CCA can be successfully treated by using endovascular stents.

Recurrent stenosis of common carotid-intracranial internal carotid interposition saphenous vein bypass graft caused by intimal hyperplasia and treated with endovascular stent placement. Case report and review of the literature

Intimal hyperplasia is a well-known cause of delayed stenosis in vein bypass grafts in all types of vascular surgery. Options for treatment of stenosis in peripheral and coronary artery bypass grafts include revision surgery and the application of endovascular techniques such as balloon angioplasty and stent placement. The authors present a case of stenosis caused by intimal hyperplasia in a high-flow common carotid artery-intracranial internal carotid artery (IICA) saphenous vein interposition bypass graft that had been constructed to treat a traumatic pseudoaneurysm of the intracavernous ICA. The stenosis recurred after revision surgery and was successfully treated by endovascular stent placement in the vein graft. The literature on stent placement for vein graft stenoses is reviewed, and the authors add a report of its application to external carotid-internal carotid bypass grafts. Further study is required to define the role of endovascular techniques in the management of stenotic cerebrovascular disease.

Stenting and secondary coiling of intracranial internal carotid artery aneurysm: technical case report

OBJECTIVE AND IMPORTANCE

Endovascular stents have been successfully used in the treatment of fusiform and dissecting aneurysms of the peripheral circulation and extracranial carotid and vertebral arteries. Technical limitations related to the inability to navigate the stent and the delivery system through tortuous vascular segments has limited their application with intracranial lesions. Availability of new flexible and pliable stent systems might overcome these difficulties.

CLINICAL PRESENTATION

A 49-year-old woman presented with a dissecting pseudoaneurysm of the horizontal portion of the petrous internal carotid artery that increased in size, as revealed by serial angiographic studies.

INTERVENTION

The aneurysm was treated by deploying a new flexible stent across the aneurysm neck and by then packing the aneurysm sac with Guglielmi detachable coils that were delivered by a microcatheter positioned through the stent struts into the aneurysm lumen.

CONCLUSION

New flexible stents can be used to treat intracranial internal carotid artery aneurysms in difficult-to-access areas, such as the horizontal petrous segment. The stent may disrupt the aneurysm inflow tract, thereby inducing stasis and facilitating intra-aneurysmal thrombosis. In addition, the stent acts as an endoluminal scaffold to prevent coil herniation into the parent artery, which allows tight packing of even wide-necked and irregularly shaped aneurysms. The stent may also serve as a matrix for endothelial growth. We think this new generation of flexible stents and the use of this described technique will usher in the next era of endovascular management of intracranial aneurysms.

Materials and biomaterials for interventional radiology

Devices used in interventional radiology have significantly developed in the past few years. In order to understand the trends of this development, we analyzed how new interventional devices are progressively incorporating materials having original physical properties, and how developers are today progressively turning towards biomaterials, with respect to the new regulatory environment, and the requirements of biocompatibility.

Endovascular stent treatment of cervical internal carotid artery aneurysms with parent vessel preservation

BACKGROUND

Aneurysms involving the cervical portion of the internal carotid artery (ICA) frequently result from prior trauma or dissection.

CASE DESCRIPTIONS

Two patients are reported with cervical internal carotid artery aneurysms. In both cases, disease involving the contralateral ICA precluded safe treatment of the aneurysms by ICA occlusion. Endovascular stents placed across the diseased portion of the artery resulted in thrombosis of the aneurysm with preservation of the parent artery.

CONCLUSION

Endovascular stent placement should be considered for treatment of aneurysms involving the cervical ICA when preservation of the parent vessel is necessary.

Autologous vein-covered stent repair of a cervical internal carotid artery pseudoaneurysm: technical case report

OBJECTIVE AND IMPORTANCE

Stenting of a cervical internal carotid pseudoaneurysm is presented using a stent covered with saphenous vein. This procedure resulted in immediate exclusion of the aneurysm and maintained patency of the carotid artery.

CLINICAL PRESENTATION

A gunshot to the neck resulted in airway obstruction and respiratory arrest with neurological injury in a male patient. Angiographic investigation revealed an enlarging cervical internal carotid pseudoaneurysm, possibly the source of a cerebral embolism. Anticoagulation had to be stopped because of bleeding complications. A decision was made to conduct definitive percutaneous treatment of the pseudoaneurysm.

TECHNIQUE

A Palmaz stent (JJIS, Warren, NJ) was covered with saphenous vein harvested from the patient's leg. Using standard technique and a simple innovation for stent construct introduction into the sheath, the vein-covered stent was placed across the opening of the aneurysm and dilated into position with a balloon.

CONCLUSION

Immediate exclusion of a cervical internal carotid pseudoaneurysm was performed using an autologous vein-covered stent. One-month follow-up confirmed continued exclusion of the pseudoaneurysm and carotid patency without stenosis.

Traumatic carotid artery dissection and pseudoaneurysm treated with endovascular coils and stent

PURPOSE

To report a case of post-traumatic internal carotid artery dissection and pseudoaneurysm formation at the C-1 level successfully treated by a percutaneous endovascular technique.

METHODS AND RESULTS

A 20-year-old female presented 72 hours after a motor vehicle accident with incomplete occulosympathetic paresis (Horner's syndrome), carotidynia, and leftsided 1.5-cm x 2.5-cm pseudoaneurysm at the C-1 level. Neuroradiologists embolized the pseudoaneurysm with Guglielmi detachable coils and controlled the dissection with placement of a Wallstent.

CONCLUSIONS

This report illustrates successful percutaneous endovascular treatment of a carotid dissection and pseudoaneurysm near the base of the skull.