Staged Endovascular Treatment of Left Common Carotid Artery Large Aneurysm with Gore-Hemobahn Stent-Graft After Right Common Car

J INVASIVE CARDIOL 2010;22:E129–E131

Key words: carotid endarterectomy, carotid stenting, Gore Hemobahn stent-graft    Currently, carotid artery endarterectomy is the gold standard for treating the high-grade extracranial carotid stenosis as well as surgical exclusion for the aneurysm of carotid artery.^1–4 Nevertheless, minimally invasive percutaneous endovascular treatments of symptomatic stenotic or aneurysmal lesions of the carotid arteries have been rapidly evolving and becoming acceptable alternatives to surgery, particularly in high-risk patients.^4–14 The aim of this report is to describe an interesting and rare case with the coexistence of right common carotid artery stenosis and left common carotid artery aneurysm with a past medical history of surgical aneurysmectomy that was successfully treated endovascularly.    Case Report. The patient was a 58-year-old male experiencing transient ischemic attack with transient left hemiparesia symptoms for 2 months’ duration. These symptoms were controlled medically without any neurological sequelae.    He had a past medical history of aortic arch aneurysm 14 years previously that was surgically repaired with aneurysmectomy and the reimplantation of right subclavian artery and right common carotid artery. As he did not have any symptoms at follow up, he did not pursue further evaluation during these years. However, recent symptoms caused him to seek treatment and he was admitted to our clinic for reassessment. After complete evaluation, a 60% stenosis with ulcerated lesion in the right common carotid artery was discovered (Figure 1A). This was associated with a fusiform aneurysm locating in the left common carotid artery, about 6 cm in length and 3.5 cm in diameter (Figure 1B). Therefore, he was candidate for right common carotid artery angioplasty with stenting and endovascular treatment of the left common carotid artery aneurysm with stent-graft.    After obtaining informed consent, the right carotid stenosis was initially treated. We used routine angioplasty and stenting via the right femoral artery. Carotid stenting was carried out using an 8 x 40 self-expanding stent (Wallstent, Boston Scientific Corp., Natick, Massachusetts) with the aid of 7 Fr right Judkins 3.5 guide catheter and FilterWire EZ Embolic Protection device (Boston Scientific). After the procedure, the patient was treated with 80 mg/day ASA and 75 mg/day clopidogrel for 30 days. On the first month of follow up, he had no complications from the procedure and was a candidate for the second procedure, i.e., endovascular treatment of the left common carotid artery aneurysm.    Under local anesthesia, routine carotid angiography was performed through right femoral artery with the aid of 7 Fr right Judkins 3.5 guide catheter. After heparin administration (7500 IU), a guiding catheter was placed in the proximal left common carotid artery. Then, a 0.025-inch guidewire (260 mm) was inserted through the left common carotid artery and positioned distal to the aneurysmal area through left external carotid artery. Next, the guiding catheter and 8 Fr sheath were withdrawn and the 12 Fr long sheath (Amplatzer ASD closure delivery system, AGA, Plymouth, Minnesota) was advanced over the guidewire in the proximal left common carotid artery. Due to the sharp angle between the aortic arch and carotid artery and the lack of appropriate guidewire support, one A1 catheter with 5 Fr diameter went through the long sheath and was delivered to the external carotid artery over the guidewire. Afterward, the 12 Fr sheath was placed over the A1 catheter as a feasible guide for stent-graft passing. Regarding the aneurysm dimensions (6 cm in length and 3.5 cm in diameter) and the proximal diameter of the common carotid artery (8 mm), a 9 × 100 mm Hemobahn stent-graft (W.L. Gore and Associates, Flagstaff, Arizona) was selected and after the A1 catheter was withdrawn, the stent-graft was placed through the sheath over the guidewire. Passing the stent graft was challenging due to the sharp bend between the aortic arch and the common carotid artery which was solved with appropriate maneuvering. The stent-graft was successfully deployed and placed across the aneurysm between two healthy areas proximal and distal to the aneurysm. Control angiography showed that the stent-graft was well positioned with no sign of endoleak (Figure 2). Moreover, angiography of the cerebral vessels revealed a significant increase in cerebral blood flow compared to the initial angiography. Considering that the aneurysm exclusion was done without any complications and due to the presence of the irregular surface of the carotid (plaque surface ulceration) distal to the stent-graft, the probability of distal cerebral embolization after balloon postdilation might increase. Therefore, postdilation was not performed.    The patient was discharged 2 days later without any complications on the previous regimen consisting of clopidogrel (75 mg/day) for 30 days and aspirin (80 mg/day) indefinitely. The patient was followed for 12 months. Follow up was performed at 1, 3, 6 and 12 months after the procedure. At 1- and 6-month follow up, Doppler ultrasound scan was performed and on 12-month follow-up CT angiography of the carotid arteries and cerebral vessels was performed (Figure 3), respectively and demonstrated the appropriate position of stent-graft and neither endoleak nor any other complications were discovered. The patient’s symptoms had ameliorated dramatically.    Discussion. Carotid surgery has been well established for treatment of carotid symptomatic stenosis or aneurysm.^1,2 With the recent improvements in endovascular techniques, therapeutic strategy has shifted toward catheter-based intervention from traditional open repair.^3–5,15,16    Our case demonstrated the association of stenosis of one carotid artery and aneurysm of the other carotid artery, which is extremely rare and difficult to treat. Self-expanding stents are a well-known treatment for treating carotid artery stenosis during recent years.^5,11,17 They have also become popular due to the lack of recoil or late deformation, the ease of implantation and the ability to deploy the proximal end of the stent in the common carotid artery. On the other hand, endovascular stent-graft application in treatment of carotid artery aneurysm is still developing. Even though rapid improvements in endovascular therapy have resulted in various minimally-invasive treatment modalities in arterial aneurysmal diseases, there are only a few reports concerning endovascular treatment of carotid aneurysms.^15–17    In this patient with the coexistence of stenosis and aneurysm of carotid arteries and the past history of aorta arch surgery, the risk of re-do carotid operation was high. Therefore, the endovascular repair seemed to be the first choice of treatment. Considering the probability of carotid intervention complications during the first month after treatment, we decided to have at least a one-month interval between the first and second procedure. Moreover, because of the recent transient ischemic attacks due to right common carotid stenosis (ulcerated lesion), the stenting for right common carotid artery was given priority as the first intervention.    Passing and deployment of a stent-graft with long sheath and large diameter (if needed) through a tortuous aorta or carotid artery, especially in older patients, is difficult. Based on our experience, after the stent-graft is released by pulling the deployment knob, it is pulled down and locates more proximally than the initial determined location. Consequently, it seems that the stent-graft should be initially placed approximately one centimeter above the initial determined position.    Even though post-stent dilation is routinely used after Gore Hemobahn stent-grafts deployment in peripheral vessel stenosis, it increases the risk of cerebral microemboli due to the balloon squeezing the stent struts against the atheromatous material, particularly in higher carotid stenosis (more than 50%), symptomatic patients, and the plaque surface ulceration.¹⁸    In our patient’s case, stent-graft dislodgment, the absence of an endoleak, and other neurological complications were documented by clinical evaluation, Doppler ultrasound scan and conventional angiography. Even though we have witnessed a good result in this isolated case, more widespread use of this approach will require a long-term evaluation in a large group of patients.    Conclusion. Endovascular treatment of common carotid artery aneurysms using the Gore Hemobahn stent graft seems to be safe and technically feasible. Moreover, it can be an effective alternative to surgery in favorable anatomical condition and the high surgical risk such as in patients who have undergone previous thoracic aorta surgery. From Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran. The authors report no financial relationships or conflicts of interest regarding the content herein. Manuscript submitted October 20, 2009, provisional acceptance given November 23, 2009, final version accepted December 7, 2009. Address for correspondence: Ali-Mohammad Haji-Zeinali, MD, Assistant Professor of Interventional Cardiology, Department of Interventional Cardiology, North Kargar and Jalal-Al-Ahmad Cross, Tehran Heart Center, Tehran 1411713138, Iran. E-mail: ali_ zeinali_ cardio@yahoo.com References

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