Two Cases of Carotid Artery Stenting Combined Balloon- and Self-expanding Stent for the Spontaneous Internal Carotid Artery Dissections

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1 Journal of Neuroendovascular Therapy 2017; 11: Online June 13, 2017 DOI: /jnet.tn Two Cases of Carotid Artery Stenting Combined Balloon- and Self-expanding Stent for the Spontaneous Internal Carotid Artery Dissections Michiyuki Miyamoto, Takayuki Nonaka, Minoru Ajiki, Hiroshi Yasuda, and Satoshi Ushikoshi Objective: Although conservative treatment is the first choice for high cervical internal carotid artery (ICA) stenosis due to spontaneous cervical ICA dissection, surgical revascularization is necessary when the disease resists conservative treatment. Although such lesions are difficult to treat by conventional carotid endarterectomy (CEA) or carotid artery stenting (CAS), they may be treated less invasively by modified CAS with add-on devices. In this report, we present two cases of CAS performed by the combined use of balloon- and self-expanding stents with a review of the literature. Case Presentations: Revascularization was performed by the same procedure in a 47-year-old man and a 43-year-old woman with left high cervical ICA stenosis. In the first case, no restenosis was noted on follow-up DSA performed after 1 year, but the self-expanding stent that initially overlapped the balloon-expandable stent had slipped off. Conclusion: High cervical carotid artery stenosis due to spontaneous cervical ICA dissection can be treated by CAS using the proximal protection technique with the combined use of a balloon-expandable stent. Keywords carotid artery stenting, balloon-expanding stent, carotid artery dissection, spontaneous Introduction In Japan, spontaneous cervical internal carotid artery (ICA) dissection is a relatively rare disease, and conservative treatment is the first priority for its management. However, patients, who resist medical treatment, show exacerbation of symptoms, or have circulation disturbance may have indications for stent therapy. 1,2) ICA dissection may occasionally extend to a high position near the carotid canal, and is difficult to treat by carotid endarterectomy (CEA), but may be treated by carotid artery stenting (CAS) Department of Neurosurgery, Hokkaido Medical Center, Sapporo, Hokkaido, Japan Received: May 20, 2016; Accepted: April 14, 2017 Corresponding author: Michiyuki Miyamoto. Department of Neurosurgery, Hokkaido Medical Center, Yamanote, Nishi, Sapporo, Hokkaido , Japan michi-miya@umin.ac.jp This work is licensed under a Creative Commons Attribution-NonCommercial- NoDerivatives International License The Japanese Society for Neuroendovascular Therapy with modified technique. But in the cases in which dissection extended near the carotid canal, self-expanding stent is often difficult to be navigated and deployed at targeting position through the torturous vessel. In this report, we present two cases in which CAS was performed by the combined use of a balloon-expandable stent for spontaneous cervical ICA dissection. Case Presentations Case 1 The patient was a 47-year-old male with transient weakness and numbness of the right upper and lower extremities. He had a history of hypertension, hyperlipidemia, and hyperuricemia. He had experienced a few seconds weakness of the right lower extremity 9 months before. Thereafter, he noted weakness and numbness of the right upper extremity, was diagnosed with subacute infarction of the left frontal lobe and spontaneous dissection of the left cervical ICA at a local neurosurgery clinic, and was referred to our department. 437

2 Miyamoto M, et al. A B C Fig. 1 ( A) Diffusion-weighted MR image shows ischemic lesion in the left frontal cortex. (B) SPECT shows CBF in left ICA area is decreasing. (C) MRA shows severe stenosis in left ICA (arrows). CBF: cerebral blood flow; ICA: internal carotid artery; SPECT: Single Photon Emission Computed Tomography On admission, no neurological deficits were observed. At the previous clinic, a high-intensity area was noted in the deep white matter of the left frontal lobe on diffusionweighted imaging (DWI) (Fig. 1A). MRA showed marked stenosis in the craniocervical junction of the left internal carotid artery (ICA) (Fig. 1C), and resting 123 I IMP SPECT indicated reduced cerebral blood flow in the left ICA area (Fig. 1B). We diagnosed spontaneous cervical ICA dissection at the craniocervical junction, and revascularization was selected because of the low cerebral blood flow (CBF). Since treatment using a conventional CAS using selfexpanding stent was considered difficult due to the high cervical ICA stenosis, CAS combined using a balloonexpandable stent was selected. After our conference about the off-label use of the device, informed consent was obtained from the family. Dual-antiplatelet therapy (DAPT) consisting of 200 mg cilostazol and 75 mg clopidogrel was performed from 1 week before the procedure. Under local anesthesia, a 9 Fr balloon guiding catheter was placed in the left common carotid artery, and the left external carotid artery was occluded by placing a guard-wire (GW) (Medtronic, Santa Rosa, CA, USA). A inch micro-guidewire was carefully guided through the lesion and advanced to the cavernous portion (Figs. 2A and 2B). After blocking the common carotid artery, the flow reversal protection was performed using the venous sheath. A Palmaz genesis (Johnson & Johnson, Miami, FL, USA) 5 mm 18 mm was placed distally to the lesion, and a Wallstent (Stryker, Kalamazoo, MI, USA) 10 mm 21 mm was placed with about 6-mm overlap with the Palmaz (Fig. 2D). Blocking of the blood flow was released after sufficiently flowing debris to the venous side. Post-dilation was performed using a percutaneous transluminal angioplasty (PTA) balloon 5 mm 40 mm. The anterograde flow of ICA was improved, and satisfactory delineation of ICA was observed (Fig. 2C). Postoperatively, there was no new neurological symptoms, no new cerebral infarction was detected by DWI, and the patient was discharge to home. Follow-up DSA performed after 1 year showed adequate patency but displacement of the overlapping stent (Fig. 2E). Case 2 The patient was a 43-year-old woman complaining of a sudden onset headache and she visited a neurosurgery clinic. MRI demonstrated left vertebral artery dissection and spontaneous left cervical ICA dissection, and she was referred to our hospital for treatment. 438

3 Two Cases of CAS Combined Balloon- and Self-Expanding Stent A B C D E Fig. 2 ( A) The preoperative left common carotid angiogram (lateral view). (B) The micro-guidewire is passing through the true lumen. (C) The postoperative angiogram (lateral view) shows complete restoration of the vessel profile. (D) Xp shows the Wallstent was placed so as to overlap the Palmaz stent. (E) The 3D-angiography shows the Wallstent slip from the Palmaz stent (arrows). On admission, no neurological deficits were observed. MRI DWI showed diffuse high-intensity areas in the deep white matter of the left frontal lobe (Figs. 3A 3C). On MRA, delineation of the left ICA was poor, and spindle-shaped dilation was noted in the left vertebral artery (Figs. 3D and 3E). Resting 123 I IMP SPECT showed no laterality of the blood flow in the ICA area (Fig. 3F). While the left vertebral artery dissection was unruptured, low-pressure management was considered desirable, but as this treatment contradicted the approach to the left ICA dissection, for which mildly high-pressure management was desirable. Therefore, parent artery occlusion was performed for the left vertebral artery dissection on the day of the transfer. Then, after conservative treatment including high-pressure therapy for the left cerebral infarction, CAS for the left ICA was performed 12 days after the onset. DAPT (100 mg aspirin, 75 mg clopidogrel) was continued from the onset. Endovascular treatment was performed by proximal protection using a 9 Fr balloon guiding catheter and GW similar to the procedure in Case 1 (Figs. 4A and 4B). A inch micro-guidewire was carefully guided through the lesion and advanced to the cavernous portion. Then, after blocking of the common and external carotid arteries, pre-dilation was performed using a Gateway (Stryker) 3 mm 12 mm, and a Palmaz genesis 5.0 mm 18 mm was placed (Fig. 4C). In addition, a Wallstent 8 mm 21 mm was placed by overlapping about half of its length with the Palmaz (Fig. 4D). Since the vessel was dilated to a sufficient diameter in placing the Wallstent, post-dilation was not performed. Postoperatively, the patient was discharged to home without new neurological symptoms. Adequate patency of the stent was confirmed by DSA 1 year after the treatment. Discussion The incidence of spontaneous cervical ICA dissection in Japan has been reported to be per 100,000 persons, 3) which is about 1/2 of that in Western countries, and it is also lower than the incidence of vertebral artery dissection with a ratio of about 1:4. 2,3) However, the recent improvements in diagnostic imaging may make more chance to diagnose the ICA dissection. An onset with hemorrhage is very rare, 4,5) and with ischemia is usually. While conservative treatment is the first choice, 1 3) surgical intervention is selected in patients with unstable hemodynamics. Direct 439

4 Miyamoto M, et al. A B C D E F Fig. 3 ( A C) Diffusion-weighted MR images show ischemic lesion in the left watershed lesion. (D and E) Intracranial and neck MRA show the decreased signal in the left ICA area and the dissecting aneurysm in the left VA (arrows). (F) SPECT shows no CBF laterality in this brain. CBF: cerebral blood flow; ICA: internal carotid artery; SPECT: Single Photon Emission Computed Tomography; VA: vertebral artery A B C D Fig. 4 ( A) The preoperative left common carotid angiogram shows the severe stenosis in craniocervical lesion caused by dissection (AP view). (B) The external carotid artery was occluded by GW and the micro-guidewire is passing through the true lumen. (C) The postoperative angiogram (AP view) shows complete restoration of the vessel profile. (D) Xp shows the Wallstent was placed so as to overlap the Palmaz stent sufficiently. AP: anteroposterior; GW: guard-wire procedures including extracranial intracranial (EC-IC) bypass were reported in the past, 6,7) but treatment has shifted recently to less invasive stent therapy. 1,2,8 11) According to the report by Jeon et al., 12) all eight patients with cervical carotid artery dissection treated by stenting had favorable outcomes. We experienced two cases of spontaneous cervical ICA dissection which were treated by combined a balloon- and a self-expanding stent. We should use only a self-expanding stent because national health insurance in Japan cover only it to treat the carotid artery stenosis. However, in the cases it is often difficult to be navigated and deployed at the end of stenosis using a self-expanding stent because of the torturous vessel. The use of a Palmaz Genesis, which is a balloonexpandable stent for the renal artery, is not recommended for cervical artery lesions. However, balloon-expandable stents 440

5 Two Cases of CAS Combined Balloon- and Self-Expanding Stent are highly flexible and passable, 2) and was placed easily and appropriately in patients with spontaneous cervical internal artery dissection. In Japan, Wingspan (Stryker) is covered by insurance as an intracranial stent, but its use is presently difficult due to strict facility rules and indications. There have been reports of the use of coronary stents 2,8,11) and Palmaz, 9,11) and their use is considered to be ethically permissible if an appropriate approval procedure is followed. Concerning Case 1, a Palmaz and a Wallstent were overlapped by 6 mm, but the Wallstent slipped off the Palmaz on DSA after 1 year. This disengagement was considered to have been due to the lack of the distance of overlapping or gradual shortening of the Wallstent due to its selfexpandability. Particularly, while we used a 10-mm Wallstent in consideration of the diameter of the ICA at its bifurcation, an 8-mm Wallstent may have also been a choice. It was also considered necessary to increase the length of overlapping as much as was technically possible. Because of the etiology of dissection, a closed-cell stent may be the first choice because the stent strut may keep the dissection wall and the thrombus outside the stent than an open one, 2,10) but the use of an open-cell stent, which is less likely to shorten, may also be a reasonable choice. Case 2 had the onset with left-sided headache and simultaneously suffered dissection of the left internal carotid and left vertebral arteries. Cerebral infarction was limited to the left ICA area, the time of the onset of left vertebral artery dissection was unknown, and no sign of acute dissection was observed on MRI. Therefore, we should have treated the left ICA dissection without the parent artery occlusion of the left vertebral artery dissection. However, the left vertebral artery dissection was treated, since we were concerned about the rupture of it, because of mildly high-pressure treatment. Headache may also be caused by ICA dissection, and, according to the report by Anson et al., 13) 59% of the patients of ICA dissection complained of headache. Regarding the surgical procedure, there have been some reports of distal protection using a GW and filter devices, 2,9,12) but we considered proximal protection using a micro-guidewire to be preferable because of its good performance about the navigation to the torturous vessel and the security to the true lumen. For this purpose, we consider a balloon guiding catheter and, more recently, Mo.Ma Ultra (Medtronic) is appropriate. In the postoperative follow-up, carotid artery ultrasonography plays a major role after conventional CAS, but the evaluation to a sufficiently distal region is impossible. Since MRI does not evaluate restenosis, we consider periodic follow-up by DSA or 3D-CTA to be necessary. Conclusion Two cases of spontaneous cervical ICA dissection treated by the combined use of a balloon-expandable stent were reported. Even ICA dissections at a high position, which are difficult to treat by conventional CEA or CAS, could be treated by it. Despite the lack of insurance coverage, treatment could be performed by nearly the same procedure as usual CAS with proximal protection. Mildly invasive stenting is considered to be a useful treatment option to high cervical ICA dissection. Disclosure Statement There are no conflicts of interest to disclose regarding this paper. References 1) Suzuki I, Matsumoto Y, Kikuchi T, et al: [Endovascular stenting for the treatment of acute ischemic stroke due to spontaneous carotid artery dissection: case report]. JNET 2013; 7: (in Japanese) 2) Takeuchi M, Ishiguro T, Asamitsu A, et al: [Spontaneous dissection of the internal carotid artery: case report]. JNET 2010; 4: (in Japanese) 3) Nagoya H, Takeda E, Denpo T, et al: [Spontaneous carotid artery dissection: 10 cases report]. Jpn J Stroke 2011; 33: (in Japanese) 4) Mazighi M, Saint Maurice JP, Rogopoulos A, et al: Extracranial vertebral and carotid dissection occurring in the course of subarachnoid hemorrhage. Neurology 2005; 65: ) Nagumo K, Nakamori A, Kojima S: [Spontaneous intracranial internal carotid artery dissection: 6 case reports and a review of 39 cases in the literature]. Rinsho Shinkeigaku 2003; 43: (in Japanese) 6) Kawasaki K, Katsuno M, Miyazaki T, et al: [Literature review and report of five cases of spontaneous carotid artery dissection]. Surg Cereb Stroke (Jpn) 2015; 43: (in Japanese) 7) Morgan MK, Sekhon LH: Extracranial-intracranial saphenous vein bypass for carotid or vertebral artery dissections: a report of six cases. J Neurosurg 1994; 80: ) Malek AM, Higashida RT, Phatouros CC, et al: Endovascular management of extracranial carotid artery dissection 441

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