Angioplasty of the occluded internal carotid artery.

PURPOSETo review patients who have presented with acute strokes from a middle cerebral artery occlusion in whom in addition to the middle cerebral artery thromboembolus, an internal carotid artery occlusion has been present, and in whom angioplasty of these totally occluded internal carotid arteries has bee n successful.METHODSWe reviewed retrospectively our experience in treating a cute stroke patients with intracranial, intraarterial urokinase. Six of 27 patients had internal carotid artery occlusions in addition to middle cerebral artery occlusions. Two patients presented with spontaneous carotid dissections for wh ich no further intervention from the ipsilateral internal carotid artery was attempted. In the remaining four internal carotid artery occlusions secondary to atherosclerotic disease, standard guide wires and catheters were negotiated across the level of the internal carotid artery occlusion, which expedited intracranial catheterization for thrombolysis. Subsequently, angioplasty of the internal carotid artery was performed.RESULTSAll four occluded internal carotid arteries could be traversed. No new neurologic deficits occurred. No vascular injuries occurred. No deaths occurred. Four- to 6-month follow-up showed all four internal carotid arteries remained patent.CONCLUSIONIn acute occlusions of the internal carotid artery from atherosclerosis, the occluded vessel can sometimes be recanalized with low morbidity. In addition, endovascular access to the intracranial circulation can be expedited by using the recanalized internal carotid artery.     

Transorbital puncture for the treatment of cavernous sinus dural arteriovenous fistulas

This report describes a series of patients for whom dural arteriovenous fistulae (DAVFs) of the cavernous sinus were successfully embolized using a percutaneous, transorbital technique to directly cannulate the cavernous sinus. A vascular access needle and catheter are percutaneously advanced along the inferolateral aspect of the orbit to access the cavernous sinus via the superior orbital fissure. Safe and effective embolization is achieved without the need for a surgical cut-down.     

Direct percutaneous puncture of a cervical internal carotid artery aneurysm for coil placement after previous incomplete stent-assisted endovascular treatment

Direct percutaneous puncture for coil placement has been described for visceral aneurysms, but the procedure has not been previously reported for aneurysms of the head and neck. We report a case in which stent-assisted endovascular treatment was successfully combined with direct puncture for additional coil placement to treat a symptomatic giant aneurysm of the cervical internal carotid artery.     

Intravenous digital subtraction angiography of the nearly occluded internal carotid artery

Three patients with nearly occluded internal carotid artery origins were evaluated with intravenous digital subtraction angiography and subsequently had successful carotid endarterectomies. The angiographic features are described. Although conventional arterial angiography offers superior spatial resolution and selectivity, the thorough mixing of blood and contrast medium that occurs with the intravenous technique minimizes the tendency toward layering beyond a high-grade stenosis, which may occur with selective arterial injection. In cooperative patients, the intravenous digital technique may be sufficiently reliable in the detection of the nearly occluded internal carotid artery to obviate conventional selective common carotid angiography.     

Double-balloon technique for embolization of carotid cavernous fistulas

Embolization of a carotid cavernous fistula (CCF) by means of a detachable balloon is an established method for treating CCFs while preserving a patent parent internal carotid artery (ICA). However, failure to embolize the CCF may occur on a few occasions, such as when the balloon cannot pass through the fistula into the cavernous sinus by blood flow, or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Under these circumstances, the ICA may have to be sacrificed in order to treat the CCF. Herein we describe a double-balloon technique for embolization of a CCF. By applying this technique, we successfully treated nine of 11 CCFs, without compromise of the parent ICA when the conventional one-balloon technique failed.     

Balloon catheters for investigating carotid cavernous fistulas.

A simple and reliable technique is described for investigating the precise location of an arteriovenous fistulous communication and its hemodynamics by temporary and complete vessel occlusion with a double-lumen balloon catheter.     

Direct carotid puncture for the endovascular treatment of anterior circulation aneurysms

We report the usefulness of Guglielmi detachable coil (GDC) embolization by direct carotid puncture for anterior circulation aneurysms. For all 27 patients, GDC embolization by direct carotid puncture was safely performed by using a 5F sheath introducer 5 cm long and a Tracker-38 catheter. Neurologic deficits and hemorrhage were not found in any patient during the follow-up period. If the transfemoral approach cannot be applied, GDC embolization should be considered as an alternative method.     

Direct sac puncture and N-butyl cyanoacrylate embolization of medial canthal arteriovenous malformation supplied by the external carotid artery and the internal carotid artery branches

We report a periorbital arteriovenous fistula that was treated with direct sac puncture N-butyl cyanoacrylate embolization under controlled inflow and outflow. The efficacy of this technique in a periorbital lesion is discussed.     

Agenesis of the internal carotid artery and cavernous sinus hypoplasia with contralateral cavernous sinus meningioma

We report a cavernous sinus meningioma encasing the cavernous internal carotid artery in a patient with congenital agenesis of the contralateral internal carotid artery and cavernous sinus hypoplasia.     

Endovascular treatment of high-flow carotid cavernous fistulas by stent-assisted coil placement

BACKGROUND AND PURPOSE: Endovascular techniques are the methods of choice for the treatment of patients with carotid cavernous fistulas. We report our experience using stent-assisted coil placement for treatment of patients with high-flow fistulas that are associated with severe laceration of the internal carotid artery. METHODS: In a retrospective review of an internal endovascular therapy database covering the interval between October 2001 and October 2003, we identified a total of 5 patients presenting with 6 high-flow type A carotid cavernous fistulas (one had a bilateral fistula) that were associated with severe laceration of the internal carotid artery. All were treated first with stenting of the injured segment of the internal carotid artery followed by transarterial (3/6) and/or transvenous (4/6) obliteration of the fistula with detachable platinum coils. In 2 cases, a liquid adhesive was also used. In all instances, a compliant balloon was inflated within the stented arterial segment during coil deposition to avoid extension of coils into the parent artery. RESULTS: All 6 fistulas were obliterated, and each internal carotid artery was successfully reconstructed. Except for posttraumatic cranial nerve dysfunction in 1 patient, clinical outcome was very good. Follow-up angiograms in 3 of the 6 patients obtained at intervals between 3 and 6 months (mean, 4.5 months) revealed no fistula recurrence and no evidence of intimal hyperplasia within the stent. CONCLUSION: In this series of patients with high-flow carotid cavernous fistula associated with severe injury to the internal carotid artery, stent-assisted coil placement offered a safe and effective treatment. Stent-assisted coil placement may increase the ability to successfully treat fistulas with severe injury to the internal carotid artery with preservation of the parent artery.     

Transvenous embolization of direct carotid cavernous fistulas

Of 165 cases of direct carotid cavernous fistula, 14 (8.5%) were treated from a transvenous approach. Twelve of these were treated through the inferior petrosal sinus and one through the superior ophthalmic vein. In one patient, both approaches were used. The embolic agents were as follows: five patients had balloons only, four patients had minicoils alone, three patients had coils and liquid adhesives, one had balloons and coils, and one had balloons and liquid adhesives. Among the patients who were treated from a transvenous approach, three had an occluded carotid artery caused by trauma, nine failed transarterial balloon attempts, and one had a prior trapping procedure. In the remaining patient, who had Ehlers-Danlos syndrome, a transarterial approach was judged to be too dangerous. This patient suffered a fatal pontine hemorrhage after subtotal transvenous occlusion of the carotid cavernous fistula with diversion of flow into cortical veins. Another complication occurred when the inferior petrosal sinus was perforated during catheterization, causing a small subarachnoid hemorrhage. The tear was immediately closed with minicoils, and surgical exposure and embolization resulted in complete cure. Of the remaining 12 patients treated, 11 were completely cured and one showed angiographic and clinical improvement. Transarterial balloon embolization remains the procedure of choice in the treatment of symptomatic carotid cavernous fistulas; however, transvenous embolization is an alternative when the arterial route fails.     

双导管球囊技术治疗高流量颈动脉海绵窦瘘

目的探讨双球囊导管技术治疗高流量颈动脉海绵窦瘘(CCF)的可行性及疗效。方法随机选择1枚可脱性球囊无法闭塞的CCF患者3例,双侧股动脉置管,送2枚球囊进入瘘口,调整位置,充盈2枚球囊,使瘘口完全闭塞后再解脱球囊,观察栓塞效果和颈内动脉通畅情况,评价该技术的可行性。结果3例患者均1次性完全闭塞瘘口,颈内动脉皆通畅,操作过程简单易行,未增加介入治疗的危险性。结论双导管球囊技术能在保证颈内动脉通畅的前提下简单有效地治疗1枚球囊无法闭塞的CCF。     

Anterior inferior cerebellar artery originating from the cavernous portion of the internal carotid artery.

An anomalous branch of the cavernous carotid artery, not reported previously, is described. Its appearance and distribution were unlike those of any known cavernous branch, originating at the level where the trigeminal artery is usually found but having no communication with the basilar artery. Its distribution approximated that of the anterior inferior cerebellar artery. The author believes that this is an unusual form of persistent embryonic communication between the carotid artery and the vessels of the posterior fossa.     

Embolization of branches arising from the cavernous portion of the internal carotid artery

Seven patients with vascular disease (four with cavernous and two with transverse sinus dural fistulas and one with a facial arteriovenous malformation, all supplied primarily from cavernous branches of the internal carotid artery) underwent subselective catheterization and embolization. Ten branches were catheterized (seven meningohypophyseal trunks and three inferolateral trunks) and eight branches were embolized. The embolic agents were as follows: polyvinyl alcohol particles in five, hypertonic glucose in two, and liquid adhesive in one. All four cavernous sinus dural fistulas were occluded after embolization. In the two transverse sinus fistulas, the goal of embolization was to obliterate the tentorial supply prior to surgery. This goal was achieved in both cases. In the remaining patient, who had a large facial arteriovenous malformation and recurrent epistaxis, the embolization obliterated the cavernous supply to the nasal cavity and the patient remains hemorrhage-free. Despite one complication, which occurred in the first case when a thrombus formed and dislodged, resulting in an embolic stroke, this study shows that subselective catheterization and embolization can obliterate lesions of the branches arising from the cavernous internal carotid artery.     

Endovascular treatment of carotid cavernous fistulae (CCF). Direct venous puncture using road mapping in dural CCF

Introduction

Endovascular treatment offers different options to treat CCF by less invasive approach avoiding morbidity and residual fistulas. The choice depends on the anatomy of the fistula and operator/Institutional preferences.

Objective

Describe options in endovascular treatment of Barrow Type A and Type D Carotid Cavernous fistulas (CCF).

Patients and methods

We report 10 cases of carotid cavernous fistula (CCF) that received endovascular treatment using coils and liquid embolic materials. Seven cases Barrow Type A, done through an arterial approach and three cases Barrow Type D, done through venous approach. The cavernous sinus in Type D cases was approached via the inferior petrosal sinus in one case and the other two cases by direct puncture of the facial and supra-orbital veins using road mapping. Using road mapping in venous approach to treat CCF is not reported in the literature before.

Results

Successful obliteration of the fistula was achieved in all cases with transient VI nerve palsy in one case and post procedure ophthalmic vein thrombosis in another.

Conclusion

With the observed favorable outcomes and lack of significant procedural morbidity, direct puncture of the facial and supra-orbital veins using road mapping to reach the cavernous sinus, might be an addition in the armamentarium available for endovascular treatment of CCF.     

Embolization of meningohypophyseal and inferolateral branches of the cavernous internal carotid artery.

BACKGROUND AND PURPOSE: Despite the continued improvements in endovascular techniques this decade, few dedicated studies addressing the feasibility of such procedures or their efficacy relative to risk have been conducted. The purpose of this study was to use current endovascular techniques to assess the feasibility, effectiveness, and safety of direct selective catheterization and embolization of the small branches of the cavernous segment of the internal carotid artery. METHODS: We retrospectively reviewed the findings in 10 patients with lesions (five meningiomas and five arteriovenous malformations) primarily or partly supplied by branches of the meningohypophyseal trunk or inferolateral trunk who had undergone endovascular embolization of the feeding arteries during the period from 1991 to 1997. In each case, the artery was selectively catheterized with a microcatheter/microguidewire system and embolized with polyvinyl alcohol particles (n = 5), n-butyl cyanoacrylate tissue adhesive (n = 4), or both (n = 1). RESULTS: In all 10 patients, the feeding artery from the meningohypophyseal trunk (eight patients) or inferolateral trunk (three patients; one patient with both) was successfully catheterized and embolized. In nine patients, embolization resulted in complete obliteration of the vascular territory; in the remaining patient, blood supply was decreased by an estimated 80%. No immediate or delayed complications occurred. CONCLUSION: Advances in microcatheter and microguidewire technology allow more efficient and safer selective catheterization and embolization of branches of the cavernous segment of the internal carotid artery than in the recent past. Meticulous technique and detailed knowledge of the vascular anatomy of the cavernous sinus region are necessary to maximize lesion devascularization and to minimize the risk of stroke, cranial nerve palsies, and blindness.     

Rheolytic thrombectomy of the occluded internal carotid artery in the setting of acute ischemic stroke

BACKGROUND AND PURPOSE: Acute thromboembolic stroke complicated by ipsilateral carotid occlusion may present both mechanical and inflow-related barriers to effective intracranial thrombolysis. We sought to review our experience with a novel method of mechanical thrombectomy, in such cases, using the Possis AngioJet system, a rheolytic thrombectomy device. METHODS: A review of our interventional neuroradiology database revealed three patients in whom an occluded cervical internal carotid artery was encountered during endovascular treatment for acute stroke and in whom thrombectomy was attempted, using the 5F Possis AngioJet thrombectomy catheter. The medical records and radiographic studies of these patients were reviewed. RESULTS: Three patients were identified (ages, 52--84 years). Two patients had isolated occlusion of the internal carotid artery; in one patient, thrombus extended down into the common carotid artery. Treatment was initiated within 190 to 360 minutes of stroke onset. Thrombectomy of the carotid artery was deemed necessary because of poor collateral flow to the affected hemisphere (chronic contralateral internal carotid artery occlusion [one patient] and thrombus extending to the carotid "T" [one patient]) or inability to pass a microcatheter through the occluded vessel (one patient). Adjunctive therapy included pharmacologic thrombolysis with tissue plasminogen activator (all patients), carotid angioplasty and stenting (two patients), and middle cerebral artery angioplasty (one patient). Patency of the carotid artery was reestablished in two patients, with some residual thrombus burden. In the third patient, the device was able to create a channel through the column of thrombus, allowing intracranial access. CONCLUSION: Rheolytic thrombectomy shows potential for rapid, large-burden thrombus removal in cases of internal carotid artery thrombosis, allowing expedient access to the intracranial circulation for additional thrombolytic therapy.