Intravascular stenting as a definitive treatment of spontaneous carotid artery dissection

Neurovascular trauma: Diagnosis and therapy

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

Anchoring Pipeline Flow Diverter Construct in the Treatment of Traumatic Distal Cervical Carotid Artery Injury

Background

Traumatic extracranial internal carotid artery (ICA) dissections are uncommon and can be difficult to treat. Thinning of adventitia and dilatation may occur following arterial dissection, thus resulting in a fusiform pseudoaneurysm, which can subsequently cause bleeding, expanding, or pulsatile hematoma. Currently, medical management with anticoagulation remains the first line of treatment and yields good outcomes in 75% of cases with a mortality rate of 3-4%. Endovascular intervention is indicated with failure of medical therapy, progressive enlargement of a traumatic pseudoaneurysm, acute flow-related infarcts due to vessel occlusion, or when anticoagulation is contraindicated due to risk of pseudoaneurysm rupture and hemorrhage. Recognized interventional treatments include parent artery occlusion with or without revascularization, endovascular coil embolization, and covered stenting.

Summary

A wide variety of endovascular stents are available that are capable of opening a stenosed vessel while obliterating the associated false lumen and providing a scaffold for embolization of the pseudoaneurysm. The use of the Pipeline Embolization Device (PED) in the management of traumatic intracranial pseudoaneurysms has been described. However, there are few reports on the usage of the PED for treating traumatic extracranial ICA dissection and/or pseudoaneurysms. However, a potential complication of the use of PED in the extracranial ICA is a hypothetical tendency to migrate in a mobile vessel. Thus, the risk of migration of the PED has encouraged practitioners to adopt strategies to limit this risk.

Key Messages

We describe different techniques employed to anchor the flow-diverting construct within tortuous, mobile vessels.

Stent recanalization of carotid tonsillar loop dissection using the Enterprise vascular reconstruction device

Although advances in endovascular techniques have permitted reconstruction of intimal dissections and related pseudoaneurysms of the extracranial cervical internal carotid artery, highly tortuous tonsillar loop anatomic variants still pose an obstacle to conventional extracranial self-expanding carotid stents. During a 12 year period, nine of 48 cases with cervical carotid dissections were associated with a tonsillar loop. Five patients required endovascular treatment, which was performed using a microcatheter-based technique with the low-profile Enterprise vascular reconstruction device (Codman Neurovascular, Raynham, MA, USA). Technical, radiographic, and clinical outcomes were analyzed for each patient. Dissection etiology was spontaneous in three patients, iatrogenic in one, and traumatic in one. Four near-occlusive tonsillar loop dissections were successfully recanalized during the acute phase. Dissection-related stenosis improved from 90±22% to 31±13%, with tandem stents needed in three instances to seal the inflow zone. There were no procedure-related transient ischemic attacks (TIA), minor/major strokes, or deaths. Angiographic follow-up for a mean of 28.0±21.6 months showed all stents were patent, with average stenosis of 25.2±12.2%. Focal ovalization and kinking of the closed-cell design was noted at the sharpest curve in one patient. Clinical outcome (follow-up of 28.1±21.5 months) demonstrated overall improvement with no clinical worsening, new TIA, or stroke. Tonsillar loop-associated carotid dissections can be successfully and durably recanalized using the low-profile Enterprise stent with an excellent long-term patency rate and low procedural risk. The possibility of stent kinking and low radial force should be considered when planning reconstruction with this device.

Endovascular recanalization of symptomatic flow-limiting cervical carotid dissection in an isolated hemisphere

Object

Internal carotid artery dissection (ICAD) is a common cause of stroke in young patients, which may lead to major transient or permanent disability. Internal carotid artery dissection may occur spontaneously or after trauma and may present with a rapid neurological deterioration or with hemodynamic compromise and a delayed and unstable neurological deficit. Endovascular intervention using stent angioplasty can be used as an alternative to anticoagulation and open surgical therapy in this setting to restore blood flow through the affected carotid artery.

Methods

The authors present the cases of 2 patients with flow-limiting symptomatic ICAD leading to near-complete occlusion and without sufficient collateral supply. Both patients had isolated cerebral hemispheres without significant blood flow from the anterior or posterior communicating arteries. In both cases, the patients demonstrated blood pressure–dependent subacute unstable neurological deficits as a result of the hemodynamic compromise resulting from the dissection.

Results

Both patients underwent careful microwire-based selection of the true lumen followed by confirmatory microinjection and subsequent exchange-length microwire-based recanalization using tandem telescoping endovascular stenting. In both cases the neurological state improved, and no permanent neurological deficit ensued.

Conclusions

The treatment of ICAD may be difficult in patients with subacute unstable neurological deficits related to symptomatic hypoperfusion, especially in the setting of a hemodynamically isolated hemisphere. Anticoagulation alone may be insufficient in these patients. Although there is no widely accepted guideline for the treatment of ICAD, the authors recommend stent-mediated endovascular recanalization in cases of symptomatic flow-limiting hemodynamic compromise, especially in cases of an isolated hemisphere lacking sufficient communicating artery compensatory perfusion.

Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature

BACKGROUND:

Carotid and vertebral artery dissections are a leading cause of stroke in young individuals.

OBJECTIVE:

To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection.

METHODS:

We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections.

RESULTS:

For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months).

CONCLUSION:

Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.

Evaluation and management for carotid dissection in patients presenting after choking or strangulation

BACKGROUND

Carotid dissection (CD) is often overlooked as a concern in strangulation and choking cases. When the diagnosis is considered, the question remains what is the best means of evaluation, and which imaging study should be obtained.

OBJECTIVE

To evaluate the literature for evaluation of choking- and strangulation-related injuries and their association with CD.

DISCUSSION

This article will review the literature on blunt carotid injuries, with particular attention to subjects with choking and strangulation mechanisms of injury, and will include important physical findings, when and which radiographic evaluations are indicated, and treatment.

CONCLUSION

Although rare, CD can occur after strangulation and choking. When suspected, evaluation should include imaging studies including computed tomography angiography.

Spontaneous dissection of internal carotid artery masquerading as angioedema

Spontaneous dissection of the internal carotid artery usually presents with stroke-like symptoms secondary to ischemia in its vascular territory, as well as local signs and symptoms, which may include head, face or neck pain, Horner's syndrome, pulsatile tinnitus, and cranial nerve palsies. We report a case of a 44-year-old healthy white male who presented with tongue swelling mimicking angioedema as an unusual manifestation of spontaneous dissection of the internal carotid artery. Two weeks after the initial presentation, the patient returned with similar symptoms and slurred speech. Upon physical examination, he was noted to have isolated left-sided hypoglossal nerve palsy. Subsequent diagnostic imaging revealed segmental narrowing of the left internal carotid artery. The appearance was consistent with the presence of a spontaneous internal carotid artery dissection with associated pseudoaneurysm formation.

Symptomatic spontaneous intracranial carotid artery dissection treated with a self-expanding intracranial nitinol stent: a case report

BACKGROUND

Although extracranial carotid dissection with stroke is common, intracranial dissection with stroke is rare. Stenting has been used to treat extracranial carotid dissections. Intracranially, however, it is only recently that stents have become a feasible option for this disease. We present a case of a spontaneous intracranial CAD with progressive symptoms despite medical management treated with a self-expanding intracranial micronitinol stent.

CASE DESCRIPTION

A 47-year-old, right-handed woman presented to the emergency department after noticing left-sided face and arm weakness and numbness, along with slurred speech. The patient was started on aspirin 325 mg/d orally and lovenox 40 mg/d subcutaneously. On hospital day 2, the patient was noted to have repeated episodes of weakness and numbness on the left side and MRI evidence of a new stroke. A diagnostic cerebral angiogram from a selective right internal carotid injection revealed a flow-limiting stenosis secondary to a dissection of the supraclinoid internal carotid artery with severe flow limitation to the hemisphere. Endovascular management was decided on, and a Neuroform stent measuring 4.5 x 20 mm (Boston Scientific Corporation, Natick, Mass) was deployed across the dissection with significant improvement of flow to that hemisphere on the poststent angiogram.

CONCLUSIONS

This case illustrates the successful off-label use of a self-expanding intracranial nitinol stent to treat a symptomatic intracranial internal CAD in the setting of failure of traditional medical management. This is a promising application of novel endovascular technology.

Treatment of Intra- and Extracranial Arterial Dissections Using Stents and Embolization

PURPOSE

To evaluate the safety and efficacy of stent placement for extracranial and intracranial arterial dissections.

METHODS

Eighteen patients underwent endovascular treatment of carotid and vertebral dissections using intraluminal stent placement. Five patients with arterial dissection were treated, 2 using one insertion of a single stent and 3 using placement of two stents. Patients with a dissecting aneurysm were treated as follows: 7 patients with insertion of one stent, 4 with placement of two stents, and 2 by stent-assisted Guglielmi detachable coil embolization. In the 18 patients in whom stenting was attempted, the overall success in reaching the target lesion was 94.4%. Of the 17 patients treated with stents, stent release and positioning were considered optimal in 16 (94%) and suboptimal in one (6%). In patients who underwent a successful procedure, all parent arteries were preserved. There were no instances of postprocedural ischemic attacks, new neurologic deficits, or new minor or major strokes prior to patient discharge. In follow up, all patients were assessed, using the modified Rankin scale, as functionally improved or of stable clinical status. The reduction in dissection-induced stenosis or pseudoaneurysm, the patency rate obtained at follow-up, and the lack of strokes (ischemic or hemorrhagic) suggest that stent placement offers a viable alternative to complex surgical bypass or reconstructive procedures. The long-term efficacy and durability of stent placement for arterial dissection remain to be determined in a larger series.

Nonsurgical carotid revascularization

Carotid endarterectomy is a well-established treatment of improving the carotid luminal diameter and preventing strokes, and the indications and complications are well-defined. Carotid angioplasty and stent placements are relatively newer ways of treating carotid artery stenosis. In certain contexts, they may have some advantages over carotid endarterectomy. However, the success rates, morbidity, and mortality associated with these procedures are less well characterized. In earlier comparative studies, the incidence of ipsilateral stroke rate was higher with angioplasty, but in later studies, this trend is reversing. Angioplasty may also have an edge in specific situations like patients with coexisting significant coronary arterial disease, contralateral carotid artery occlusion, and in instances when the narrowing is long and at multiple sites. Protective devices like distal occlusion balloon and filter protection devices may reduce the incidence of stroke. We are still awaiting the results of some major randomized head-to-head trials comparing carotid endarterectomy and stenting.

Penetrating Injuries of the Neck: Use of Helical Computed Tomographic Angiography

The diagnostic evaluation of stable patients with penetrating trauma to the neck remains controversial. Conventional angiography has traditionally been considered the gold standard for evaluation of vascular injuries. The use of angiography for stable patients with penetrating neck trauma has been questioned because of its invasive nature and reported low yield. In recent years, there has been a renewed interest in the use of noninvasive techniques such as helical computed tomographic (CT) angiography for the evaluation of these patients. Helical CT angiography, a low-risk, rapid, accurate, noninvasive, reproducible technique, is less expensive than conventional angiography. Helical CT angiography also can provide information about potential lesions of associated vital structures such as the cervical spine and the aerodigestive tract. This review evaluates the authors' current protocol for penetrating neck wounds and identifies indications for helical CT angiography.

Penetrating injuries of the neck and the increasing role of CTA

Vascular injuries of the neck are most frequently the result of penetrating trauma. Diagnostic evaluation of hemodynamically stable patients who have suffered penetrating neck wounds is challenging and remains controversial. In order to reduce morbidity and mortality, prompt diagnosis and subsequent treatment of these injuries is critical. Traditionally, these patients undergo direct contrast angiography. However, this technique has limitations including its invasive nature and potential complications. The use of routine screening angiography has also been questioned because of the low rate of positive examinations. More recently, helical and multislice CT angiography (CTA) has emerged as a fast, minimally invasive accurate study to evaluate penetrating neck injuries. CTA is not operator-dependent and the results can be reproduced easily by using established technical parameters. It is readily available in most centers and allows the simultaneous evaluation of the extravascular soft tissues and bones.

Carotid artery stenting to prevent stroke in a patient with bilateral extracranial internal carotid dissection and vasospasm following rupture of an intracranial aneurysm

The stenting of carotid dissection has been described for the prevention of cerebral ischemia in patients who remain symptomatic despite therapeutic anticoagulation, in those who present contraindications for anticoagulation therapy, or who present a local or extensive stenosis, with an associated pseudoaneurysm. We here report a case associating a high clinical grade aneurysmal rupture with a bilateral extracranial carotid dissection. Because of the haemodynamic risk due to the acute bilateral stenosis-induced dissection and the occurrence of a vasospasm, the carotid dissections were treated with self-expendable stents.

Subacute hypoglossal nerve paresis with internal carotid artery dissection

OBJECTIVES

To describe a case of an isolated hypoglossal nerve palsy in a patient with a spontaneous internal carotid artery dissection (ICAD). This condition is a well-recognized cause of cerebral ischemic stroke in patients younger than 45 years of age. Isolated cranial nerve neuropathy is a rare presentation. More common manifestations include incomplete hemiparesis, hemicrania, Horner syndrome, cervical bruit, pulsatile tinnitus, and multiple cranial nerve palsies.

METHODS

A comprehensive literature search (Ovid, MEDLINE) for the presentation, diagnostic evaluation, treatment, and outcome of patients with internal carotid artery dissection was performed.

RESULTS

A 43-year-old man presented with a 3-week history of mild dysarthria. There was no history of craniocervical trauma. The physical examination revealed an isolated left hypoglossal nerve paresis. Magnetic resonance imaging and angiography findings were consistent with a left skull base ICAD. The patient was successfully treated with anticoagulation therapy. The current rate of cranial nerve involvement is estimated at 10% of all ICADs. This is the second report of isolated hypoglossal nerve palsy without hemicrania in a case of atraumatic ICAD.

CONCLUSIONS

Patients with an ICAD infrequently present to the otolaryngologist because of its head and neck manifestations. It is crucial to recognize atypical findings and to perform an accurate and prompt diagnostic evaluation. The foundation of treatment is aggressive anticoagulation, with surgical or radiologic intervention reserved for cases demonstrating life-threatening progression.

Emergent endovascular treatment of a spontaneous internal carotid artery dissection with pseudoaneurysm

PURPOSE

To report the use of a coronary stent-graft for the endovascular treatment of a spontaneous internal carotid artery (ICA) dissection complicated by a large pseudoaneurysm.

CASE REPORT

A 68-year-old man presented to an outside hospital with complaints of headache, severe left-sided neck pain, fever, chills, and vomiting. Contrast-enhanced computed tomography revealed a large (3.5x3 cm) extracranial aneurysm of the left ICA. The patient was emergently transferred to our facility for endovascular treatment of the carotid aneurysm. Via a percutaneous access in the right common femoral artery, 2 Jostent coronary stent-grafts were deployed across the aneurysm with no evidence of a residual pseudoaneurysm. The patient was hemodynamically stable throughout the procedure. Duplex examination at 9 months revealed no evidence of a residual pseudoaneurysm, dissection, or endoleak.

CONCLUSIONS

Covered coronary stents may have a role in the treatment of spontaneous ICA dissection with pseudoaneurysm formation.

Endovascular management of acute carotid artery dissection with a waxing and waning neurological deficit

PURPOSE

To evaluate the feasibility and efficacy of emergent carotid stenting for an acute internal carotid artery (ICA) dissection.

CASE REPORT

A 51-year-old man was admitted to our emergency department's stroke unit 1 hour after the onset of left hemiparesis. Computed tomographic and transcranial Doppler scans showed no pathological findings, but the color Doppler study detected a double lumen in the right carotid bifurcation extending to the proximal ICA. Within the first 2 hours after admission, the patient's neurological status began to fluctuate; the NIH Stroke Scale (NIHSS) and Rankin scores evaluated each hour after admission ranged from 0 to 12 and from 0 to 3, respectively. Emergency carotid angiography confirmed the dissection of the bulb and proximal right ICA, which prompted implantation of 2 Wallstents from the internal to common carotid artery. Forty-eight hours later, the patient was almost totally asymptomatic with an NIHSS score of 1 and a Rankin score of 0; he was discharged on postoperative day 3. At 3 months, the patient was free of neurological symptoms and the stented carotid artery was patent.

CONCLUSIONS

In patients with fluctuating neurological signs and symptoms consistent with carotid artery dissection that are refractory to medical therapy, a stent can be placed to prevent permanent neurological deficits provided that the anatomical conditions are suitable.

Penetrating neck injuries: helical CT angiography for initial evaluation

PURPOSE

To report an experience with helical computed tomographic (CT) angiography as the initial procedure to rule out arterial lesions caused by penetrating neck injuries.

MATERIALS AND METHODS

During 27 months, 175 patients were referred for helical CT angiography of the neck because of clinical suspicion of arterial injuries. The protocol included a 100-mL bolus of nonionic contrast material injected at 4.5 mL/sec, with 11-second scanning delay, 3-mm collimation, and pitch of 1.3-2.0. CT images were interpreted prospectively by the emergency radiologist, and two radiologists retrospectively interpreted studies with consensus. Outcome was determined with examination of patients and their charts. The sensitivity, specificity, and positive and negative predictive values were calculated.

RESULTS

Studies in two patients were considered inadequate for diagnosis; these patients were referred for conventional arteriography and had normal findings. In 27 patients (15.6%), arterial lesions were detected. One patient had two arterial injuries. Lesions demonstrated with helical CT angiography were arterial occlusion (n = 14), pseudoaneurysm (n = 8), pseudoaneurysm and arteriovenous fistulae (n = 4), and partial thrombosis (n = 2). The remaining 146 patients had normal arteries. On the basis of these findings, patients were treated with surgery (n = 21), endovascular intervention (n = 7), and observation alone (n = 146).

CONCLUSION

Results indicate that helical CT angiography can be used as the initial method for evaluation in patients with possible arterial injuries of the neck.

Carotid dissection: technical factors affecting endovascular therapy

BACKGROUND AND PURPOSE

To delineate factors associated with the successful endovascular treatment of extracranial carotid dissections, the authors review their management of 13 cases.

METHODS

The records of 12 patients with 13 dissections were assessed with reference to mechanism of dissection, preoperative symptoms, presence of a pseudoaneurysm, treatment success, and etiology of treatment failure. Patients were followed prospectively and included six men and six women, ranging in age from 27 to 62 years.

RESULTS

Angioplasty and stenting were performed successfully in 11 of 13 procedures (10 of 12 patients). Follow-up in these 10 patients demonstrated excellent patency through the stented segment in nine of the 11 treated vessels. Two patients, both of whom suffered their original dissection as a result of endarterectomy, required further angioplasty and stenting for stenosis outside the previously treated arterial segment. Regarding the treatment failures, a stent deployment device could not navigate a tortuous loop in one, while a microwire could not be advanced beyond a pseudoaneurysm in the second. Six patients had pseudoaneurysms, four of which were treated only with stenting across the dissected arterial segment. All pseudoaneurysms treated in this fashion resolved. No permanent complications occurred as a result of endovascular therapy.

CONCLUSIONS

Angioplasty and stenting can be performed safely to manage carotid dissection. A pseudoaneurysm or tortuous anatomy can preclude therapy although the former typically resolves if angioplasty and stenting are feasible. Dissections secondary to endarterectomy may be associated with a higher rate of restenosis after stenting and may require further treatment.

Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography

PURPOSE

To determine the sensitivity and specificity of helical computed tomographic (CT) angiography in the diagnosis of carotid and vertebral arterial injuries caused by penetrating neck trauma.

MATERIALS AND METHODS

A prospective study was conducted during 24 months in 60 patients with penetrating neck trauma who were referred for conventional angiography owing to clinical suspicion of arterial injury. In the patient population, 146 arteries (77 carotid, 69 vertebral) were studied by means of conventional angiography. In all patients, conventional angiography and helical CT angiography were completed within 6 hours. Two radiologists interpreted helical CT angiographic studies by means of consensus. Conventional angiography was the standard of reference for determining the sensitivity and specificity of helical CT angiography.

RESULTS

Conventional angiograms showed arterial injuries in 10 (17%) of 60 patients. Conventional angiographic findings were arterial occlusion (n = 4), arteriovenous fistula (n = 2), pseudoaneurysm (n = 3), pseudoaneurysm with arteriovenous fistula (n = 1), and normal arteries (n = 136). Nine of 10 arterial injuries and all normal arteries were depicted adequately at helical CT angiography. Sensitivity of helical CT angiography was 90%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 98%.

CONCLUSION

The sensitivity and specificity of helical CT angiography are high for detection of major carotid and vertebral arterial injuries resulting from penetrating trauma.

Carotid artery dissection

Among the large variety of cerebrovascular syndromes, carotid artery dissections remain often under-recognized. Many patients present with minor or transient symptoms, some with local pain only, and some are asymptomatic. A useful rule is that the coincidence of any local pain in neck or face with an ipsilateral Horner's syndrome preceding transient or persistent retinal or cerebral ischemic symptoms should alert physicians--notably those treating emergencies--to rule out an underlying dissection of the ipsilateral carotid artery. In most cases the extracranial part of the carotid artery is affected; therefore, this review will focus on this main subgroup of patients. We review the pathological anatomy, as well as possible underlying causes, clinical features, diagnostic tools, differential diagnosis, treatment options, and outcome data.

Persistent dissection of carotid artery in patients operated on for type A acute aortic dissection--carotid ultrasound follow-up

Over a period of 5 years, 124 patients were operated on at the National Institute of Cardiology in Warsaw for acute aortic dissection, 27 of whom died. The 97 patients discharged from the hospital were included in the present analysis. The age of the patients ranged from 25 to 73 years with a mean of 50+/-10 years. Ultrasound examination of carotid arteries was performed with the patient lying on his back using a Toshiba 340A color Doppler system with a linear array probe of 7.5 MHz. Of the 97 patients examined, 15 (15%) had a dissection of at least one of the common carotid arteries (CCA). Two had Marfan syndrome. In 11 patients the dissection involved the right common carotid artery and in four it involved both the left and right common carotid arteries. The flow in the true lumen of CCA and ICA was preserved in all patients and the degree of narrowing ranged from 30 to -70%. Only one of the 15 patients with CCA dissection had an ipsilateral neurological deficit which was already present before the aortic aneurysm operation. Ultrasound follow-up was performed in all patients with the CCA dissection found on first examination. The mean duration of follow-up was 21 months. In 14 patients the degree and extent of the dissection as well as the narrowing of the true lumen was comparable, and in one patient the false channel closed spontaneously. During follow-up there were no new major neurological events despite the persistence of the CCA dissection with different degrees of narrowing of the true lumen. Doppler ultrasound examination of the carotid arteries can supply additional information about the extent of the dissection, and help to assess the flow in the persisting 'double channel' common carotid artery during the follow-up of patients.

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.