Bovine Aortic Arch Research Articles

Unilateral Cardioembolic Stroke in a Patient With Aortic Arch Anomaly

A human immunodeficiency virus (HIV)-positive 29-year-old man presented with pre-syncope and acute left hemispheric infarction in multiple vascular territories. Thorax computed tomography (CT) with contrast showed bovine aortic arch and a left atrium large mass. On transthoracic echo, a 2.1 × 2.6 cm mass pointed to the heart as the embolic source. Successful surgical resection revealed cardiac myxoma. Although this presentation mimicked artery to artery embolization but having a bovine aortic arch can contribute to this stroke propensity to the left hemisphere. J Neurol Res. 2020;10(3):95-98 doi: https://doi.org/10.14740/jnr584

Computational Fluid Dynamics Modeling of Proximal Landing Zones for Thoracic Endovascular Aortic Repair in the Bovine Arch Variant

To assess the endograft displacement forces (DF), which quantify the forces exerted by the pulsatile blood flow on the vessel wall and transmitted on the terminal fixation site of the endograft after its deployment in proximal landing zones (PLZs) of the bovine aortic arch variant. Thirty healthy aortic computed tomographic angiographies of subjects with bovine arch configuration (10 per type of arch, I-III) were selected for the purpose of the study. A 3-dimensional model of the aortic arch lumen was reconstructed. Computational fluid dynamics modeling was then used to compute DF magnitude and orientation (i.e., x, y, and z axes) in PLZs of each case. DF values were normalized to the corresponding aortic wall area to estimate equivalent surface traction (EST). DF were highest in zone 0, consistently with the greater surface area. DF in zone 3 were much greater than in zone 2 because of a 3-fold greater upward component (z axis) (P<0.001), being therefore mainly oriented orthogonally to the aortic blood flow and to the vessel longitudinal axis in that zone. EST progressively increased from zone 0 toward more distal PLZs, with EST in zone 3 being much greater than that in zone 2 (P<0.001). The same pattern was observed after stratification by type of arch. The bovine arch is associated with a consistent fluid dynamic pattern, which identifies in zone 3 an unfavorable biomechanical environment for endograft deployment.

Unusual enhancement patterns from inadvertent arterial contrast injection during CT angiography

Investigation of cerebrovascular incidents typically involve non-contrast intracranial computed tomography (CT) and CT angiography (CTA) of the arch of aorta to vertex with or without CT perfusion. Though rare, inadvertent direct arterial contrast injection is a potentially serious complication which can alter contrast distribution and timing resulting in non-diagnostic intracranial studies. If unnoticed, they can be misinterpreted as pathology leading to further unnecessary investigations, increasing patient radiation dose and delaying appropriate management.To date, there have been two documented case reports describing arterial contrast injection in cerebral CTA or CT perfusion. We describe two further cases of arterial contrast administration. Furthermore, by describing various contrast enhancement patterns in normal and variant anatomy – such as bovine aortic arch, vertebral artery dominance, posterior inferior cerebellar artery (PICA) continuation of vertebral artery and fetal posterior communicating artery (PCOM) – we hope to improve clinician recognition of inadvertent arterial contrast injection in a timely fashion.

Significance of clamping distance in bovine and normal aortic arch patients

Bovine aortic arch is an anatomical variant in which the innominate and left common carotid arteries share a common origin. Coarctation of the aorta is a congenital heart defect characterized by narrowing of the aortic arch. Resection with extended end-to-end anastomosis through left thoracotomy, the usual preferred approach for coarctation repair, requires the placement of a proximal clamp just distal to the innominate artery and a distal clamp on the descending aorta. The clamping distance between the proximal clamp and the coarctation represents the length of vessel available for reconstructing the aorta. The goal of this study is to determine if bovine aortic arch anatomy affects clamping distance.Five hundred and fifty-four computed tomography scans performed on infants at our institution between 2012 and 2017 were analyzed. One hundred and sixty-nine scans met inclusion criteria. Fifty-eight exhibited bovine arch anatomy. Clamping distances were measured using multiplanar reconstruction. Clamping distances were indexed to body surface area to yield clamping index.The mean clamping distance was significantly shorter in bovine arch patients than in normal arch patients (p = 1.57 × 10−10). The mean clamping index was also significantly shorter in bovine arch patients (p = 0.0000014).This study demonstrates significantly shorter clamping indices in patients with bovine arch. Adequate clamping distance is required for a successful repair. Therefore, repair via lateral thoracotomy may not be ideal in bovine arch patients and adverse outcomes may be more likely. These patients may benefit from repair through median sternotomy.

Bovine Aortic Arch Variation in a Symptomatic Patient

Bovine Aortic Arch Variation in a Symptomatic Patient

Computed tomography angiographic anatomical features for successful transbrachial insertion of a balloon guide catheter for mechanical thrombectomy in acute ischemic stroke.

BACKGROUND AND PURPOSE:When the femoral approach for mechanical thrombectomy (MT) in acute ischemic stroke (AIS) is limited, trans-brachial or-radial access is an alternative. However, transbrachial insertion of a 9Fr (outer diameter [OD]) balloon guide catheter (BGC) into the carotid artery is not feasible. Computed tomographic (CT) angiography (CTA) may provide vascular anatomical information for successful insertion. We investigated CTA anatomical features for successful transbrachial insertion of a 9Fr BGC into the carotid artery.MATERIALS AND METHODS:We analyzed AIS patients who underwent CTA and transbrachial MT using a 9Fr BGC between 2014 and 2016. We evaluated the successful insertion rate and CT angiographic anatomical features.RESULTS:Twenty-four patients met our inclusion criteria. We achieved successful insertion in 18 (75%) of 24 cases: 7 (58.3%) of 12 for left carotid arteries and 11 (91.7%) of 12 for right carotid arteries. Successful insertion was achieved in 4 of 4 bovine aortic arch for left carotid occlusion and in 3 of 8 nonbovine aortic arches for left carotid occlusion. We achieved successful insertion in 3 nonbovine cases with takeoff angles ≥23° and failed insertion in 5 cases with takeoff angles <23°. We achieved successful insertion in 10 of the 10 cases with takeoff angles ≥25° in the right common carotid artery. The BGC was broken in 1 of 2 cases with takeoff angles <25°.CONCLUSIONS:The CTA provided a high likelihood of successful 9Fr OD BGC insertion without an introducer sheath. Successful transbrachial insertion was achieved in bovine left carotid cases, in nonbovine left carotid cases with takeoff angles ≥23°, and in right carotid cases with takeoff angles ≥25°.

Geometric Pattern of Proximal Landing Zones for Thoracic Endovascular Aortic Repair in the Bovine Arch Variant

Introduction: The so-called “bovine” aortic arch (BAA) is the second more common arch configuration and is characterized by the presence of a common origin of the innominate and left carotid artery, or, less frequently, by the origin of the left carotid directly from the innominate artery (i.e. type 2 BAA) (1). Its peculiar anatomic features mandate specific management strategies and preoperative planning in both surgical and endovascular procedures involving the aortic arch. Also, the BAA is recognized as a potential determinant of the onset of thoracic aortic disease (2), and this entails a relevant prevalence of this anatomic variant among patients requiring thoracic endovascular aortic repair (TEVAR). The aim of the present study was to investigate whether the BAA is associated with a consistent geometric pattern, and the potential impact of the BAA configuration on TEVAR planning. Methods: Anonymized thoracic computed tomography scans of healthy aortas were reviewed to retrieve 100 cases of BAA. Suitable cases were stratified according to type 1 and 2 BAA, and also based on the Aortic Arch Classification in Type I, II and III arch. Further processing allowed calculation of angulation and tortuosity of each proximal landing zone (PLZ). Center lumen line (CLL) lengths of each PLZ were measured in view perpendicular to the CLL. PLZs lengths were compared to those measured in healthy patients with a standard arch configuration (3). Results: The 100 selected patients (63% male) were 70±10 years old. Type 1 BAA (62/100) was more prevalent than type 2 BAA (38/100), and the two groups were comparable in age (P=.114). Zone 3 was associated with a severe angulation (i.e. >60°), whereas Zone 2 had a much lesser angulation compared to Zone 3 (P< .001), and a consistent moderate degree of angulation (i.e. 40°- 60°). Zone 3 was also associated with a consistently greater tortuosity than Zone 2 (P=.003). This pattern did not differ between type 1 and type 2 BAA. A greater tortuosity was also observed in Zone 0, which was related to increased elongation of the ascending aorta (i.e. Zone 0) compared to standard configuration. The BAA had an overall greater elongation, and Zone 2 also was specifically longer. When stratifying by Type of Arch, reversely from Type III to Type I (Figure 1), the BAA presented a gradual flattening of its transverse tract, providing a “cubic shape” to the whole arch (4). This entailed a consistent progressive elongation (P=.034) and kinking of the ascending aorta, with a significant increase of Zone 0 angulation to even a severe degree (P=.001). Also, from Type III to Type I, Zone 2 presented a progressively shorter length (P=.004), which was associated with an increased tortuosity (P=.045). Conclusion: BAA is associated with a consistent geometric configuration, which provides relevant information to improve preoperative TEVAR planning. Also, our findings suggest a potential role of the described anatomic pattern in the development of aortic aneurysms and dissections in patients with BAA variant, which warrants further specific biomechanical studies. Disclosure: Nothing to disclose

A Systematic Review and Meta-analysis of the Bovine Aortic Arch Variant as a Determinant of Thoracic Aortic Disease

Introduction: The Bovine Aortic Arch (BAA) is the second most common arch configuration in the general population.1Recent studies reported a higher BAA prevalence among patients affected with thoracic aortic disease (TAD).2-5This hypothesis, however, remains to be confirmed due to the limited evidence available. The objective of the present work was to statistically address the association between the BAA and the onset of TAD. Methods: A systematic review and meta-analysis was conducted according to the PRISMA statement standards.The PubMed, EMBASE and Cochrane databases were searched to identify all case series reporting about BAA and TAD between January 2008 and September 2018. A total of 462 studies were screened. The prevalence of BAA was assessed, and data analysis was performed considering the difference in the risk of TAD for the presence versus the absence of BAA. Results: Eight studies enrolling 10,513 subjects were retrieved for quantitative analysis. The prevalence of BAA among patients with TAD was higher (30.2%; 559/1852) than the prevalence in subjects without TAD (24.8%; 2367/9529). The risk of developing TAD was 1.4 times higher in subjects with BAA (Odds Ratio, 1.40; 95% CI 1,068-1,839).The test for an overall effect strongly indicated a significant association between BAA and TAD with a P value of < .0015 (Figure 1). The I2 was 78.1% with p< 0.001 for heterogeneity and therefore the random effect model was adopted. The Egger test did not show evidence of publication bias (p=0.317). Conclusion: Our meta-analysis strongly supports the hypothesis of a causative association between the presence of BAA and the onset of TAD. Our results warrant a specific and long-term surveillance for patients with BAA, and also a thorough awareness of the BAA potential clinical implications during image interpretation. Further studies are required to disclose the underlying pathophysiologic mechanism, which predispose these subjects to a higher risk of aortic disease. [Graph] Disclosure: Nothing to disclose

Prevalence of Bovine Aortic Arch Variant and its Implication in Outcome of Patients with Acute Type B Aortic Dissection

Introduction - Bovine aortic arch represents the most common variation of the aortic arch with a prevalence of 1-41% according to cadaveral or imaging studies.1,2,3 Although in older studies this pattern has been considered to cause no physiological abnormalities and to have less clinical impact, nowadays with the evolution of the surgical and endovascular interventions in the aortic arch, the presence of this variant could pose significant challenges to the surgeon or even implicate the outcome.4,5 This study aims to investigate the prevalence of bovine aortic arch (BAA) among patients with acute and/or subacute aortic dissection (AD) and to provide an insightful view of the implication of this arch variant on the outcome. Methods - A retrospective cohort analysis of two prospectively maintained databases with all patients with acute/subacute type B AD admitted to two tertiary university hospitals between January 2006 and December 2016 was conducted. All diagnostic CTAs were retrospectively reevaluated by two independent observers. A control group of 110 oncological patients was used, where the CT-scan for staging demonstrated aortic arch anatomy with no evidence of thoracic aortic disease. Patients with congenital heart defects or connective tissue disorders were excluded from the study. The presence of BAA was determined if the innominate artery and left common carotid artery had their separation point cranial to the plane of the greater curvature of the aortic arch. Two patterns were referred to as a BAA: a common origin of the innominate artery and left common carotid artery (BAA1) and the origin of the left common carotid of the innominate artery (BAA2). Results - A total of 154 patients (mean age 58.75±12.89, 64.3% males) with acute/subacute type B AD during the study period were identified. A total of 264 CTAs, including the control group, were analyzed. Prevalence of 18.2% (n=48) for BAA variants was revealed in the cohort. An isolated left vertebral artery was found in 13 patients (4.9%) whereas an aberrant right subclavian artery in 5 patients (1.9%). The BAA prevalence among the patients with acute/subacute type B AD was not statistically significantly different from the control group (18.8% vs. 17.3%, p=0.435). With regard to the patients with acute/subacute type B AD, 12 patients (7.8%) succumbed within 30 days from diagnosis, whereas 13 patients were lost during the median follow up of 27.8 (range 1.3-172.5) months. Among the remaining, 18 further patients died, resulting in an overall mortality of 21.3%. The multivariate analysis revealed the presence of a BAA as an independent predictor for overall mortality (Adjusted OR 3.44, 95%CI 1.2–9.8). Conclusion - A difference in the prevalence of the BAA between patients with AD and control group could not be confirmed. In patients with acute/subacute type B AD, the presence of a BAA may be considered as a predictor for mortality. Larger studies are needed to further investigate this observation.

Bovine aortic arch: Prevalence in human fetuses.

"Bovine aortic arch" is the second most common variant of aortic arch branching, in which only two branches originate directly from the aorta. The prevalence of this condition has been reported in different studies to be around 6% in human fetuses and 11-27% in the adult population. In this study, we describe the prevalence of bovine aortic arch in fetuses, and assess the prevalence of concomitant fetal anomalies. A retrospective analysis of 417 fetuses between 15-40 weeks of gestation. Data regarding branching of the fetal aortic arch and other fetal anomalies were collected by fetal echocardiography and/or fetal ultrasonography. A bovine arch was found in 20/413 fetuses (4.8%, 95CI 3.1-7.3%), of whom 14/310 (4.5%) had no fetal anomalies, and 6/77 (7.8%) exhibited minor changes (P = .241). None of the 26 fetuses with major anomalies had a bovine arch. Fetuses in this study had a lower prevalence of bovine aortic arch than that previously reported in adults, most probably due to differences in the population examined. This study was underpowered to determine that bovine arch is a common anatomic variant, and is not associated with fetal anomalies.

Higher Prevalence of Bovine Aortic Arch Configuration in Patients Undergoing Blunt Isthmic Aortic Trauma Repair

The prevalence of a bovine aortic arch configuration is higher in patients treated for thoracic aortic aneurysms and type B dissection; its prevalence in aortic isthmic trauma has not been described. A case control study was performed comparing consecutive patients treated at our institution for acute isthmic aortic transection after blunt trauma between 2002 and 2019 and a control group of consecutive sex-matched individuals undergoing imaging for nonaortic disease. Imaging and clinical findings were reviewed. Subjects were divided into bovine and nonbovine groups and prevalence was compared. The length of the aortic segment between the left subclavian artery (LSA) and the next proximal great vessel was measured in the control population and a comparison was performed between bovine and nonbovine aortic arch subjects. Thirty-three consecutive (30 male) patients were reviewed, 66 individuals (60 male) were included in the control group. A higher incidence of bovine arch in trauma patients was found: 57.6% vs. 34.8% (P=0.007). The median (range, mm) and mean (SD) distance between the bovine trunk and the LSA were 13mm (2-27) and 12.4mm (5.9), respectively, compared with 5mm (1-27) and 7.8mm (6.1) between the left common carotid and LSA in nonbovine aortic arches (P<0.005). A higher incidence of bovine arch in patients reaching out for surgical treatment for traumatic isthmic aortic transection was found in our population. Clinical interpretation of this finding can lead to several alternatives. Confirmation with larger series and data on prevalence of this anatomic variation in nonsurvivors is needed to provide a better understanding of this finding.

P20.01: Bovine aortic arch variant T2BAA: association with cardiovascular pathologies and fetal structural abnormalities

P20.01: Bovine aortic arch variant T2BAA: association with cardiovascular pathologies and fetal structural abnormalities

Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair in a Patient with Bovine Aortic Arch

Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair in a Patient with Bovine Aortic Arch

The so-called "bovine aortic arch": a possible biomarker for embolic strokes?

To examine the prevalence of the so-called bovine aortic arch variation (common origin of the brachiocephalic trunk and the left common carotid artery) in embolic stroke patients, compared with a control group. Aortic arch branching patterns were retrospectively evaluated in 474 individuals with (n = 152) and without (n = 322) acute embolic stroke of the anterior circulation. Contrast-enhanced CT scans of the chest and neck (arterial contrast phase, 1-2-mm slice thickness) were used to evaluate aortic arch anatomy. The stroke cohort included 152 patients who were treated for embolic strokes of the anterior circulation between 2008 and 2018. A total of 322 randomly selected patients who had received thoracic CT angiographies within the same time frame were included as a control group. With a prevalence of 25.7%, the bovine aortic arch variant was significantly more common among patients suffering from embolic strokes, compared with 17.1% of control patients (p = 0.039, OR = 1.67, 95%CI = 1.05-1.97). Stroke patients were more likely to show the bovine arch subtype B (left common carotid artery originating from the brachiocephalic trunk instead of the aortic arch) (10.5% vs. 5.0%, p = 0.039, OR = 2.25, 95%CI = 1.09-4.63), while subtype A (V-shaped common aortic origin of the brachiocephalic trunk and the left carotid) was similarly common in both groups. There was no significant difference regarding the frequency of other commonly observed variant branching patterns of the aortic arch. The bovine aortic arch, particularly the bovine arch subtype B, was significantly more common among embolic stroke patients. This might be due to altered hemodynamic properties within the bovine arch.

Insights into Arch Vessel Development in the Bovine Aortic Arch.

A bovine arch is the most common aortic arch variant, characterized by a common origin of the innominate artery and the left common carotid artery. Data have shown that children with bovine arch anatomy and coarctation are at a significantly higher risk of recoarctation following coarctation repair. This study aims to explain the higher coarctation rates, assess the branching of the arch vessels, understand their embryologic origins, and delineate the patterns of displacement of the arch vessels in bovine versus normal anatomy. This retrospective study reviewed the medical records of 178 infants ( < 1-year-old) who had a chest CT Angiogram (58) or CT (120) at our institution between 2007 and 2017. Multiplanar reconstruction software was used to obtain the best image plane to display the sinotubular junction, innominate artery, left common carotid artery, and left subclavian artery. We measured the distances between the branches as HV1, HV2, and HV3. All distances were standardized to body surface area and sinotubular junction diameter, which is a novel method. Bovine arches were found in 32.6% of patients. The total arch length of both arch anatomies was similar. HV3 is longer in bovine arches. HV1 + HV2 and HV2 + HV3 are longer in the normal arches than the bovine arches. The left subclavian artery moves proximally, and the innominate artery moves slightly distally to form the bovine arch and decreasing the clamping distance for coarctation repair. Aortic arch distances were similar when standardized to either sinotubular junction diameter and body surface area.

Total Endovascular Aortic Arch Repair with Branched Graft.

In selected cases, the utilization of branched endografts for the treatment of aortic arch aneurysms could be a safe and advantageous alternative to high-risk procedures such as open total aortic arch replacement or hybrid arch repair. We present the case of a 70-year-old man with saccular aneurysm of a bovine aortic arch which was endovascularly treated using a double-branched custom-made aortic endoprosthesis based on the Relay NBS (Non-Bare Stent) Plus platform intended for zone 0 deployment. The postoperative clinical course was uneventful. The postoperative computed tomography scan showed a good result of the implant. The patient was discharged 6 days after the procedure.

Successful mechanical thrombectomy via the transbrachial approach for acute ischemic stroke patient with chronic aortic dissection and bovine type aortic arch

Successful mechanical thrombectomy via the transbrachial approach for acute ischemic stroke patient with chronic aortic dissection and bovine type aortic arch

TRANSRADIAL APPROACH FOR CAROTID ARTERY STENTING

Approximately 20% of ischemic strokes are provoked by stenotic carotid artery lesions. With the growing experience of surgeons and the continued improvement of devices, carotid artery stenting has become an effective alternative to carotid endarterectomy. Traditional access to carotid artery stenting is transfemoral approach. However, due to peripheral artery disease and challenging anatomy of the aortic arch, transfemoral approach may be problematic. A number of randomized trials have proven the effcacy and safety of transradial access for coronary interventions. A similar technique was adapted for coronary artery stenting. The article provides a review of the major studies dedicated to coronary artery stenting via transradial approach, discusses all benefts and limitations as well as provide the guide to select an optimal vascular access, depending on the patient's anatomical characteristics. Transradial approach is shown to be a good alternative to transfemoral approach for coronary artery stenting. However, it is accompanied by a high rate of unsuccessful procedures compared to transfemoral approach. Nevertheless, transradial approach is accompanied by a decrease in the rate of vascular complications, and is preferable for intervening on the right ICA, or on the left with bovine aortic arch.

"Bovine Aortic Arch" in a Patient with Simultaneous Bihemispheric Embolic Infarcts.

"Bovine Aortic Arch" in a Patient with Simultaneous Bihemispheric Embolic Infarcts.

Sequential aneurysms of the internal carotid artery with fibromuscular dysplasia

A 50-year-old woman presented with a 6-month history of left-sided neck discomfort and headaches. She denied any history of lateralizing neurologic deficits and denied vascular risk factors including smoking and connective tissue disorders. Her physical examination demonstrated a tender pulsatile mass on the left side of the neck and an associated carotid bruit. Carotid duplex ultrasound revealed four left internal carotid artery (ICA) aneurysms consistent with aneurysmal degeneration secondary to fibromuscular dysplasia. Computed tomography angiography of the neck confirmed these findings and revealed a bovine aortic arch without significant occlusive disease. The largest aneurysm measured 2.0 cm in diameter with three smaller “string-of-beads” dilations extending to within 1 cm of the skull base (A/Cover). Treatment options included ongoing surveillance, open repair with an interposition graft, and endovascular repair using stent grafts to exclude the aneurysms. The patient rejected surveillance, given her symptoms and concern for thromboembolization. Open repair was deemed high risk because of the superior extent of the aneurysms. Therefore, we proceeded with an endovascular strategy using transfemoral access to select the left common carotid artery. Embolic protection was deferred because of the low atherosclerotic burden, and awake neuromonitoring was performed. Selective arteriography demonstrated the known left ICA aneurysms (B). A 0.018-inch wire was used to traverse the ICA aneurysms. A 6-mm × 5-cm Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) stent graft was placed distally and overlapped with an 8-mm × 5-cm Viabahn stent graft proximally to accommodate tapering of the native vessel. Completion arteriography revealed aneurysm exclusion and excellent flow to the intracranial ICA (C). The patient was maintained on clopidogrel postoperatively. At 1 month, she was free from complications, and follow-up computed tomography angiography demonstrated aneurysm exclusion and patent stent grafts (D). The patient's consent was obtained for publication. Extracranial carotid artery aneurysms (ECAAs) are rare and have primarily been treated with open surgery.1McCollum C.H. Wheeler W.G. Noon G.P. DeBakey M.E. Aneurysms of the extracranial carotid artery. Twenty-one years' experience.Am J Surg. 1979; 137: 196-200Abstract Full Text PDF PubMed Scopus (231) Google Scholar Common causes of ECAAs remain atherosclerosis and trauma; however, fibromuscular dysplasia is responsible for 8% to 11% of all ECAAs.2El-Sabrout R. Cooley D.A. Extracranial carotid artery aneurysms: Texas Heart Institute experience.J Vasc Surg. 2000; 31: 702-712Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 3Fankhauser G.T. Stone W.M. Fowl R.J. O'Donnell M.E. Bower T.C. Meyer F.B. et al.Surgical and medical management of extracranial carotid artery aneurysms.J Vasc Surg. 2015; 61: 389-393Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Endovascular repair of ECAAs is increasingly used to decrease morbidity and mortality associated with repair of ECAAs complicated by redo surgical fields or prior radiation exposure and for those that extend to the skull base.2El-Sabrout R. Cooley D.A. Extracranial carotid artery aneurysms: Texas Heart Institute experience.J Vasc Surg. 2000; 31: 702-712Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 3Fankhauser G.T. Stone W.M. Fowl R.J. O'Donnell M.E. Bower T.C. Meyer F.B. et al.Surgical and medical management of extracranial carotid artery aneurysms.J Vasc Surg. 2015; 61: 389-393Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 4Zhou W. Lin P.H. Bush R.L. Peden E. Guerrero M.A. Terramani T. et al.Carotid artery aneurysm: evolution of management over two decades.J Vasc Surg. 2006; 43 (discussion: 497): 493-496Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 5Li Z. Chang G. Yao C. Guo L. Liu Y. Wang M. et al.Endovascular stenting of extracranial carotid artery aneurysm: a systematic review.Eur J Vasc Endovasc Surg. 2011; 42: 419-426Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar