Carotid Aneurysm Research Articles

Flow diversion device for the management of an extracranial internal carotid artery aneurysm.

Our patient is a 60-year-old woman with a history of hypertension, hypothyroidism, and glossal hemangioma. She works as a standardized patient actor in our simulation center. A neck ultrasound scan performed during one of the simulation sessions demonstrated a left internal carotid artery aneurysm, which prompted a consultation with Vascular Surgery. She denied any symptoms associated with this aneurysm. On physical examination, there was a palpable pulsatile mass below the left mandibular angle. On computed tomography angiography, a 2.3- × 1.9- × 2.2-cm saccular aneurysm of the extracranial left internal carotid artery was noted (A). After multidisciplinary discussion, the decision was made to proceed with endovascular treatment using flow diversion due to the patient's desire of avoiding a scar in the neck, aneurysm size, and risk for thrombus formation and embolization. A 5.0- × 25-mm Pipeline flow-diversion device (PED; Medtronic) was deployed across the lesion with no event. The patient was observed overnight and discharged the following day with a normal neurological examination and on aspirin 81 mg and clopidogrel 75 mg daily as an antiplatelet regimen. On 1-month follow-up computed tomography angiography, the stent demonstrated excellent apposition to the wall of the artery and excellent flow through this vessel (B). Extracranial carotid artery aneurysm has a prevalence of 0.4%-1% among all peripheral artery aneurysms.1Qiu J. Zhou W. Zhu X. Zhou W. Zeng Q. Huang L. et al.Treatment of extracranial carotid artery aneurysm: fifteen years' experience at a single institution.Ann Vasc Surg. 2020; 69: 174-181Google Scholar The neurologic symptoms experienced by patients include transient ischemic attacks and ischemic strokes.2Welleweerd J.C. den Ruijter H.M. Nelissen B.G. Bots M.L. Kappelle L.J. Rinkel G.J. et al.Management of extracranial carotid artery aneurysm.Eur J Vasc Endovasc Surg. 2015; 50: 141-147Google Scholar The first successful treatment for an aneurysm in this location was performed by Sir Astley Cooper in 1808 through ligation of the proximal carotid artery.3Kraemer C.J.K. Zhou W. Carotid aneurysm review.Int J Angiol. 2019; 28: 17-19Google Scholar Then, in 1952, Dimtza4Dimtza A. Aneurysms of the carotid arteries; report of two cases.Angiology. 1956; 7: 218-227Google Scholar reported the first successful resection with end-to-end anastomosis. In the past 10 years, with the development of endovascular techniques, the treatment options of carotid artery aneurysms have included open surgery, endovascular procedures, and hybrid techniques.1Qiu J. Zhou W. Zhu X. Zhou W. Zeng Q. Huang L. et al.Treatment of extracranial carotid artery aneurysm: fifteen years' experience at a single institution.Ann Vasc Surg. 2020; 69: 174-181Google Scholar A review published by Qiu et al1Qiu J. Zhou W. Zhu X. Zhou W. Zeng Q. Huang L. et al.Treatment of extracranial carotid artery aneurysm: fifteen years' experience at a single institution.Ann Vasc Surg. 2020; 69: 174-181Google Scholar reports that the optimal management option for the treatment of carotid artery aneurysms is dependent on the morphology of the artery and the properties of the aneurysm. Recent advances in endovascular treatment allow for the utilization of flow diversion outside the skull, and treatment of extracranial internal carotid artery pseudoaneurysms with flow diversion has been shown to be safe and effective in selected patients.5Akinduro O.O. Gopal N. Hasan T.F. Nourollah-Zadeh E. Vakharia K. De Leacy R. et al.Pipeline embolization device for treatment of extracranial internal carotid artery pseudoaneurysms: a multicenter evaluation of safety and efficacy.Neurosurgery. 2020; 87: 770-778Google Scholar Informed consent was obtained from this patient for this publication.

Long-term results and comparison of flow re-direction endoluminal device and pipeline embolization device in endovascular treatment of intracranial carotid aneurysms.

This study aims to compare the efficacy, safety, and long-term outcomes of two flow diverters, i.e., pipeline embolization device and flow re-direction endoluminal device, in the treatment of distal carotid aneurysms. A total of 138 patients with 175 aneurysms were included from February 2012 to September 2019. Ninety-nine aneurysms were treated with flow re-direction endoluminal device and 76 with pipeline embolization device. Angiographic follow-ups were at the 6th, 12th, 24th, 36th, and 60th months; the O'Kelly-Marotta grading scale was used to assess aneurysms occlusion. Outcomes of two devices were compared; possible associations regarding patient characteristics, aneurysm properties, treatment details, and adverse events were evaluated. The mean follow-up period was 33 months, with 10 patients lost to follow-up. Occlusion rates at the 6th and 12th months and during the last follow-up were similar for flow re-direction endoluminal device (81%, 84%, and 90%) and pipeline embolization device (82%, 85%, and 93%). Occlusion rates were also similar after stand-alone use without coiling. There was no significant difference regarding adverse event rates with a 10.9% overall complication rate, 3.6% mortality, and 0.7% permanent morbidity. All the mortality and morbidity were related to hemorrhagic complications. Device deployment failure was observed with five flow re-direction endoluminal devices and two pipeline embolization devices, whereas two severe in-stent stenoses occurred with each device. Both flow re-direction endoluminal device and pipeline embolization device are feasible and effective in flow diversion of distal internal carotid artery aneurysms, with similar adverse events rates and aneurysm occlusion success. Aneurysm occlusion rates increase with time, while the presence of an integrated branch significantly decreases treatment success.

Prediction of atherosclerotic changes in cavernous carotid aneurysms based on computational fluid dynamics analysis: a proof-of-concept study.

Recent computational fluid dynamics (CFD) studies have demonstrated the concurrence of atherosclerotic changes in regions exposed to prolonged blood residence. In this proof-of-concept study, we investigated a small but homogeneous cohort of large, cavernous carotid aneurysms (CCAs) to establish the clinical feasibility of CFD analysis in treatment planning, based on the association between pathophysiology and hemodynamics. This study included 15 patients with individual large CCAs. We identified calcifications, which indicated atherosclerotic changes, using the masking data of digital subtraction angiography. We conducted a CFD simulation under patient-specific inlet flow rates measured using magnetic resonance (MR) velocimetry. In the post-CFD analysis, we calculated the blood residence time ([Formula: see text]) and segmented the surface exposed to blood residence time over 1s ([Formula: see text]). We measured the decrease in volume after flow diversion using the original time-of-flight MR angiography data. Calcifications were observed in the region with [Formula: see text]. In addition, the ratio of [Formula: see text] to the surface of the aneurysmal domain exhibited a negative relationship with the rate of volume reduction at the 6- and 12-month follow-ups. Post-CFD visualization demonstrated that intra-aneurysmal swirling flow prolonged blood residence time under the condition of a small inlet flow rate, when compared to the aneurysmal volume. The results of this study suggest the usefulness of CFD analysis for the diagnosis of atherosclerotic changes in large CCAs that may affect the therapeutic response after flow diversion.

A Novel Technique of Microcatheter Shaping using Real Image Display for Endovascular Aneurysmal Coil Embolization.

In coil embolization of intracranial aneurysms, guiding the microcatheter to an appropriate site in the aneurysm and stabilizing it there are important. In paraclinoid internal carotid aneurysms, complicated three-dimensional (3-D) shaping of the microcatheter tip is occasionally required. We devised a novel shaping method for microcatheters by using a real image display (RID). The usefulness of this technique was validated. We used a RID consisting of a couple of concave mirrors. A piece of patient-specific vascular model, which was made using a 3-D printer before the operation, was set inside the RID. We obtained a real 3-D image just above the RID. As a microcatheter and its shaping inner mandrel could be entered in the hologram of the vasculature, we could create the actual shape of the microcatheter. The shaped microcatheter could be navigated at the desired position in the aneurysm. Complete obliteration of the aneurysm was achieved without any trouble among 30 consecutive cases. We evaluated the effectiveness of the RID for making and navigating a microcatheter in cases with challenging anatomies. It was useful for favorable microcatheter shaping, as the RID could be entered inside the aneurysm models, unlike when tracing the outer surface of rigid 3-D models.

Peri-operative Myocardial Injury After Complex Endovascular Aortic Aneurysm Repair: MINS Is Not Meaningless

Ischaemic cardiomyopathy is prevalent in peripheral vascular patients, with surgically correctable coronary lesions identified in one of three patients with abdominal aortic aneurysms (AAAs).1 Therefore, it is not surprising that peri-operative myocardial injury after non-cardiac surgery (MINS) remains a common complication, probably due to multiple factors such as demand ischaemia and systemic inflammatory response. Although MINS is largely a laboratory diagnosis based on rising troponin levels without symptoms of myocardial infarction, it has been shown to affect short and long term survival after carotid, lower extremity, and aortic aneurysm surgery.

Surgical and Endovascular Management of Extracranial Carotid Aneurysms, Outcomes from the American College of Surgeons, National Surgical Quality Improvement Program

Extracranial carotid artery aneurysms (ECAAs) are rare. Etiologies include dissection, atherosclerosis, trauma, mycotic infection, and iatrogenic. Patients are often asymptomatic at the time of diagnosis, but some present with a palpable mass or after an embolic cerebrovascular accident. Management of ECAAs includes thromboprophylaxis and surgical excision or exclusion of the aneurysmal segment. Intervention criterion for ECAAs has not been clearly delineated for either asymptomatic or symptomatic disease.

Management of Coincident Pituitary Macroadenoma and Cavernous Carotid Aneurysm: A Systematic Literature Review

Introduction Pituitary adenomas are a common intracranial pathology with an incidence of 15 to 20% in the population while cerebral aneurysms are less common with a prevalence of 1:50 patients. The incidence of aneurysms in patients with pituitary adenoma has been estimated at 2.3 to 5.4% of patients; however, this remains unclear. Equally, the management of concomitant lesions lacks significant understanding. Methods A case report is presented of a concomitant cerebral aneurysm and pituitary adenoma managed by minimally invasive endovascular and endoscopic methods, respectively. A systematic review of the literature for terms “pituitary adenoma” and “aneurysm” yielded 494 studies that were narrowed to 19 relevant articles. Results We report a case of a 67-year-old patient with an enlarging pituitary macroadenoma, cavernous carotid aneurysm, and unilateral carotid occlusion. After successful treatment of the aneurysm by a pipeline flow diverter, the pituitary adenoma was surgically resected by an endoscopic transsphenoidal approach. Conclusion The use of a pipeline flow diverter and endonasal approach was feasible in the treatment of our patient. This is the first report to our knowledge of the use of pipeline flow diversion in the management of a cavernous carotid aneurysm prior to pituitary adenoma treatment.

Role of 3D Printing and Modeling to Aid in Neuroradiology Education for Medical Trainees.

Applications of 3-dimensional (3D) printing in medical imaging and health care are expanding. Currently, primary uses involve presurgical planning and patient and medical trainee education. Neuroradiology is a complex subdiscipline of radiology that requires further training beyond radiology residency. This review seeks to explore the clinical value of 3D printing and modeling specifically in enhancing neuroradiology education for radiology physician residents and medical trainees. A brief review summarizing the key steps from radiologic image to 3D printed model is provided, including storage of computed tomography and magnetic resonance imaging data as digital imaging and communications in medicine files; conversion to standard tessellation language (STL) format; manipulation of STL files in interactive medical image control system software (Materialise) to create 3D models; and 3D printing using various resins via a Formlabs 2 printer. For the purposes of demonstration and proof of concept, neuroanatomy models deemed crucial in early radiology education were created via open-source hardware designs under free or open licenses. 3D-printed objects included a sphenoid bone, cerebellum, skull base, middle ear labyrinth and ossicles, mandible, circle of Willis, carotid aneurysm, and lumbar spine using a combination of clear, white, and elastic resins. Based on this single-institution experience, 3D-printed complex neuroanatomical structures seem feasible and may enhance resident education and patient safety. These same steps and principles may be applied to other subspecialties of radiology. Artificial intelligence also has the potential to advance the 3D process.

ANTERIOR CLINOIDECTOMY IN CLINOID SEGMENT INTERNAL CAROTID ANEURYSMS AND PARACLINOID MENINGIOMA: FROM ANATOMY TO NEUROSURGERY

Objectives: To assess the role of anatomy in the anterior clinoidectomy. Patients and methods: Retrospective study with ten patients who were surgically treated with the anterior clinoidectomy for the paraclinoid lesions at Viet-Duc Hospital from January 2020 to December 2020. Results: Mean age: 42.58 ± 12.49; sixty percents male and forty percents female. There was only one case that had pneumatization of the anterior clinoid process. On diagnosis, there were four cases with internal carotid aneurysms and six cases of paraclinoid meningioma. The extradural anterior clinoidectomy were in seven cases while the intradural way was in three cases. There was only one case of cerebrospinal fluid rhinorrhea as a complication. Conclusion: The anterior cliniodectomy was still challenging in neurosurgery. Understanding the anatomy of the anterior clinoid process was mandatory.

Unruptured Paraclinoid Carotid Aneurysms Occur More Frequently in Younger Ages.

PurposeWe investigated the age distribution of cerebral saccular aneurysms in various locations to clarify the differences by location and discuss the mechanism of formation.Materials and MethodsWe retrospectively assessed clinical material obtained from 1,252 unruptured aneurysms treated with endovascular embolization between 2004 and 2019. Age, sex, laterality, and size were investigated by the location of aneurysms, classified as cavernous internal carotid artery (ICA), paraclinoid ICA, supraclinoid ICA, anterior communicating artery, anterior cerebral artery, middle cerebral artery, basilar artery complex, and posterior inferior cerebellar artery. Paraclinoid aneurysms were subclassified into 3 patterns according to their projecting direction: S-type, with superior protrusion; M-type, with medial protrusion; and P-type, with posteroinferior protrusion.ResultsThere was no significant difference by location for sex, laterality, and size. The mean age of patients with paraclinoid aneurysms (56.5 years old) was significantly lower than that of other aneurysm patients (64.3 years old). Notably, 40% of the patients with M-type aneurysms were <50 years old. This percentage was significantly higher than that of aneurysms at other locations (P<0.05).ConclusionWe found a young female predominance for patients with paraclinoid carotid aneurysms. This study may suggest that congenital factors contribute to paraclinoid aneurysm formation as well acquired factors, such as hemodynamic stress, atherosclerotic wall damage, and local inflammation.

Evaluation of a novel flow diverter, the DiVeRt system, in an animal model

BackgroundUsing a surgical aneurysm model, this study assessed the performance of a new flow diverter (FD), the DiVeRt, and evaluated the angiographic and histologic features at different periods after stent...

Clinical application of combined infratemporal fossa approaches for internal carotid artery in petrous bone reconstruction for large lateral skull base tumors

Objective: By summarizing the technical points and therapeutic outcomes of combing infratemporal fossa approach (IFA) and internal carotid artery (ICA) reconstruction for the colossal skull base tumor invading ICA in petrous bone, the clinical application value was discussed. Methods: Five patients (2 males, 3 females,aging from 27 to 55 years old) who received surgeries between July 2015 and May 2017 for lateral skull base pathology involved petrous ICA using technique combined IFA and pre-reconstruction, were reviewed. Results: Among the five patients, three were paraganglioma of head and neck, one was carotid aneurysms, and one was recurrent adenoid cystic carcinoma (ACC). The median tumor size in the largest cross-section was 60 mm × 51 mm (range, 28 mm × 22 mm-72 mm × 58 mm). Complete excision was achieved with IFA and ICA reconstruction. The median blood loss volume was 1 000 ml (range, 600-2 500 ml). Four cases showed no new long-term neurologic sequelae, while one showed hemiplegia due to graft vessel occlusion. Except for the one with ACC having facial nerve cut, others achieved good facial nerve function of HB grade Ⅰ to Ⅱ during 3 to 12 months, follow-up. No tumor recurrence was observed over the median duration of follow-up for above 36 months (range, 36-58 months). Conclusion: For lesions involved superior part of ICA, which is unable to separate from ICA, IFA and ICA reconstruction can achieve complete excision.

Quantitative Assessment of Changes in Hemodynamics After Obliteration of Large Intracranial Carotid Aneurysms Using Computational Fluid Dynamics.

Background: It was speculated that the alteration of the geometry of the artery might lead to hemodynamic changes of distal arteries. This study was to investigate the hemodynamic changes of distal arterial trees, and to identify the factors accounting for hyperperfusion after the obliteration of large intracranial aneurysms.Methods: We retrospectively reviewed data of 12 patients with intracranial carotid aneurysms. Parametric models with intracranial carotid aneurysm were created. Patient-specific geometries were generated by three-dimensional rotational angiography. To mimic the arterial geometries after complete obliteration of the aneurysms, the aneurysms were virtually removed. The Navier–Stokes equations were solved using ANSYS CFX 14. The average wall shear stress, pressure and flow velocity were measured.Results: Pressure ratio values were significantly higher in A1 segments, M1 segments, and M2 + M3 segments after obliteration of the aneurysms (p = 0.048 in A1 segments, p = 0.017 in M1 segments, p = 0.001 in M2 + M3 segments). Velocity ratio values were significantly higher in M1 segments and M2 + M3 segments after obliteration of the aneurysms (p = 0.047 in M1 segments, p = 0.046 in M2 + M3 segments). The percentage of pressure ratio increase after obliteration of aneurysms was significantly correlated with aneurysmal angle (r = 0.739, p = 0.006 for M2 + M3).Conclusions: The pressure and flow velocity of distal arterial trees became higher after obliteration of aneurysms. The angle between the aneurysm and the parent artery was the factor accounting for pressure increase after treatment.

Internal carotid artery false aneurysm as a fatal complication of transsphenoidal surgery

False aneurysm of internal carotid artery (ICA) is a rare but serious vascular complication observed after transsphenoidal pituitary surgery. Here, we present a 41-year-old woman with a pseudoaneurysm in the ophthalmic1 segment of the left ICA after exoscopic transsphenoidal pituitary surgery. The initially uneventful procedure was complicated by a subarachnoidal hemorrhage 10 days after the surgery, which was confirmed by cranial computed tomography scan. The emergency angiography revealed a pseudoaneurysm of the ophthalmic1 part of the left ICA. Despite repeated endovascular treatments with a flow diverter and coiling, the patient experienced a re-bleeding with consecutive vasospasms, occlusion hydrocephalus and finally bifrontal intracerebral hemorrhage with fatal outcome. As a conclusion in irregular post-operative courses with for example headache, a post-operative magnetic resonance imaging with vessel presentation using TOF sequence and contrast-enhanced MRA might be recommended in order to detect a possible pseudoaneurysm in an early stage.

Bypass Surgery to Treat Giant Cavernous Carotid Artery Aneurysms.

With the development of bypass technique, more and more complex aneurysms can be treated with bypass surgery. The goal of this study is to evaluate the efficacy and safety of bypass in patients with giant cavernous carotid aneurysms (GCCAs). To further discuss the treatment of asymptomatic GCCAs. The authors retrospectively reviewed our experience of the internal carotid artery (ICA) ligation/constriction combined with high/low-flow bypass surgery in the treatment of GCCAs. Among the entire cohort, 4 patients underwent ICA ligation combined with high-flow bypass, 7 patients underwent ICA ligation/constriction combined with low-flow bypass. The postoperative symptom improvement: of 9 patients with preoperative ophthalmoplegia, the symptom resolved in 2 patients, improved in 7 patients, of 7 patients with preoperative pain, the symptom resolved in 2 patients, improved in 4 patients and was unchanged in 1 patient. The results of following-up were measured using the modified Rankin scale (mRS). During the follow-up, there were 9 patients with mRS score 0 to 1, 1 patient with mRS score 2, and 1 patient with mRS score 3. The long-term graft patency rate was 100%. All patients had no recurrence of intracranial aneurysm. Bypass surgery is a safe and effective method to treat GCCAs. Because of the risk of GCCAs and the improvement of bypass surgery technology, active surgical strategies should be adopted for asymptomatic or mild symptomatic GCCAs.

Comparison of Patient Outcomes Among Integrated Residency Versus Fellowship-Trained Vascular Surgeons.

Objective This study aims to evaluate whether graduates of integrated vascular surgery residency (IVSR) programs achieve similar surgical outcomes in clinical practice as compared to graduates of vascular surgery fellowships (VSF). Summary background data Early sub-specialization through IVSR programs decreases the total years of surgical training. However, it is unclear whether IVSR graduates achieve comparable outcomes to fellowship-trained surgeons once in clinical practice. Methods We identified all vascular surgeons who finished IVSR and VSF programs between 2013-2017 using American Board of Surgery data, which was linked to the Vascular Quality Initiative (VQI) registry (2013-2019) to evaluate provider-specific clinical outcomes following carotid, lower extremity, and aortic aneurysm repair procedures. The association between training models and the composite outcome of 1-year mortality, major adverse cardiac events and/or other major complications were analyzed using mixed-effects logistic regression models. Results A total of 338 surgeons (31% IVSR, 69% VSF) submitted cases into the VQI registry, including 8,155 carotid, 21,428 lower extremity, and 5,800 aortic aneurysm repair procedures. Composite 1-year outcome rates were comparable between IVSR and VSF-trained surgeons following carotid endarterectomy (8%-IVSR vs. 7%-VSF), lower extremity revascularization (19%-IVSR vs. 16%-VSF), and aortic aneurysm repair (13%-IVSR vs. 13%-VSF) procedures. These findings among IVSR-trained surgeons persisted following risk adjustment for severity of patient disease and indications for undertaking carotid [aOR:1.04 (0.84-1.28)], lower extremity [aOR:1.03 (0.84-1.26)], and aortic [aOR:0.96 (0.76-1.21)] procedures when compared to VSF-trained surgeons. Conclusions Despite fewer total years of training, graduates of IVSR programs achieve equivalent surgical outcomes as fellowship-trained vascular surgeons once in practice. These results suggest that concerns about differential competence among integrated residency graduates are not warranted.

Medical treatment of polymeric cerebral granulomatous reactions following endovascular procedures

BackgroundEndovascular procedures are standard of care for an increasing range of cerebrovascular diseases. Many endovascular devices contain plastic and are coated with a hydrophilic polymer which has been rarely described...

Treatment of distal unruptured intracranial aneurysms using a surface-modified flow diverter under prasugrel monotherapy: a pilot safety trial

BackgroundFlow diverters (FDs) are effective in the treatment of carotid aneurysms. Compared with carotid aneurysms, the treatment of distal intracranial aneurysms with FDs has been associated with a relatively high...

Emergency Endovascular Treatment of Recurrent Internal Carotid Artery False Aneurysm Complicated By Carotid-Cutaneous Fistula and Life-Threatening Bleeding

Background: Carotid pseudoaneurysms can generally be the result of arterial wall degeneration developed after carotid endarterectomy, previous spontaneous carotid dissection, post-traumatic neck injuries, non-vascular procedures and, rarely, infections. The ideal surgical management of extracranial carotid artery false aneurysms is still controversial and treatment should be tailored to the aneurysm’s aetiology, anatomy and presentation. Case presentation: We describe the case of an 81-year-old man presented with an enlarged pulsatile cervical mass coupled with a small cutaneous fistula, which had developed in roughly 1 year. He had undergone several carotid operations over the last 15 years (endarterectomy, venous-patch-angioplasty for restenosis and bovine-pericardial patch-angioplasty for a pseudoaneurysm). Methods: A CT-Scan revealed a recurrent pseudoaneurysm. Due to the previous multiple cervicotomies, the aneurysm wall was very closely adjacent to the skin plane; no gas bubbles or cervical fluid collections were evident. The patient rejected treatment at first, but six months later suffered major bleeding from the fistula. Results: The pseudoaneurysm was emergency excluded with a Viabhan-Stent-graft while the external carotid artery was occluded via vascular-plug. The fistula healed spontaneously in four months. There was no pseudo-aneurysm recurrence, endoleak or any sign of graft infection at 36-month follow-up. Conclusion: We present a singular case of emergency endovascular treatment of recurrent post-surgical internal carotid artery pseudoaneurysm complicated by a carotid-cutaneous and life-threatening bleeding. In these cases emergency endovascular treatment via covered-stent-graft represents the most effective, definitive or “bridge” management option. Carotid sheath protection via a myo-cutaneous flap could be considered in cases of previous multiple cerivcotomies.

A novel approach to high-grade carotid stenosis with concomitant extracranial carotid aneurysms using transcarotid artery revascularization

We present the novel application of transcarotid artery revascularization (TCAR) in two high-risk patients with high-grade internal artery stenosis and concomitant atherosclerotic extracranial carotid artery aneurysms (ECAAs). ECAAs account for <1% of arterial aneurysms and are usually clinically silent at presentation. Historically, the treatment of ECAAs has been via open reconstruction or stent grafting. TCAR is an effective alternative for carotid revascularization in high-risk patients with high-grade carotid stenosis, but has not been widely used for aneurysmal management. We report two cases to describe our management of concomitant carotid stenoses and ECCA with TCAR.