A novel treatment approach for common carotid artery bifurcation aneurysms.

Introduction

An aneurysm involved in common carotid artery (CCA) bifurcation is a rare clinical condition. There are not enough natural follow-up data, and there is no evidence-based treatment algorithm [1]. An endovascular approach is used to treat CCA bifurcation aneurysms, as it offers some advantages in selected patient populations; nonetheless, closure of the aneurysmal segment in CCA bifurcation using a graft stent has some challenges, mainly occluding the ostial part of the external carotid artery (ECA). Coil embolization of a CCA bifurcation aneurysm is preferred over graft stent implantation in this condition; however, coil embolization cannot provide appropriate treatment in patients suffering from a CCA bifurcation aneurysm with significant stenosis in the proximal part of the internal carotid artery (ICA).

Herein, we present a male patient whose CCA bifurcation aneurysm with significant stenosis in the proximal part of the ipsilateral ICA was successfully treated with the implantation of two nested self-expandable closed-cell stents.

Case report

A 54-year-old hypertensive male patient was admitted to our clinic due to recurrent episodes of transient ischemic attack in the last 3 months. His carotid angiography revealed a right-sided CCA bifurcation aneurysm with 50–60% stenosis in the proximal part of the ICA (Figure 1 A). Due to the possibility of occluding the ostial part of the right ECA if we close the aneurysmal segment with a graft stent, we preferred to close the aneurysmal segment by implanting two nested self-expandable closed-cell stents. The patient had already been on 100 mg/day aspirin for 2 months and received a 300 mg loading dose of clopidogrel the day before the procedure. A written informed consent form was provided before the procedure. A 40 × 8–6 mm Xact stent (Abbott Vascular, USA) was implanted successfully after the Emboshield NAV6 Embolic Protection System (Abbott Vascular, USA) had been placed distally to the target lesion (Figure 1 B). However, we observed that the CCA bifurcation aneurysm persisted after stent implantation (Figure 1 C). Therefore, a 30 × 7 mm Xact stent (Abbott Vascular, USA) was implanted inside the first stent. The final carotid injection showed that the aneurysm was substantially closed (Figure 1 D). After the procedure, a combination of clopidogrel 75 mg/day and aspirin 100 mg/day was planned for 2 months and aspirin 100 mg/day indefinitely. The patient was scheduled for control CT angiography 3 months later to check the stent appositions, the patency of the vessel and the exclusion of the aneurysm.

Figure 1

A – Angiographic view of a right-sided common carotid artery (CCA) bifurcation aneurysm with 50–60% stenosis in the proximal part of the internal carotid artery (ICA). B – Deployment of the first Xact (Abbott Vascular, USA) self-expandable closed-cell stent. C – Persistence of the CCA aneurysm after implantation of the first stent. D – Final carotid injection showing substantial closure of the CCA bifurcation aneurysm after deployment of the second Xact (Abbott Vascular, USA) self-expandable closed-cell stent

Discussion

There are limited data available in the literature about the optimal treatment method of CCA bifurcation aneurysms. Recently, Welleweerd et al. started a registry to address diagnostic and therapeutic questions about the management of extracranial carotid artery aneurysms [1]. Alternative treatment options other than surgical resection, mainly endovascular treatment, have been debated in the last few years [2, 3]. Due to the concomitance of significant stenosis in the proximal part of the ICA with a CCA bifurcation aneurysm and the unsuitability of closing it with a graft stent, in this case we treated the CCA bifurcation aneurysm with the implantation of two nested self-expandable closed-cell stents. The final carotid injection showed a satisfactory result.

Conclusions

Coil embolization of CCA bifurcation aneurysms cannot provide sufficient treatment in patients suffering from a CCA bifurcation aneurysm with significant stenosis in the proximal part of the ipsilateral ICA. Therefore, we suggest deploying two nested self-expandable closed-cell stents as an alternative method for the treatment of CCA bifurcation aneurysms, particularly if accompanied by significant stenosis in the proximal part of the ipsilateral ICA.