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Jayaraj A. Successful Wallstent exclusion of iliofemoral venous aneurysms-a new treatment paradigm. J Vasc Surg Cases Innov Tech 2023; 9:101304. [PMID: 37808553 PMCID: PMC10556760 DOI: 10.1016/j.jvscit.2023.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/04/2023] [Indexed: 10/10/2023] Open
Abstract
Treatment of venous aneurysms involving the iliac and femoral veins has generally been an open surgical approach, with a few case reports noting use of an endovascular approach. We report three cases: (1) a patient with an iliocaval occlusion involving an occluded TrapEase filter who presented with a large left external iliac vein aneurysm; (2) a patient with a left common femoral vein aneurysm; and (3) a patient with left profunda femoris vein aneurysms with associated pulmonary embolism. All three patients were successfully managed with the use of appropriately sized bare metal woven stents (Wallstents; Boston Scientific). Their clinical presentation, technical considerations, and outcomes are reviewed.
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Affiliation(s)
- Arjun Jayaraj
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
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2
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Mak MHW, Tan GWL, Wu YW, Quek LHH. Use of Wallstent device as an embolic protection device during stenting of aortic thrombus. J Vasc Surg Cases Innov Tech 2023; 9:101340. [PMID: 37965113 PMCID: PMC10641675 DOI: 10.1016/j.jvscit.2023.101340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/20/2023] [Indexed: 11/16/2023] Open
Abstract
Blue toe syndrome can occur due to distal embolization from proximal lesions such as an aortic thrombus. We describe the case of a patient who presented with chronic limb threatening ischemia due to a flow-limiting infrarenal aortic thrombus, with gangrene from distal embolization to the left fifth toe, and was successfully treated with endovascular aortic stent graft insertion. Distal embolization during instrumentation was successfully prevented by using a partially deployed Wallstent (Boston Scientific) as an embolic protection device. The reconstrainable Wallstent device can be considered for distal thromboembolic protection during aortic stenting, in particular, when distal embolization is a concern and commercial devices are not readily available.
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Affiliation(s)
- Malcolm Han Wen Mak
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Glenn Wei Leong Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yi-Wei Wu
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore
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Schafer K, Goldschmidt E, Seiwert A. Surgical removal of a foreshortened right innominate vein Wallstent causing venous outflow obstruction. Vascular 2022; 31:594-597. [PMID: 34979834 DOI: 10.1177/17085381211068996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Stenting of central venous stenosis to preserve upper extremity hemodialysis access is well-described, though upper extremity complications secondary to these stents are less frequently discussed. METHODS We present the case of a 43-year-old male with a right brachiocephalic fistula who developed symptoms of venous hypertension following placement of a Wallstent for central venous stenosis. Workup demonstrated venous outflow obstruction secondary to stent foreshortening into the right subclavian vein. RESULTS The Wallstent was removed in a piecemeal fashion using an open surgical technique and a HeRO graft was placed for dedicated fistula outflow with complete relief of the patient's symptoms. CONCLUSION In situations where a stent has migrated and endovascular removal is not possible, individual Wallstent fibers can be removed through a limited venotomy.
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Affiliation(s)
- Kristin Schafer
- Department of General Surgery, 89021University of Toledo, Toledo, OH, USA
| | - Eric Goldschmidt
- Department of General Surgery, 89021University of Toledo, Toledo, OH, USA
| | - Andrew Seiwert
- Promedica, 92661Jobst Vascular Institute, Toledo, OH, USA
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Saleem T, Raju S. Management of iatrogenic inferior vena cava perforation with composite Wallstent-Z-stent technique. J Vasc Surg Cases Innov Tech 2021; 7:630-633. [PMID: 34693091 PMCID: PMC8515163 DOI: 10.1016/j.jvscit.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/17/2021] [Indexed: 11/29/2022] Open
Abstract
Inferior vena cava rupture is uncommon but can occur as a result of trauma or catheterization and during venous interventions. We have described two cases of iatrogenic inferior vena cava perforation, with their successful management with bare metal stents (a composite Wallstent–Z-stent technique). This management strategy was possible owing to the unique properties of the venous system.
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Affiliation(s)
- Taimur Saleem
- The RANE Center for Venous and Lymphatic Diseases, Jackson, Miss
| | - Seshadri Raju
- The RANE Center for Venous and Lymphatic Diseases, Jackson, Miss
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Shammas NW. Worsening Back and Lower Leg Pain Post Stenting of the Common Iliac Vein: Is There Evidence it is Related to Stent Size? J Invasive Cardiol 2020; 32:E250-E253. [PMID: 32999095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Sizing of iliac vein stents remains controversial. We present the first Venovo venous stent (BD/Bard) that was explanted because of worsening of back and leg pain post treatment and analyze data from the first 50 consecutive Venovo venous stents from our center. Stent size was obtained with intravascular ultrasound of the ipsilateral common iliac vein. The data indicate that there is no statistical relationship between the stent size and worsening or emergence of low back and leg pain. Patient-specific factors may be contributing to this extremely rare and persistent pain beyond the 30-day follow-up.
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Affiliation(s)
- Nicolas W Shammas
- Research Director, Midwest Cardiovascular Research Foundation, 1622 E. Lombard Street, Davenport, IA 52803 USA.
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Abdullayev N, Maus V, Mpotsaris A, Henning TD, Goertz L, Borggrefe J, Chang DH, Onur OA, Liebig T, Schlamann M, Kabbasch C. Comparative analysis of CGUARD embolic prevention stent with Casper-RX and Wallstent for the treatment of carotid artery stenosis. J Clin Neurosci 2020; 75:117-121. [PMID: 32173154 DOI: 10.1016/j.jocn.2020.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/28/2019] [Accepted: 03/08/2020] [Indexed: 10/24/2022]
Abstract
Stent protected Angioplasty of extracranial carotid artery stenosis using the dual-layered CGUARD stent is a novel treatment option. In this study we evaluate the feasibility and the safety of the CGUARD in symptomatic and asymptomatic patients in comparison to Casper-RX and Wallstent. This is a multi-center study of consecutive patients treated with the CGUARD, Casper-RX and Wallstent at two German high volume neurovascular centers between April 2017 and May 2018. Patient characteristics, neuroimaging data and angiographic outcome were retrospectively analyzed. The primary end points of the study were acute occlusion of the carotid stent and symptomatic intracerebral hemorrhage (sICH). Carotid artery stenting was performed in 76 patients; of those 26 (34%) were treated with the CGUARD, 25 (33%) with Casper-RX, and 25 (33%) with Wallstent. In 58/76 (76%) cases carotid artery stenosis was symptomatic with a median baseline National Institutes of Health Stroke Scale of 4. Angioplasty and stenting as part of a mechanical thrombectomy for acute ischemic stroke was performed in 25/76 (33%) patients. Baseline patient characteristics were similar between the treatment groups, except for a higher portion of scheduled cases in the Casper-RX group. There were no significant differences in the rate of acute in stent occlusions (CGUARD, 2/26 (8%); Casper-RX, 1/25(4%); Wallstent, 1/25 (4%)) and postinterventional sICH (1/26 (4%), 0/25(0%), 0/25 (0%)). Clinical outcome at discharge did not differ between groups. Treatment of carotid artery stenosis using CGUARD is feasible with a good safety profile comparable to that of Casper-RX and Wallstent.
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Affiliation(s)
- N Abdullayev
- Institute for Diagnostic and Interventional Radiology, University Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - V Maus
- Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - A Mpotsaris
- Department of Neuroradiology, RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - T D Henning
- Department of Radiology, Krankenhaus der Barmherzigen Brüder Trier, Nordallee 1, 54292 Trier, Germany
| | - L Goertz
- Department of Neurosurgery, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - J Borggrefe
- Institute for Diagnostic and Interventional Radiology, University Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - D H Chang
- Department of Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - O A Onur
- Department of Neurology, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - T Liebig
- Institute of Neuroradiology, University Hospital Munich (LMU), Marchioninistraße 15, 81377 Munich, Germany
| | - M Schlamann
- Institute for Diagnostic and Interventional Radiology, University Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - C Kabbasch
- Institute for Diagnostic and Interventional Radiology, University Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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Amllay A, Sweid A, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour PM. Cervical carotid pseudoaneurysm eroding the skin with impending blowout. Clin Neurol Neurosurg 2019; 182:104-106. [PMID: 31112810 DOI: 10.1016/j.clineuro.2019.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 11/19/2022]
Affiliation(s)
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
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Chick JFB, Gemmete JJ, Hage AN, Bundy JJ, Brewerton C, Fenlon JB, Abramowitz SD, Coleman DM, Srinivasa RN, Williams DM. Stent Placement Across the Renal Vein Inflow in Patients Undergoing Venous Reconstruction Preserves Renal Function and Renal Vein Patency: Experience in 93 Patients. J Endovasc Ther 2019; 26:258-264. [PMID: 30681021 PMCID: PMC6431779 DOI: 10.1177/1526602818806653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Purpose: To determine if stent placement across the renal vein inflow affects kidney function and renal vein patency. Methods: Between June 2008 and September 2016, 93 patients (mean age 39 years, range 15–70; 54 women) with iliocaval occlusion underwent venous stent placement and were retrospectively reviewed. For this analysis, the patients were separated into treatment and control groups: 51 (55%) patients had suprarenal and infrarenal iliocaval venous disease requiring inferior vena cava stent reconstruction across the renal vein inflow (treatment group) and 42 (45%) patients had iliac vein stenting sparing the renal veins (control group). Treatment group patients received Wallstents (n=15), Gianturco Z-stents (n=24), or suprarenal and infrarenal Wallstents such that the renal veins were bracketed with a “renal gap” (n=12). Stenting technical success, stent type, glomerular filtration rate (GFR), and creatinine before and after stent placement were recorded, along with renal vein patency and complications. Results: All procedures were technically successful. In the 51-patient treatment group, 15 (29%) patients received Wallstents and 24 (47%) received Gianturco Z-stents across the renal veins, while 12 (24%) were given a “renal gap” with no stent placement directly across the renal vein inflow. In the control group, 42 patients received iliac vein Wallstents only. Mean prestent GFR was 59±1.8 mL/min/1.73 m2 and mean prestent creatinine was 0.8±0.2 mg/dL for the entire cohort. Mean prestent GFR and creatinine values in the Wallstent, Gianturco Z-stent, and “renal gap” subgroups did not differ from the iliac vein stent group. Mean poststent GFR and creatinine values were 59±3.3 mL/min/1.73 m2 and 0.8±0.3 mg/dL, respectively. There were no differences between mean pre- and poststent GFR (p=0.32) or creatinine (p=0.41) values when considering all patients or when comparing the treatment subgroups and the control group. There were no differences in the poststent mean GFR or creatinine values between the Wallstent (p=0.21 and p=0.34, respectively) and Gianturco Z-stent (p=0.43 and p=0.41, respectively) groups and the “renal gap” group. One patient with a Wallstent across the renal veins developed right renal vein thrombosis 7 days after the procedure. Conclusion: Stent placement across the renal vein inflow did not compromise renal function. A very small risk of renal vein thrombosis was seen.
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Affiliation(s)
| | - Joseph J Gemmete
- 2 Department of Radiology, Division of Vascular and Interventional Radiology, Michigan Health System, Ann Arbor, MI, USA
| | - Anthony N Hage
- 2 Department of Radiology, Division of Vascular and Interventional Radiology, Michigan Health System, Ann Arbor, MI, USA
| | - Jacob J Bundy
- 2 Department of Radiology, Division of Vascular and Interventional Radiology, Michigan Health System, Ann Arbor, MI, USA
| | - Charles Brewerton
- 3 Western Michigan University School of Medicine, Kalamazoo, MI, USA
| | - Jordan B Fenlon
- 3 Western Michigan University School of Medicine, Kalamazoo, MI, USA
| | - Steven D Abramowitz
- 4 Department of Surgery, Division of Vascular Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| | - Dawn M Coleman
- 5 Department of Surgery, Division of Vascular Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ravi N Srinivasa
- 6 Department of Interventional Radiology, University of California Los Angeles, CA, USA
| | - David M Williams
- 2 Department of Radiology, Division of Vascular and Interventional Radiology, Michigan Health System, Ann Arbor, MI, USA
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Garofalo F, Noreau-Nguyen M, Denis R, Atlas H, Garneau P, Pescarus R. Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents. Surg Obes Relat Dis 2016; 13:925-932. [PMID: 28237561 DOI: 10.1016/j.soard.2016.12.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/05/2016] [Accepted: 12/16/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (SG) has become a widely accepted option in the treatment of morbid obesity. Gastric leaks after SG occur in .9%-2.2% of the patients, mostly at the gastroesophageal junction. The current treatment algorithm includes drainage, antibiotics, nutritional support, and endoluminal control. OBJECTIVES Our hypothesis is that long, fully covered stents represent a safe, effective solution for SG leaks. SETTING University hospital. METHODS A retrospective analysis of our prospectively collected bariatric database was performed between June 2014 and May 2016. We included all patients treated for leaks after SG. Endoscopic treatment included partially covered metallic stent (Wallstent, Boston Scientific, Galway, Ireland), fully covered stent (Mega stent, Taewoong Medical Industries, Gyeonggi-do, South Korea), over-the-scope clip (Ovesco Endoscopy, Tubingen, Germany), and internal pigtail drainage. RESULTS A total of 872 SGs were performed. Overall, 10 of 872 patients (1.1%) developed a gastric leak. One patient was an outside referral. The 11 patients underwent endoscopic treatment accompanied by either percutaneous or laparoscopic abscess drainage. Endoscopic fistula closure at the gastroesophageal junction was achieved in 10 of 11 cases and the average time for closure was 9.9 (range: 4-24) weeks. One patient developed a second leak in the antrum, treated by subtotal gastrectomy. Overall, treatment with Wallstent failed in 3 of 5 patients, and these patients were eventually successfully treated with a Mega stent. The initial use of long, fully covered stents was successful in 5 of 6 cases. CONCLUSION Long, fully covered stents appear to be a good alternative to traditional stents either as primary treatment or after failure of other endoscopic treatments.
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Affiliation(s)
- Fabio Garofalo
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Maxime Noreau-Nguyen
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Ronald Denis
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Henri Atlas
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Pierre Garneau
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Radu Pescarus
- Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada.
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Watanabe M, Shiozawa K, Mimura T, Ito K, Kamata I, Kishimoto Y, Momiyama K, Igarashi Y, Sumino Y. Hepatic artery pseudoaneurysm after endoscopic biliary stenting for bile duct cancer. World J Radiol 2012; 4:115-20. [PMID: 22468193 PMCID: PMC3314928 DOI: 10.4329/wjr.v4.i3.115] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 11/14/2011] [Accepted: 11/21/2011] [Indexed: 02/06/2023] Open
Abstract
We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.
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Dima Ş, Scheau C, Ştefănescu F, Tuţa S. The management of the bilateral internal carotid dissection clinical case presentation. J Med Life 2012; 5:28-34. [PMID: 31803282 PMCID: PMC6880210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction:We present the case of a 36-year-old patient who was treated in the National Institute of Neurology and Cerebrovascular Diseases in Bucharest - in the neurology and the imagistic departments - for bilateral carotid dissection. Goals: The main goal of this article was to discover the cause that lead to the symptoms of the patient using MRI and angio-MRI.In the process,we tried to dilate the stenosis (due to dissection) on 2 internal carotid arteries by using stents in order to keep the true lumen open. Methods:In order to make a diagnosis we used the Magnetic resonance imaging machine (MRI) (1,5 T from GE), the multislice Computer Tomography (CT) scan (16 detectors from Siemens) and the digital substraction angiography (Siemens Axiom Artis). In addition, we used the same angiography machine for the endovascular procedure. The stents that we used were Wallstents from Boston Scientific Company. Results: The patient left the hospital having a NIHSS=10, with dysarthria and left hemiplegia that were 80% recovered after 2 months. Discussion: The particularity of this case study is the spontaneous bilateral internal carotid dissection. The second dissection might have resulted in being also iatrogenic, due to several attempts of stenting the first one. Conclusions: The successful treatment of this patient was the result of the collaboration between the neurology and neuroradiology departments.The first therapeutic option in carotid dissection has to be stenting, under certain conditions.
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Affiliation(s)
- Ş Dima
- Department of Cerebral Angiography, National Institute of Neurology and Cerebrovascular Diseases in Bucharest; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - C Scheau
- Department of Radiology and Medical Imaging, “Fundeni” Clinical Institute, Bucharest, Romania; “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - F Ştefănescu
- Neurosurgery Clinic, National Institute of Neurology and Cerebrovascular Diseases from Bucharest; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - S Tuţa
- Neurology Clinic, National Institute of Neurology and Cerebrovascular Diseases from Bucharest; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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