Treatment of internal carotid artery aneurysms with a covered stent: experience in 24 patients with mid-term follow-up results

Abstract

Background and purpose: We present our preliminary experience, including mid-term angiographic and clinical follow-up results, with an alternative technique for the endovascular treatment of intracranial aneurysms in a series of patients. This new method, previously described in anecdotal case reports, consists of endovascular deployment of an artificial vessel graft (stent graft or covered stent) in the parent vessel to exclude the intracranial aneurysm sac from circulation.

Methods: Twenty-five internal carotid artery (ICA) aneurysms in 24 patients were successfully treated by using a Jostent coronary stent graft deployed in the parent artery across the aneurysm neck. All except four aneurysms were extradural, located in the petrous or cavernous portion of the ICA. The four intradural aneurysms were located in the carotico-ophthalmic region. Seventeen aneurysms in 16 patients occurred posttraumatically, secondary to motor vehicle accidents or surgical injury.

Results: Twenty-three aneurysms were immediately excluded from circulation after stent graft placement. In two aneurysms, a slow contrast material filling (endoleak) into the aneurysm cavity was observed immediately after treatment. One was thrombosed, as shown by late control angiography; in the other one, a second larger bare stent was used to appose the stent graft's distal end to the ICA wall, thus sealing the endoleak into the distal graft. No technical adverse event, including vessel dissection, vessel perforation, or thromboembolism, occurred with or without clinical consequence. No mortality or morbidity developed during or after the procedure, including the follow-up period. Two-year control angiography in one patient, 1.5-year control angiography in two patients, 1-year control angiography in six patients, and 6-month control angiography in 12 patients were performed, revealing reconstruction of the ICA with no aneurysm recanalization. All symptoms resolved after treatment in the patients who had initially presented with mass effect.

Conclusion: Initial anatomic, clinical and mid-term follow-up results in this small series of patients are encouraging. This technique has been proved to have potential in the reconstructive treatment of intracranial aneurysms. Further research and development are needed to optimize the stent graft technology for the cerebrovascular system.

Fig 1.

A, Lateral angiogram obtained before treatment shows a right ruptured dissecting ICA aneurysm. B, 4 × 9 mm Jomed covered stent placed across the aneurysm neck with the support of a long reinforced Arrow sheath in the proximal petrous (straight arrow) and a 6-French Envoy guiding catheter in the distal petrous ICA (arrowhead). Extreme care was taken not to cover the anterior choroidal artery origin with the graft (curved arrow). C, Post-treatment lateral view shows exclusion of the aneurysm and the reconstructed internal carotid artery.

Fig 2.

A, Giant right carotico-ophthalmic aneurysm. B, Oblique image of stent graft placed across the aneurysm neck before its deployment. Note that the ophthalmic artery is covered with the graft but not the anterior choroidal artery. C, Non-subtracted view of the deployed stent graft (curved arrow). Note the contrast material trapped in the aneurysm sac because of the immediate exclusion. D, Oblique angiogram obtained after treatment reveals the reconstruction of the ICA. Note that the ophthalmic artery is not filling but the anterior choroidal artery origin is preserved. E, Oblique control angiogram obtained 18 months later shows no stenosis.

Fig 3.

A, Oblique angiogram of the left carotid artery reveals two posttraumatic aneurysms. One is giant, extending medially, and the other is small, extending laterally. Both originate from the cavernous portion of the ICA. B, Oblique post-treatment angiogram obtained after deployment of the stent graft reveals exclusion of the giant aneurysm but persistent endoleak into the small aneurysm (arrow). C, Control angiogram obtained 2 years later reveals spontaneous occlusion of the endoleak and excellent reconstruction of the ICA, with no stenosis.

Fig 4.

A, Oblique posttraumatic angiogram of a left cavernous ICA aneurysm. B, Oblique angiogram obtained after stent graft deployment shows reconstruction of the ICA with no residual aneurysm filling. C, Oblique control angiogram obtained 6 months later reveals intimal hyperplasia (arrow) with no hemodynamic significance.

Fig 5.

A, Lateral angiogram shows a broad based, bilobulated carotico-ophthalmic ICA aneurysm for which a previous seal test for Onyx treatment failed. B, Lateral angiogram obtained after treatment shows reconstruction of the ICA with the stent graft deployed across the aneurysm neck. Note the occlusion of the ophthalmic artery origin covered by the graft. C, Retrograde filling of the ophthalmic artery via external carotid artery.