J Cerebrovasc Endovasc Neurosurg.  2014 Sep;16(3):200-208. 10.7461/jcen.2014.16.3.200.

Endovascular Treatment of the Distal Internal Carotid Artery Large Aneurysm

• Bae HJ
• Yoo DS
• Huh PW
• Lee TG
• Cho KS
• Lee SB

• KMID: 1963157
• DOI: http://doi.org/10.7461/jcen.2014.16.3.200

Abstract

OBJECTIVE
According to the development of endovascular technique and devices, larger aneurysms on the distal internal carotid artery (ICA) can be treated using a less invasive method. The authors report on clinical and angiographic outcomes of these aneurysms treated using an endovascular technique.
MATERIALS AND METHODS
Data on 21 patients with large aneurysms at distal ICA treated by endovascular method between January 2005 and December 2012 were included in this retrospective analysis.
RESULTS
Clinical outcome of patients showed strong correlation with the initial neurologic status (p < 0.05). Aneurysm morphology showed saccular, fusiform, and wide-neck in 12, six and three patients. Six patients underwent stent assisted coiling and the other 15 patients underwent simple coiling. Aneurysm occlusion was performed immediately after embolization with near-complete (Raymond class 1-2) in 20 patients (95.2%) and incomplete (Raymond class 3) in one patient (4.8%). Delayed thrombotic occlusion occurred in two patients and their clinical result was fatal. Another five patients died in the hospital, from massive brain edema and/or increased intracranial pressure due to initial subarachnoid hemorrhage. Overall mortality was 30% (seven out of 21). Fatal complication related to the endovascular procedure occurred in two patients with thrombosis at middle cerebral artery (one with stent, the other without it).
CONCLUSION
Recent developed endovascular device and technique is safe enough and a less invasive method for distal large or giant aneurysms. Based on our analysis of the study, we suspect that coil embolization of large distal ICA aneurysms (with or without stenting) is effective and safe.

Keyword

Large aneurysm; Internal carotid artery; Endovascular; Stent

MeSH Terms

Aneurysm*
Brain Edema
Carotid Artery, Internal*
Embolization, Therapeutic
Endovascular Procedures
Humans
Intracranial Pressure
Middle Cerebral Artery
Mortality
Retrospective Studies
Stents
Subarachnoid Hemorrhage
Thrombosis

Figure

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  Fig. 1 Left distal internal carotid artery (ICA) aneurysm (14 mm) with near-complete occlusion. (A, B) Pre-embolization computed tomography (CT) images (A, plain CT; B, 3D-rotational reconstructed CT-angiography) and (C, D) digital subtraction angiogram (DSA) (C, towne view; D, 3D-rotational reconstructed images) demonstrating the 14 mm distal internal carotid artery aneurysm with a wide-neck. (E) Microscopic surgical view of the aneurysm, distal ICA (red arrow) and atherosclerotic aneurysm wall (Black arrow). During (F) and after (G) deployment of a stent assisted coil, (F) the proximal stent guiding tip wire is placed at the middle cerebral artery (MCA) with coil packed coils. And (G) 3D-rotational reconstructed image demonstrates well packed coils and patent parent artery.

• 

  Fig. 2 Left distal internal carotid artery (ICA) aneurysm (18 mm) with near-complete occlusion. (A, B) Pre-embolization computed tomography (CT) images (A, plain CT; B, 3D-rotational reconstructed CT-angiography) and (C, D) digital subtraction angiogram (DSA) (C, towne view; D, 3D-rotational reconstructed images) demonstrate the 18 mm distal internal carotid artery aneurysm with a wide-neck. (E) Micro-catheter placed in the aneurysm sac. (F, G) DSA after coil deployment. (H) 3D-rotational reconstructed image demonstrates well packed coils.

• 

  Fig. 3 Wide-neck right posterior communication artery aneurysm (10 mm) was treated by stent assisted coiling. (A, B) Pre-embolization computed tomography angiography (CTA) (A, plain CT, B, 3D-rotational reconstructed angiography) and (C, D) digital subtraction angiogram (DSA) demonstrating stent assisted coiling. (E, F) Plain CT and 3D-rotational reconstructed CTA after stent assisted coiling show no flow arrest. (G, H) The next day follow-up plain CT and 3D-rotational reconstructed CTA show flow arrest at the right distal ICA and massive brain swelling at the right hemisphere.

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