Dissecting Pseudoaneurysm Research Articles

A rare dissecting anterior inferior cerebellar artery aneurysm treated with flow diversion using a silk vista baby device.

Dissecting intracranial pseudoaneurysms represent a challenge for treatment both endovascularly and surgically. We review the treatment course of a ruptured anterior inferior cerebellar artery (AICA) dissecting pseudoaneurysm in a 50-year-old patient and review the history of dissecting aneurysms and AICA aneurysms treatment. An aneurysm cure was achieved using flow diversion in the AICA. The recent introduction of flow diversion devices that can be deployed through 0.017" microcatheters represents a new avenue for treatment of aneurysms. To the best of our knowledge this is the first published case of flow diversion in the(?) AICA to treat a dissecting aneurysm. The introduction of Silk Vista Baby and similar future devices is likely to widen the scope of aneurysm treatment utilizing flow diversion in distal distribution with small parent arteries.

Clinical outcomes after successful revascularization of long chronic total occlusions using amphilimus-eluting polymer-free stent: a single center experience.

Chronic total occlusions (CTOs) are complex lesions that usually require stenting of long segments, and, therefore more prone to restenosis and/or thrombosis. Polymer-free stents to avoid chronic inflammatory response in the vessel wall are a potential solution to reduce target lesion revascularization. We, therefore, investigated the clinical outcomes following successful amphilimus-eluting polymer-free stent implantation in long CTOs. A total of 77 consecutive patients who underwent successful revascularization for long CTOs (lesion length ≥30 mm) using Cre8 stents were included. Baseline demographics, periprocedural characteristics, in-hospital events, and post-discharge long-term cardiovascular events were retrospectively screened for all patients. The Japanese CTO score was 1.58 ± 0.96, and the lesion length was 54.0 ± 9.89 mm. All cases were technically successful (n = 77, 100%), while procedural success was obtained in 74 patients (96.1%). Periprocedural complications were contrast-induced nephropathy (n = 4, 5.2%), coronary perforation (n = 3, 3.8%), residual dissection (n = 1, 1.3%), and femoral artery pseudoaneurysm (n = 1, 1.3%). Three patients (3.9%) presented periprocedural myocardial infarction requiring repeat percutaneous coronary intervention. At 25.0 ± 15.8 months follow-up, major adverse cardiac and cerebrovascular events were observed in 14 patients (18.1%). The Cre8 polymer-free drug- eluting stents seems safe and effective for percutaneous revascularization of long CTO lesions with a high success and low adverse event rate.

Safety and efficacy of the Pipeline Flex embolization device with Shield Technology for the acute treatment of ruptured internal carotid artery pseudoaneurysms: a multi-institution case series.

Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0-2. Complete occlusion at follow-up was observed in 82.6% of patients. PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.

Teaching NeuroImages: Rupture and spontaneous resolution of a P1 perforator pseudoaneurysm

A 47-year-old man with a history of smoking and hypertension had a severe, sudden headache. Head CT showed subarachnoid hemorrhage (SAH) (figure, A). Progressive ophthalmoplegia developed without alteration of consciousness. Catheter angiography was normal (figure, B). Brain MRI documented bilateral thalamic infarcts (figure, C). Repeat catheter angiography after 4 days showed a 2-mm dissecting pseudoaneurysm of a thalamoperforator (figure, D and E). Serial noninvasive vascular studies documented no growth. Six weeks later, a catheter angiogram demonstrated complete resolution of the pseudoaneurysm (figure, F).Bilateral third nerve palsy persisted at 1 year follow-up. Dissecting pseudoaneurysms of perforating posterior circulation vessels can present with a pattern suggestive of perimesencephalic SAH. Presence of associated neurologic deficits should increase the level of suspicion. Spontaneous resolution can occur without invasive treatment.1

Abstract Number ‐ 138: Complex symptomatic dissecting pseudoaneurysm with inflow zone stenosis required angioplasty before flow‐diversion‐a technical report.

Introduction 16.4 percent of patients diagnosed with fibromuscular dysplasia (FMD) are found to have internal carotid artery (ICA) dissection [1] which may lead to life threatening ICA dissecting pseudoaneurysm (ICADPA). Endovascular repair of ICADPA may be urgent when ICADPA is symptomatic, potential for rupture with no good alternatives. Tortuous anatomy with FMD and ICADS can represent a significant endovascular challenge, especially if there is an aneurysmal inflow‐zone stenosis.Objective: We present a unique case of right ICADPA with an inflow‐zone parent artery stenosis underwent angioplasty and repair with surpass evolve flow diverter (SEFD). Methods Case report and chart review. Results 49‐year‐old man history of hypertension, hyperlipidemia, and left ICADPA status post stenting/stent‐assisted coiling in 2017, who presented with right‐sided pulsatile tinnitus after a facial injury. Cerebral angiography revealed a tortuous right ICA with FMD, and presence of a right ICADPA at the skull base measuring 16×8 mm with inflow zone stenosis and a post‐stenotic dilatation. An emergency repair was performed with an informed consent under general anesthesia. In order for the SEFD to deploy properly, an angioplasty of inflow‐zone parent artery stenosis was performed with a 3×20mm Maverick balloon. Subsequently, a SEFD measuring 5×40 mm was deployed to cover the dissecting pseudoaneurysm, and a second SEFD measuring 5×20 mm was deployed covering the ICADS resulting in good apposition of SEFD and securement of ICADS.Use of a metal self‐deployable stent prior to flow diversion was not an option due to the presence of extreme tortuosity and acute angulations on the parent artery.patient was discharged home after 24 hours with 325 mg of aspirin and 75 mg of clopidogrel and good blood pressure control. 90‐days follow‐up, demonstrated good recovery with modified Rankin score of 0 with no symptoms. Conclusions ICADPA with aneurysmal inflow zone parent artery stenosis and the presence of extream tortuosity and acute angulations, may require angioplasty prior to the flow diversion for successful repair. Further studies are required.

Unusual Intracerebral Hemorrhage Secondary to Delayed Posttraumatic Middle Meningeal Artery Pseudoaneurysm, Successfully Treated by Endovascular N-Butyl Cyanoacrylate Embolization

AbstractPseudoaneurysm of the middle meningeal artery, presenting as a delayed sequela of trauma, being a rare entity, may sometimes present as an acute intraparenchymal hemorrhage, with a risk of rerupture and mortality. The optimal management in acute settings remains undetermined. We, hereby, report a case of elderly gentleman with a history of a road traffic accident. Noncontrast computed tomography (NCCT) brain was reported to have left parietal hemorrhagic contusion without any mass effect. The patient was managed conservatively without any major neurological deficits. After 7 months, the patient presented with severe headache, altered sensorium, and right hemiparesis. NCCT brain showed acute left thalamocapsular hemorrhage with minimal subarachnoid hemorrhage with associated mass effect and impending herniation. Considering the fall in patient's baseline Glasgow comma scale response, pupillary asymmetry, and CT findings, immediate decompression and hematoma evacuation were advised. In view of atypical morphology, the patient was planned for urgent digital subtraction angiography prior to the surgery to rule out the ruptured aneurysm or pial arterio-venous fistula. Selective angiography of the left external carotid artery demonstrated a dissecting pseudoaneurysm feeding from the middle meningeal artery (MMA), which was embolized using n-butyl cyanoacrylate (NBCA). Postprocedure DynaCT revealed the left temporal bone fracture, indicating this pseudoaneurysm to be most likely posttraumatic delayed sequelae. Postembolization, the patient underwent surgical decompression and excision of hematoma. Patient's neurological status gradually improved and was discharged with the minimal deficit. Our case highlights the importance of awareness of the posttraumatic MMA pseudoaneurysm as an uncommon but treatable entity, which can be easily diagnosed using cerebral angiography and amenable to safe and effective endovascular embolization using NBCA.

Cardiovascular manifestations of hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders.

Introduction: Mitral valve prolapse and aortic root dilatation are reported in association with hypermobile Ehlers-Danlos syndrome (hEDS), but the full phenotypic spectrum of cardiovascular complications in this condition has not been studied in the aftermath of updated nosology and diagnostic criteria. Methods: We performed a retrospective review of 258 patients (> 94% adults) referred to a multidisciplinary clinic for evaluation of joint hypermobility between January 2017 and December 2020 and diagnosed with hEDS or a hypermobility spectrum disorder (HSD) to determine the incidence and spectrum of cardiovascular involvement. Results: Mitral valve prolapse was present in 7.5% and thoracic aortic dilatation in 15.2%. Aortic dilatation was more frequent in individuals with hEDS (20.7%) than with HSD (7.7%) and similarly prevalent between males and females, although was mild in > 90% of females and moderate-to-severe in 50% of males. Five individuals (1.9%) with hEDS/HSD had extra-aortic arterial involvement, including cervical artery dissection (CeAD, n = 2), spontaneous coronary artery dissection (SCAD, n = 2), and SCAD plus celiac artery pseudoaneurysm (n = 1). This is the first series to report the prevalence of CeAD and SCAD in hEDS/HSD. Conclusions: Cardiovascular manifestations in adults with hEDS/HSD, especially females, are typically mild and readily assessed by echocardiography. Since the risk of progression has not yet been defined, adults with hEDS/HSD who are found to have aortic dilatation at baseline should continue ongoing surveillance to monitor for progressive dilatation. Cardiovascular medicine specialists, neurologists, and neurosurgeons should consider hEDS/HSD on the differential for patients with CeAD or SCAD who also have joint hypermobility.

An Odd Case of Melena: Chronic Celiac Artery Dissection and Hepatic Arterioduodenal Fistula

AbstractWe present the case of a 54-year-old chronic alcoholic man who presented to the emergency department with intermittent melena for 3 days. Imaging revealed a large dissecting pseudoaneurysm of the common hepatic artery with an arterioduodenal fistula in the second part of the duodenum. The pseudoaneurysm and fistula were managed with refined interventional techniques, and supply to the hepatic arteries was salvaged. In cases of melena that are difficult to diagnose through traditional means, early imaging and interventional management can prove beneficial and improve short-term survival.

Dissecting pseudoaneurysms: predictors of symptom occurrence, enlargement, clinical outcome, and treatment.

OBJECTIVE Dissection of the carotid and vertebral arteries can result in the development of aneurysmal dilations. These dissecting pseudoaneurysms can enlarge and cause symptoms. The objective of this study is to provide insight into the progression of dissecting pseudoaneurysms and the treatments required to manage them. METHODS A review of the electronic medical records was conducted to detect patients with carotid and vertebral artery dissection. An imaging review was conducted to identify patients with dissecting pseudoaneurysms. One hundred twelve patients with 120 dissecting pseudoaneurysms were identified. Univariate and multivariate analyses were conducted to assess the factors associated with undergoing further interventions other than medical treatment, pseudoaneurysm enlargement, pseudoaneurysms resulting in ischemic and nonischemic symptoms, and clinical outcome. RESULTS Overall, 18.3% of pseudoaneurysms were intracranial and 81.7% were extracranial, and the average size was 7.3 mm. The mean follow-up time was 29.3 months; 3.3% of patients had a recurrent transient ischemic attack, no patients had a recurrent stroke, and 14.2% of patients had recurrence of nonischemic symptoms (headache, neck pain, Horner syndrome, or cranial nerve palsy). Follow-up imaging demonstrated that 13.8% of pseudoaneurysms had enlarged, 30.2% had healed, and 56% had remained stable. In total, 20.8% of patients had an intervention other than medical treatment. Interventions included stenting, coiling, flow diversion, and clipping. Predictors of intervention included increasing size, size > 10 mm, location in the C2 (petrous) segment of the internal carotid artery (ICA), younger age, hyperlipidemia, pseudoaneurysm enlargement, and any symptom development. Significant predictors of enlargement included smoking, history of trauma, C2 location, hyperlipidemia, and larger initial pseudoaneurysm size. Predictors of pseudoaneurysm resulting in recurrent ischemic and nonischemic symptoms included increasing size and location in the petrous segment of the ICA. Smoking was a predictor of unfavorable outcome. CONCLUSIONS Dissecting pseudoaneurysms have a benign course and most will not cause symptoms or enlarge on follow-up. Medical treatment can be a sufficient, initial treatment for dissecting pseudoaneurysms.

Post Stab Injury Subclavin Artery Pseudoaneurysm Excision

Figure 1: Stab wound in supraclavicular region already sewn at local hospital. Figure 2: CT angiography showing subclavin artery pseudoaneurysm with two openings in subclavin artery anterior and posterior. Figure 3: A) Supraclavicular inscision to expose proximal subclavin artery B) Exposed subclavin artery. Figure 4: A) Excised pseudoaneurysm B) Opening in subclavin artery closed with vein patch. Figure 5: Closed tranaxillary and supraclavicular surgical incision with negative suction drain in situ. Abstract A pseudoaneurysm, also known as a false aneurysm, is a hematoma that forms as a result of a leaking hole in artery. Hematoma was contained by the surrounding tissues. Also it must continue to communicate with the artery to be considered a pseudoaneurysm. Post stab injury subclavin artery pseudoaneurysm is rare entity with great significance because of risk of complications like thrombosis, rupture, gangrene, limb loss and should be operated early whenever diagnosed. Our case report has 24 year male patient with history of stab injury to left supraclavicular region followed by pulsatile swelling after two days due to subclavin artery pseudoaneurysm. We excised pseudoaneurysm with vein patch closure of opening in subclavin artery. Introduction According to the literature data, post traumatic pseudoaneurysm is rare entity [1]. Most common site is common femoral artery, followed by radial and brachial artery but subclavin artery is very rare because trauma to it is rare. Incidence of complications associated with such pseudoaneurysm is estimated around 2-6% [2]. We present a case of the patient in whom pseudoaneurysm of left subclavin artery developed after two days of stab injury by pointed object and was successfully treated by surgical excision and vein patch closure of opening in subclavin artery. Case Report A 24 -years-old male patient was admitted at our Institute with history of stab injury to left supraclavicular region lateral side that was closed at local hospital (Figure 1). After two days the patient noticed gradually increasing pulsatile swelling at closed stab injury site. Clinical examination revealed presence of pulsating mass at stab injury site of 10 by 10 cm in diameter. Left brachial, radial and ulnar artery pulsations are palpable. Ultrasonography and CT angiography verified presence of pseudoaneurysm connected by two opening in third part of left subclavin artery (10 cm in diameter) (Figure 2). After short preoperative preparation, the patient underwent surgical intervention under general anaesthesia. Left supraclavicular incision taken to access and loop the proximal subclavin artery (Figure 3A and 3B). Left side transaxillary incision taken to access and loop the axillary artery. Intravenous heparin (5000 IU) was administered. Proximal subclavin artery and axillary artery both clamped. Dissection and separation of pseudoaneurysm followed by excision was done with cautery along with its content the clotted blood (Figure 4A and 4B). The opening of pseudoaneurysm in left subclavin artery was closed with vein patch with prolene 6-0. The vein patch was prepared from small axillary vein tributary. After putting 14 number negative suction romovac drain n supraclavicular and axillary region, wound closed in layer (Figure 5). Skin closed with stappler. Radial and ulnar artery pulsation checked. Drain removed after 48 hours. On the tenth postoperative day the patient was discharged. Discussion Post traumatic pseudoaneurysm is rare. The most common cause for such pseudoaneurysm is itragenic like post av fistula dialysis needle puncture or invasive procedures like percutaneous coronary interventions. Most common site for such pseudoaneurysm is radial, brachial and common femoral artery. Post stab injury pseudoaneurysm is rare in that subclavin artery pseudoaneurysm was rarest. If such pseudoaneurysm became infected, the surgical treatment can be extremely difficult. Although recently published, meta-analyses showed no superiority of subclavin artery stenting in such pseudoaneurysm because even after closing the opening which connect subclavin artery with pseudoaneurysm, the already formed pseudoaneurysm is high risk of infection [3,4]. So excision of that pseudoaneurysm is must. If the subclavin artery is normal with clearly visible opening that connect with pseudoaneurysm then pseudoaneurysm can be excised without sacrificing the part of subclavin artery by just vein patch closure of that opening with prolene suture. Sometimes rarely excision of part of subclavin artery with interposition grafting may be required. Conclusion The pseudo aneurysm excision was simple and safe even in inexperienced hands by proper anatomical knowledge. Proximal and distal control of artery is must for safe excision of pseudoaneurysm. By proper anatomical dissection pseudo aneurysm can be excised without damaging the surrounding vital structure like brachial plexus and axillary vein. Timely management was important to prevent complications like infection, rupture and gangrene. If the subclavin artery is normal with clearly visible opening feeding pseudoaneurysm then pseudoaneurysm can be excised without sacrificing the part of subclavin artery by just vein patch closure of opening in subclavin artery with prolene. Sometimes rarely excision of part of subclavin artery with interposition grafting may be required.

E-007 Unusual Two Cases of Dissecting Cervical Internal Carotid Artery Pseudo-aneurysm with Symptomatic Intracranial Aneurysm

BackgroundThe incidence and the relationship between the symptomatic cervical internal carotid artery dissecting pseudoaneurysm (DP) and the presence of intracranial aneurysm in the same ICA distribution is unknown.ObjectiveTo describe two...

E-009 Dissecting Ruptured and Symptomatic Intracranial Pseudo-aneurysm who Underwent Endovascular Repair-A Case Series

BackgroundThe natural history of intracranial dissecting pseudo-aneurysm is not known. The optimum treatment strategies are not defined. The recent case series demonstrated non favorable clinical outcome when endovascular pipeline device...

Early Diagnosis and Treatment of a Posttraumatic Pseudoaneurysm/Dissection of the Innominate Artery

A 25-year-old male developed a traumatic intimo-medial dissection and saccular pseudoaneurysm at the origin of the innominate artery following a motorcycle accident. On physical examination there was no perceivable trauma to the chest. In addition, there were no clinical symptoms that suggested this serious injury. The patient was managed with successful stent-graft placement on an elective basis.

Use of concentric Solitaire stent to anchor Pipeline flow diverter constructs in treatment of shallow cervical carotid dissecting pseudoaneurysms

The flow-diverting Pipeline Embolization Device (PED; ev3 Neurovascular, Irvine, CA, USA) provides proven flow diversion for intracranial wide-necked and fusiform aneurysms. The tendency of the PED to migrate and foreshorten when its size is mismatched with the parent vessel makes its use more difficult for cervical carotid pseudoaneurysms, as the parent vessel regains its luminal diameter during the healing phase, and because of its mobility during head movement. We present a novel technique of using a Solitaire detachable stent (ev3 Neurovascular) to anchor PED constructs to mitigate these shortcomings. Two patients with shallow and broad-necked cervical carotid pseudoaneurysms with underlying parent vessel stenosis deemed poor candidates for conventional stent-supported coiling were treated using tandem overlapping PED centered over the neck of the pseudoaneurysm and a Solitaire concentric anchor was deployed to overlap distally and proximally. As predicted, both patients revealed carotid luminal gain after aneurysm thrombosis with attendant migration (3.8 and 2.8mm) and expansion of the PED construct (14% and 7.8%) which remained constrained within the Solitaire anchoring device with persistent luminal patency and no evidence of endoleak at follow-up (3 and 5months). The use of a concentric anchoring stent can mitigate the inherent tendency of the braided flow-diverting PED to migrate and foreshorten as the target vessel heals upon pseudoaneurysm thrombosis. This novel technique opens the possibility of using PED to treat shallow or fusiform lesions in mobile cervical arteries previously relegated to stent-supported coiling or surgical reconstruction.

Thoracic Aortic Dissection and Mycotic Pseudoaneurysm in the Setting of an Unstable Upper Thoracic Type B2 Fracture

Thoracic type B2 fractures are high-energy injuries. It is crucial to maintain a high index of suspicion for concomitant visceral injuries. A 33-year-old man presented after a motor vehicle accident with a T4 type B2.3 fracture with an associated sternum fracture. He was treated with a T4 corpectomy and an expandable titanium cage and lateral plate construct at T3–T5. Two months later he developed focal kyphosis and loosening of his screws. This was addressed with an instrumented posterior fusion from T1 to T8 complicated by a wound infection, pneumonia, and fungal esophagitis requiring several debridements and vacuum assisted closure therapy. Worsening back pain prompted a thoracic computed tomography scan, revealing a dissecting thoracic-aortic aneurysm, which was treated with an endovascular stent graft. Few months later, he presented with fevers, chills, and hemoptysis secondary to Staphylococcus aureus bacteremia, endovascular leak, and T3–T5 osteomyelitis. He was transferred to our institution and restented by the cardiothoracic service. Subsequently, he underwent a thoracotomy, evacuation of infected aneurysmal hematoma with removal of instrumentation. A revision corpectomy with iliac crest autograft reconstruction was performed without complications. The patient's infection and thoracic pain resolved. However, there was a significant delay in treatment, resulting in substantial morbidity. Patients with thoracic type B2 fractures require careful evaluation for concomitant aortic and visceral injuries. Missed associated injuries result in increased morbidity and mortality.

Dissecting Pseudoaneurysm of the Proper Hepatic Artery Repaired by Primary Anastomosis: A Case Report

Background. Although rare, visceral artery pseudoaneurysms often present as surgical emergencies with a specific mortality rate as high as 35% related to aneurysmal rupture. Risk factors for the development of iatrogenic pseudoaneurysms include anticoagulation, female gender, obesity, and vessel calcification. Case Report. We present a case of an elderly female who developed a dissecting pseudoaneurysm of the proper hepatic artery after undergoing routine surgery to resect a large duodenal adenoma. Surgical repair comprised of resection and primary anastomosis was employed resulting in a favourable outcome. Discussion/Conclusion. Surgical management reduces the risk of hepatic ischemia, biliary complications, and abscess formation. Although stenting, coil embolization, and thrombin injection are all plausible options for management, we propose that surgical reconstruction be considered seriously as a treatment for such spontaneous pseudoaneurysms.

Vertebral artery dissection in a patient practicing self-manipulation of the neck

Objective The purpose of this case report is to describe a patient who regularly practiced self-manipulation of her neck who presented with shoulder and neck pain and was undergoing a vertebral artery dissection. Clinical Features A 42-year-old female patient sought care for left shoulder pain with a secondary complaint of left lower neck pain. Twelve days prior, she had had “the worst headache of her life,” which began in her left lower cervical spine and extended to her left temporal region. The pain was sudden and severe, was described as sharp and burning, and lasted 3 hours. She reported nausea, vomiting, and blurred vision. Intervention and Outcome Initial history and examination suggested that the patient's head and neck pain was not musculoskeletal in origin, but vascular. She repeatedly requested that an adjustment be performed, but instead was referred to the local emergency department for further evaluation. Magnetic resonance angiogram revealed a dissection of the left vertebral artery from C6 to the C2-C3 interspace and a 3-mm dissecting pseudoaneurysm at the C3 level. She underwent stent-assisted percutaneous transluminal angioplasty combined with antiplatelet therapy (clopidogrel) and experienced a good outcome. Conclusion This case suggests that careful history taking and awareness of the symptoms of VAD are necessary in cases of sudden head and neck pain. More research is needed on the relationship between vertebral artery dissection and self-manipulation of the neck.

Vascular anomaly at the craniocervical junction presenting with sub arachnoid hemorrhage: Dilemma in Imaging Diagnosis, Endovascular Management and Complications

We present a case of a ruptured vertebral artery dissecting aneurysm that mimicked a presumed vascular anomaly by CTA (Computerized Tomographic Angiography). A parenchymal arteriovenous malformation (AVM) or a dural arteriovenous fistula (DAVF) at the craniocervical junction can present with a subarachnoid hemorrhage and cannot be differentiated from a vertebral artery dissection by non invasive imaging. Catheter based cerebral angiography revealed a dissecting pseudoaneurysm of a diminutive right vertebral artery terminating in the posterior inferior cerebellar artery (PICA) that to our knowledge has not been previously reported. NBCA (N-Butyl Cyanoacrylate) embolization of the pseudoaneurysm lumen and sacrifice of the parent vessel resulted in cerebellar infarction, requiring an emergent decompressive craniectomy. The patient recovered to a functional neurologic status.

Endoluminal Stent-Graft Repair in a Patient With Coarctation of the Aorta and Previous Iatrogenic Type B Aortic Dissection and Expanding Pseudoaneurysm

To report endoluminal repair of aortic coarctation in a patient with a chronic type B aortic dissection presenting with an expanding pseudoaneurysm after failure of surgical repair. This 30-year-old man with a congenital coarctation of the aorta suffered an iatrogenic type B aortic dissection during angiography at the age of 6. Emergent surgery at that time included a left subclavian artery-to-distal thoracic aorta surgical conduit; the coarctation itself was not repaired. The patient presented 24 years after the surgery with a chronic distal extension of the dissection and a pseudoaneurysm severely compressing the aortic true lumen; the disrupted surgical conduit drained into the false lumen. In a novel approach, the true aortic lumen was intentionally occluded, and the surgical conduit was secured with stent-grafts to successfully exclude the pseudoaneurysm from the circulation. Type B dissection and coarctation of the aorta, in the setting of complex aortic pathology and comorbidities, can be treated with an endovascular approach.

Aortic Pseudo Aneurysm Complicating Coarctation Stenting Successfully Treated with a PTFE Balloon Expandable Covered Stent

Percutaneous stenting of both native and recurrent coarctation of the aorta has become an acceptable alternative to surgical repair in most centers throughout the world. Severe complications such as aortic rupture, dissection, and late pseudo aneurysm formation are rare but worrisome complications. In many countries, commercially available balloon expandable covered stents designed for intravascular use are used either for primary stenting, or in treating complications once identified. These endovascular stents, however, are not available in the United States. We report the use of a commercially available covered stent, which has been approved by the Food and Drug Administration for tracheal use, to exclude an aortic pseudo aneurysm that was identified late after stenting a native coarctation.