Single-Stage Extracranial Carotid Artery Stenting and Intracranial Aneurysm Coiling: Technical Feasibility and Clinical Outcome

Abstract

<jats:p> The coexistence of carotid artery stenosis and cerebral aneurysm in a patient presents challenges for treatment decision-making. The purpose of this study was to evaluate the technical feasibility and clinical outcome after single-stage extracranial carotid artery stenting (CAS) and ipsilateral intracranial aneurysm coiling in a single institution. </jats:p><jats:p> From March 2005 to February 2011, 17 patients with 21 aneurysms underwent single-stage CAS and coiling for ipsilateral aneurysms. There were symptomatic atherosclerotic carotid stenoses with unruptured aneurysms in eight, ruptured or symptomatic aneurysms with simultaneous asymptomatic carotid stenoses in two and asymptomatic lesions in seven. CAS was followed by aneurysm coiling in all 17 patients. Clinical and radiological data were reviewed. </jats:p><jats:p> There were two procedure-related complications: acute in-stent thrombosis in one and premature aneurysmal rupture in the other. After aneurysm coiling, complete occlusion was demonstrated in 17 aneurysms and near-total occlusion in four. No neurological deficit was found at discharge and follow-up outcomes were excellent in all the patients (mean, 32.9 months). Follow-up imaging studies were performed in all the patients, including neck CT angiography in 14 (mean, 26.1 months), brain MR angiography in 14 (mean, 31.2 months), and conventional angiography in three (mean, 14.7 months). They revealed two asymptomatic, mild carotid re-stenoses and one major aneurysmal recanalization requiring re-coiling. </jats:p><jats:p> A single-stage CAS and coiling procedure appears to be feasible and the complication rate seems to be reasonable. We suggest that there is no need for separate therapeutic procedures when a patient has carotid artery stenosis and accompanying ipsilateral intracranial aneurysm. </jats:p>

Single-stage endovascular treatment in patients with severe extracranial large vessel stenosis and concomitant ipsilateral unruptured intracranial aneurysm

“…Initial stenting facilitates subsequent reliable access to the intracranial aneurysm. Moreover, in this way, the risk of thromboembolic complications related to guiding catheter manipulation while passing through the stenosis decreases (17). Park et al (17) reported that initial placement of the stent was useful for decreasing the risk of embolic complications in their 17 patients treated with a single-stage endovascular method.…”

“…Moreover, in this way, the risk of thromboembolic complications related to guiding catheter manipulation while passing through the stenosis decreases (17). Park et al (17) reported that initial placement of the stent was useful for decreasing the risk of embolic complications in their 17 patients treated with a single-stage endovascular method. In another study, Badruddin et al (18) performed CAS first, followed by treatment of the aneurysm in a single session successfully.…”

“…Detecting the coexistence of severe symptomatic extracranial large vessel stenosis and concomitant asymptomatic ipsilateral intracranial aneurysm leads to a quandary regarding the management (17). Much of the current data in the literature has been derived from case reports and case series suggesting that surgical carotid revascularization is safe for the treatment of patients with intracranial aneurysm.…”

“…Displacement of the guiding catheter due to the maneuvers of the microcatheter during treatment of the aneurysm and its inappropriate positioning in the stented segment may also cause in-stent thrombosis. Park et al (17) suggested that these two factors were responsible for the thrombogenicity in one of their patients who developed in-stent thrombosis. We did not observe in-stent thrombosis in any of our patients.…”

“…Therefore, securing the aneurysm distal to the stenosis should be taken into consideration in patients for whom carotid revascularization is planned (18). It has been recently reported that both stenosis and aneurysm can be treated safely by a single-stage endovascular approach in cases with severe carotid stenosis and a concomitant ipsilateral intracranial aneurysm (17)(18)(19). Initial CAS is suggested in single-stage endovascular treatment.…”