Endovascular Internal Carotid Artery Occlusion Research Articles

Distal Endovascular Occlusion for Incomplete Occlusion of Cavernous Carotid Aneurysms after High-flow Bypass and Cervical Internal Carotid Artery Ligation.

Internal carotid artery (ICA) ligation for placing a high-flow extracranial-intracranial (EC-IC) bypass is used in patients with aneurysms on the cavernous portion of the ICA. Recanalization and rupture after proximal ICA ligation can occur. We present four patients who underwent endovascular distal ICA occlusion and report our surgical technique and treatment results. We ligated the ICA to place an EC-IC bypass using a radial artery (RA) graft. Failure to obtain spontaneous occlusion in the distal region required endovascular treatment an average of 219 days later. A guide catheter was placed in the common carotid artery, a guide or distal access catheter was introduced in the RA graft from the external carotid artery, and a microcatheter was navigated into the cavernous aneurysm through the RA graft. Using detachable coils, endovascular ICA occlusion was from just distal to the aneurysmal neck to a site proximal to the origin of the ophthalmic artery. Aneurysmal occlusion was completed by endovascular occlusion of the distal ICA. Complications were RA graft stenosis and transient consciousness disturbance due to local subarachnoid hemorrhage. Outpatient follow-up for a mean of 109.5 months revealed no recurrences. Distal occlusion of the ICA through the implanted RA graft is simple and presents a low risk for cerebral infarction due to thrombus formation during the procedure. To treat cavernous carotid aneurysms that do not disappear after placing the EC-IC bypass after ICA ligation at the aneurysmal neck, we offer our procedure as a treatment option.

Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass

The utility of superficial temporal artery to middle cerebral artery (STA-MCA) bypass before therapeutic internal carotid artery (ICA) occlusion is unclear. A 65-year-old woman with a symptomatic giant left paraclinoid ICA aneurysm underwent endovascular ICA occlusion following STA-MCA double bypass. Preoperative balloon test occlusion (BTO) demonstrated a venous-phase delay of 1.5 s. Only focal improvement in the venous-phase delay was observed immediately after treatment, but three-week postoperative angiography showed remarkable improvement of 0.5 s. To our knowledge, this is the first known case that demonstrates the effect of STA-MCA bypass on postoperative improvement in venous-phase delay.

De Novo Large Fusiform Posterior Circulation Intracranial Aneurysm Presenting With Subarachnoid Hemorrhage 7 Years After Therapeutic Internal Carotid Artery Occlusion

Although the use of proximal artery occlusion, or hunterian ligation, for the treatment of intracranial aneurysms has decreased greatly over the past decades, this approach still finds use for certain giant and complex aneurysms. The main risks of artery sacrifice are ischemic complications but also, although rare, de novo aneurysm formation. We present here a case of de novo formation of a large fusiform basilar artery aneurysm 7 years after internal carotid artery occlusion. A 17-year-old male patient with a history of a giant right cavernous aneurysm treated 7 years earlier with right-sided endovascular internal carotid artery occlusion presented to our institution with a thunderclap headache. At the time of initial evaluation, the patient was neurologically intact and imaging revealed a 22 × 10-mm fusiform aneurysm of the distal basilar artery with mass effect on the adjacent pons as well as a small amount of subarachnoid and intraventricular blood. Complete occlusion of the right internal carotid artery was demonstrated with retrograde filling of the right middle cerebral artery from the enlarged right posterior communicating artery. The patient was subsequently treated with hunterian occlusion of the basilar artery below anterior inferior cerebellar arteries. A superficial temporal artery to middle cerebral artery bypass was performed on the right side before this occlusion. Further studies on the epidemiology of de novo aneurysms after carotid artery occlusion are warranted. Patients at higher risk of the development of intracranial aneurysms should be followed aggressively after hunterian ligation, and the possibility of an extracranial-intracranial bypass should be discussed.

Ruptured symptomatic internal carotid artery dorsal wall aneurysm with rapid configurational change. Clinical experience and management outcome: an original article

Aneurysms located at non-branching sites, protruding from the dorsal wall of the supraclinoid internal carotid artery (ICA) with rapid configurational changes, were retrospectively reviewed in effort to identify and characterize these high-risk aneurysms. A total of 447 patients with 491 intracranial aneurysms were treated from March 2005 to August 2008, and of these, eight patients had ICA dorsal wall aneurysms. Four of them suffered subarachnoid hemorrhage (SAH), and all had aneurysms undergoing rapid configuration changes during the treatment course. Digital subtraction cerebral angiography (DSA) performed soon after the SAH events. Data analyzed were patient age, sex, Hunt and Kosnik grade, time interval from first DSA to second DSA, aneurysm treatment, and modified Rankin scale score after treatment for 3 months. Success or failure of therapeutic management was examined among the patients. Digital subtraction cerebral angiography showed only lesions with small bulges in the dorsal walls of the ICAs. However, the patients underwent DSA again for re-bleeding or for post-treatment follow-up, confirming the SAH source. ICA dorsal wall aneurysms with rapid growth and configurational changes were found on subsequent DSA studies. Among the four patients, ICA dorsal wall aneurysms underwent rapid growth with configurational change from a blister type to a saccular type despite different management. ICA trapping including the lesion segment can be considered as the first treatment option if the balloon occlusion test (BOT) is successful. If a BOT is not tolerated by the patient, extracranial-intracranial bypass revascularization surgery with endovascular ICA occlusion is another treatment option.

症候性大型‐巨大海綿静脈洞部内頚動脈瘤に対する治療戦略―バイパス術・血管内治療の併用タイミングについて―

For the treatment of symptomatic large-giant aneurysm in the cavernous portion of the internal carotid artery (ICA), it is often necessary to occlude the ICA with or without extracranial-intracranial (EC-IC) bypass surgery. We report 11 patients with such symptomatic lesions treated between January 2004 and June 2008 by staged endovascular trapping of the aneurysm with detachable coils following selective EC-IC bypass placement. The necessity of the bypass was determined according to neurological conditions and radiological findings during the preoperative balloon test occlusion (BTO) of the ICA. When ischemic symptoms occurred during BTO, high-flow bypass was selected. Otherwise, findings on single-photon emission computed tomography were used for the bypass selection. Following completion of the bypass, dual antiplatelet therapy was induced. Then the confirmative BTO and endovascular ICA occlusion (ICA-O) under local anesthesia were planned several days after the bypass placement. A total of 4 high-flow bypasses with radial artery graft were placed before ICA-O, while 7 patients underwent endovascular ICA-O without bypass surgery. There were no perioperative complications related to the procedures in 10 cases, but 1 developed cerebral infarction 7 days after bypass placement possibly due to distal embolism from intraaneurysmal thrombus. No patients showed postoperative symptoms according to insufficient ipsilateral cerebral blood flow, and cranial nerve palsies improved in all patients. Favorable outcomes can be expected for patients with such aneurysms by staged endovascular ICA-O with selective EC-IC bypass. Although endovascular ICA-O can be safe and useful, understanding of adequate antithrombotic therapy and treatment timing are especially important in cases with bypass placement.

Large ophthalmic segment aneurysms with anterior optic pathway compression: assessment of anatomical and visual outcomes after endosaccular coil therapy

The optimal therapy for ophthalmic segment aneurysms with anterior optic pathway compression (AOPC) is undecided. Surgical results have been described, but the results of endovascular coil therapy have not been well documented. The authors retrospectively reviewed data obtained in all patients who harbored unruptured ophthalmic segment aneurysms with AOPC who underwent endovascular coil therapy at their institution. They analyzed baseline and outcome visual function, aneurysm features, extent of aneurysm closure, internal carotid artery (ICA) occlusion, additional interventions, and neurological outcome. In 17 patients (16 women), age 38 to 83 years, there were 28 affected eyes. All aneurysms were greater than 10 mm in diameter. In the initial procedures 16 of 17 patients received endosaccular coils and the ICA was preserved; in one patient the aneurysm was trapped and the ICA occluded. Patients then underwent follow up for a mean of 2.90 years (range 1 month-1 1.2 years) after the last procedure. One patient died of subarachnoid hemorrhage (SAH) 1 month postoperatively and thus no follow-up data were available for this case. Vision worsened in six patients, stabilized in four, and improved in six. Twelve patients underwent 13 subsequent procedures, including endovascular ICA occlusion in seven, repeated coil therapy in five, and optic nerve decompression in one; vision improved in 83% of these cases after ICA occlusion. A second patient died of SAH 5 months after repeated coil treatment. At the final follow up, vision had improved in eight patients (50%), stabilized in four (25%), and worsened in four (25%). In 16 patients with follow-up studies, aneurysm closure was complete in eight (50%) and incomplete in eight (50%). The authors found that in patients with ophthalmic segment aneurysms causing chronic AOPC, endosaccular platinum coil therapy, with ICA preservation, may not benefit vision and that additional procedures may be needed. Evaluation of their results suggests that endovascular trapping of the aneurysm and sacrifice of the ICA appear to result in good visual, clinical, and anatomical outcomes.

Occlusion of the Internal Carotid Artery Based on a Simple Tolerance Test

In order to evaluate the safety of the internal carotid artery (ICA) occlusion based on our simple tolerance test, we reviewed 142 consecutive tolerance tests. Permanent endovascular ICA occlusion was performed on 99; a tolerance test only was performed on the remaining 43. Our assessment consisted of 1) angiographic evaluation of collateral circulations without and with ICA test occlusion, 2) evaluation of clinical tolerance to balloon ICA occlusion for 15-20 minutes. Complications of test and permanent ICA occlusion were retrospectively analyzed. Complications related to test occlusion occurred in 2 cases (1.4%) without causing permanent deficits. Complications related to permanent occlusion occurred in 16 cases (16%) including 2 technical, 10 temporary (10%) and 4 permanent (4%). Complications were significantly decreased after introduction of stringent postoperative care to prevent hypotension in 1987. Since 1988, we performed 47 permanent ICA occlusion and experienced no technical, 3 temporary (6%) and no permanent complications. Our method to evaluate tolerance to ICA occlusion is simple and safe. Reliability of the results is comparable to other more complicated methods of assessing ICA occlusion.

Management of giant intracranial ICA aneurysms with combined extracranial-intracranial anastomosis and endovascular occlusion

Nine patients with giant internal carotid artery (ICA) aneurysms (greater than 2.5 cm in diameter) were subjected to a combined extracranial-intracranial (EC-IC) bypass procedure and endovascular ICA occlusion during 1987 and 1988. The procedures were performed under one anesthetic. In all cases the collateral circulation had been judged insufficient on the basis of a strict preoperative testing protocol including: cerebral panangiography, electroencephalography, somatosensory potential recording, and cerebral blood flow monitoring during manual compression of the ICA in the neck. There were four intracavernous ICA aneurysms, four carotid-ophthalmic artery aneurysms, and one supraclinoid ICA aneurysm. All patients showed symptoms and signs of compression of the surrounding nervous structures. In the five cases of intradural lesions, the artery was occluded at the level of the aneurysm neck, so the ophthalmic artery had to be occluded. There was, nevertheless, no case of worsening of vision following surgery, and all nine patients showed significant improvement following the combined procedure. A combined EC-IC bypass procedure and endovascular ICA occlusion allows for immediate verification of the surgical results and appears to be a worthwhile method for treating giant intracranial aneurysms.