Angioplasty and stenting in carotid dissection with or without associated pseudoaneurysm

Abstract

Background and purpose: Carotid angioplasty and stent placement may be the preferred treatment in patients with carotid dissection who have failed medical management. The goal of this study was to determine the procedural feasibility and safety as well as long-term complication rates of carotid angioplasty and stent placement in a consecutive cohort of relatively young, high-surgical-risk patients.

Patients and techniques: A series of 26 consecutive patients (mean age, 49 years; 15 men and 11 women) who underwent angioplasty and stent placement for carotid dissection with or without pseudoaneurysm from April 1997 to April 2005 at our institution (9 traumatic, 8 spontaneous, and 9 iatrogenic) was retrospectively reviewed. Twenty-eight stents were used in 29 procedures performed on 27 vessels (20 internal carotid arteries and 7 common carotid arteries). Patients were followed with cerebral angiography, CT, sonography, or clinically for a mean of 14.6 months (range, 5 days to 48.2 months) with 17 of 26 patients having at least 6 months of follow-up. Procedural and long-term complication rates were calculated.

Results: Dissection-induced stenosis was reduced from 71 +/- 18% to no significant stenosis in 20 of the 21 patients with measurable stenosis. The procedural transient ischemic attack (TIA) rate was 3 of 29 procedures (10.3%). There were no procedural strokes. One patient required angioplasty of a common femoral artery. One procedure was terminated when an asymptomatic new intimal flap was created before intervention. Two patients had occlusions of the treated vessel noted at 22 days (presented with contralateral stroke) and 3.4 months (asymptomatic). There were 2 unrelated deaths from myocardial infarction at 8 days and 15.2 months. Two patients had recurrent ipsilateral TIA at 2.7 months and 12 months. The 30-day occlusion and death rate was 2 of 29 procedures (6.9%).

Conclusion: In this series, angioplasty and stent placement were effective in relieving stenosis secondary to carotid dissection with or without pseudoaneurysm and have low rates of ischemic complications.

Fig 1.

Patient 11. A, Lateral digital subtraction angiography (DSA) of a 40-year-old woman with an intimal flap within the distal cervical portion of the left internal carotid artery resulting in pseudoaneurysm (windsock deformity, asterisk) and 75% stenosis. B, A 6 × 20 mm Smart stent (Cordis Corp.) was placed with no residual stenosis and improved anterograde flow (lateral projection). There was residual slow filling of the pseudoaneurysm (asterisk). C, Follow-up angiography at 25 months revealed a widely patent stent with no filling of the pseudoaneurysm (lateral projection).

Fig 2.

Patient 19. A, Lateral DSA of a 19-year-old man with a traumatic pseudoaneurysm arising from the left internal carotid artery at the level of the mid-C2 vertebral body. There was a long segment of dissection flap (arrows) from the pseudoaneurysm (asterisk) to the level of the cavernous internal carotid artery. B, Road-mapping guidance was used to select the true lumen with a 0.018-inch Roadrunner guidewire (Cook Inc.). A 9 × 30 mm Precise stent (Cordis Corp.) was placed across the neck of the pseudoaneurysm (asterisk), which resulted in slower flow within the pseudoaneurysm (lateral projection). C, Follow-up angiography at 6.2 months showed normal caliber at the site of injury with healing of the pseudoaneurysm and dissection flap (lateral projection).

Fig 3.

Patient 18. A, Oblique frontal DSA of a 22-year-old man with a traumatic dissection with flow-limiting stenosis and a large pseudoaneurysm (asterisks) of the upper cervical right internal carotid artery near the skull base. B, A 7 × 30 mm Precise stent (Cordis Corp.) was placed with reversal of the associated stenosis (lateral projection). The pseudoaneurysm associated with the dissection, aside from stent placement, was also treated by coil embolization with a reduction in its size; however, the tear in the internal carotid artery at this level was large and the pseudoaneurysm partially filled. C, There was an interval increase in the size of the pseudoaneurysm with coil compaction at 19 days (lateral projection). The pseudoaneurysm was retreated by placement of additional coils and deployment of a second 7 × 30 mm Precise stent (Cordis Corp.) across the pseudoaneurysm neck, which resulted in near-total obliteration. The internal carotid artery flow remained normal and the true lumen fully patent and clear of thrombus.