Endovascular Management of Extracranial Carotid Artery Dissection Achieved Using Stent Angioplasty

A 45-year-old woman (patient 1) noted to have developed left hemiparesis after diagnostic angiography at an outside hospital. Head CT scan shows evidence of a previous focal infarct as well as diffuse edema in the right posterior frontal lobe (A). Digital subtraction angiography of the right common carotid artery reveals tapering of the right internal carotid artery, to a complete occlusion, with appearance consistent of dissection (B). Injection of the right external carotid artery (C) shows retrograde collateral flow through the right ophthalmic artery, with filling of the cavernous segment of the right ICA. Injection of the left internal carotid artery shows no significant flow across the anterior communicating artery (D)

fig. 2 (continued). Treatment approach consisted of initial recanalization of the dissected right internal carotid artery achieved by entering the true lumen by using a Rapid Transit microcatheter and Instinct-10 microguidewire (arrowheads) (E), and advancing up to the cavernous portion of the right internal carotid artery (arrow) (F). Superselective injection shows a patent right middle and anterior cerebral artery (G). An 8-mm × 2-cm Wallstent was then deployed at the dissection site over a Stabilizer exchange microguidewire at the C2 level (H). The reconstitution of the lumen of the right internal carotid artery is shown by injection of the right common carotid artery (I), with resumption of intracranial perfusion (J)

A 51-year-old man (patient 5) with a 10-day history of left-sided TIAs now presents with sudden onset of aphasia and right hemiparesis. Axial T1-weighted contrast-enhanced MR imaging shows a left frontal infarct (A). Digital subtraction angiography of the left common carotid artery showed progression of a left internal carotid dissection from a partial stenosis, 2 days prior, to a complete occlusion despite systemic anticoagulation (B). Digital subtraction angiography of the right common carotid artery revealed a dissection of the right internal carotid artery with an associated long-segment stenosis and an expansile pseudoaneurysm at the distal end (C). A Rapid Transit microcatheter was used to navigate the patent lumen of the right internal carotid artery and to deploy three Wallstents (6 mm × 45 mm, 7 mm × 20 mm, and 8 mm × 20 mm) in a tandem overlapping fashion with postdeployment balloon angioplasty (D). The procedure resulted in reconstitution of the normal lumen of the right internal carotid artery (E)

An 83-year-old man (patient 4) with a history of aortic dissection, which was surgically repaired 10 years previously, presents with left hemispheric TIAs and episodes of aphasia. Digital subtraction angiography of the left common carotid artery outlines a chronic extensive dissection, with antegrade flow through the true lumen and retrograde flow in the false lumen down to the aorta, by virtue of the Venturi effect at the aortic arch (A, early injection; B, late injection). Two stents were placed in tandem overlapping fashion, followed by postdeployment angioplasty, resulting in a near-complete elimination of the retrograde flow in the now-reduced false lumen (C, D)