Transverse Sinus Stenting Complicated by Internal Jugular Vein Dissection: Case Report with Literature Review

Purpose: Transverse sinus (TS) stenting has become increasingly used as a treatment for intracranial hypertension. However, because of the relatively small number of cases performed worldwide, its safety profile has not been fully studied. Here we present a case of a patient with symptomatic intracranial hypertension with bilateral TS stenoses who underwent left TS stenting, complicated by intraprocedural internal jugular vein (IJ) dissection, successfully treated by IJ stenting.

Materials and Methods: We present a case of a 34-year-old woman with a history of progressive vision deficit found to have elevated cerebrospinal fluid pressure requiring increasing Diamox use without symptomatic relief. Her examination was notable for peripheral vision loss and decreased acuity. Magnetic resonance imaging and magnetic resonance venography showed a Chiari 1 malformation without hydrocephalus. The patient presented for evaluation of dural sinus stenosis as a cause of her intracranial hypertension.

Results: Diagnostic cerebral angiogram revealed stenosis in the lateral TS bilaterally, resulting in focal pressure gradient of 15 mm Hg on the right and 16 mm Hg on the left. Because of a dominant left TS in this patient, balloon angioplasty and stenting of the left-side stenosis were pursued. After stenting from the left TS into the sigmoid sinus, intraoperative pressure manometry showed persistently elevated intravascular pressure from the superior sagittal sinus through to the left jugular bulb, with a focal pressure decrease at the superior left IJ. Venogram and three-dimensional rotational angiogram revealed a short segment dissection in the left IJ, which was successfully treated by stenting the dissected segment. There were complete patency of the left IJ and a marked pressure decrease in the dural sinuses subsequently, without significant residual pressure gradient.

Conclusions: Although studies have documented the relative safety and efficacy of stenting for the treatment of intracranial hypertension, we present a previously undescribed case of iatrogenic IJ dissection as a complication of this procedure, successfully treated by stenting of the dissected segment. The dissection was most likely caused by the unfavorable force vector for a left-side stent, resulting in lateral bowing of the guide catheter and sheath during stent advancement, which would have been less likely for a right-side stent. The operator should be mindful of and evaluate for this potential complication before conclusion of cases.

(51) Abstract ID: 723316

VENOUS

10 + 10 = 12? Dual Stenting for Trauma at Vascular Confluence

Purpose: The incidence and prevalence of iatrogenic vascular trauma in the United States is staggering. This has led to the advent and implementation of more efficient and effective vascular repair methods. Previously, open repair was the gold standard until curative endovascular solutions became viable options.

Materials and Methods: We present a case of a traumatic injury and pseudoaneurysm formation at the confluence of the right jugular and right subclavian veins during a central line placement. This iatrogenic pseudoaneurysm was treated with endovascular placement of side-by-side stents. A mathematical formula, which we have designated Matteo’s law, was used to select properly sized stent grafts to reconstruct the confluence and prevent infolding and endoleaks.

Results: After deployment of kissing stents at the confluence of the right jugular and brachiocephalic veins, a venogram was performed that demonstrated successful exclusion of the pseudoaneurysm and no endoleaks. Clinical follow-up confirms continued good flow through the reconstructed venous confluence at 8 months postprocedure.

Conclusions: In reconstruction of a venous confluence, selection of properly sized stent grafts is paramount to preventing infolding and endoleaks. Matteo’s law states that the circumference of the native receiving vessel must equal the sum of the circumferences of both kissing stent grafts, subtracting the redundant material where the two stents interface.