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Endovascular Management of a Symptomatic Spontaneous Internal Carotid Artery Dissection with On-label Use of an FDA Approved Device
Austin J. Wagner, D.O.1, Melissa A. Obmann, D.O.1, Shivprasad D. Nikam, M.D.1, James R. Elmore, M.D.2, David R. Mariner, M.D.1.
1Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA, USA, 2Geisinger Medical Center, Danville, PA, USA.
Objective
Spontaneous carotid artery dissection is an uncommon phenomenon with a reported incidence ranging from 1.7 to 2.6%. Carotid artery dissection accounts for nearly 2% of all ischemic strokes and poses a serious stroke threat to young and middle aged populations. Open intervention for acute carotid dissection often results in significant morbidity and clinical failure. Anticoagulation and antiplatelet therapies have been the treatment of choice in clinically stable carotid artery dissections. However, disease progression can still occur, leading to unstable neurologic symptoms necessitating surgical intervention. Endovascular management of these lesions is an infrequently described and evolving treatment modality. We present the case of a 45 year old woman with a symptomatic spontaneous carotid dissection treated with an FDA approved carotid stenting device.
Methods
Our patient had a known right internal carotid artery dissection from previous hospital admissions. She had been managed with aspirin and warfarin with subsequent cessation of warfarin due to a subarachnoid hemorrhage. A CT Angiogram(CTA) at this presentation demonstrated progression the carotid stenosis from 60-70% to nearly 99%, which was anatomically unfavorable for carotid endarterectomy. Therefore endovascular intervention for the carotid dissection was performed.
A carotid angiogram confirmed the right internal carotid artery had two levels of dissection with the false lumen of the proximal dissection causing an approximately 90% true luminal stenosis. The right internal carotid artery true lumen was then selectively catheterized and a 5 mm Angioguard® embolic protection device was deployed distal to the stenosis. This was followed by placement of a 7x40 mm Precise®Rx self-expanding stent across the stenosis and dissection. Completion angiography confirmed a widely patent right internal carotid artery.
Results
The patient recovered uneventfully with complete resolution of her neurologic symptoms. Follow up carotid duplex and CTA at one year did not show any in-stent stenosis or residual intimal flap with good remodeling of the carotid artery around the stent.
Conclusions
Currently there have been a few small series and case reports of carotid artery dissections managed by endovascular means, which have all demonstrated promising results. These results have primarily come from off- label use of self-expanding and balloon expandable stents without distal embolic protection. We present a unique case of a symptomatic carotid artery dissection treated with an FDA approved carotid stenting device.
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