Direct Carotid Artery Cutdown and flow diversions for the bilateral Internal Carotid Artery Dissecting Pseudoaneurysms: A Case Report

Abstract

Background: Surpass streamline flow diversion is performed by transfemoral, transradial or both approaches. Safety and feasibility of direct carotid artery cutdown and is not known. Objective is to report Surpass streamline flow diversion via direct carotid artery utdown for a patient with bilateral internal carotid artery dissecting pseudoaneurysm. Method: Case report. Outcome was measured using modified ranking scale (mRS). Results: Sixty-seven-year-old man with history of repaired aortic arch dissecting aneurysm using aortic stent, developed worsening headaches and dizziness and diagnosed with bilateral internal carotid artery dissecting pseudoaneurysm on a computed tomographic angiography; right internal carotid artery dissecting pseudoaneurysm measured 19x15x20 mm and left was 16x9x22 mm. Digital subtraction angiogram was attempted but failed.  A direct carotid artery cutdown followed by surpass streamline flow diversion was performed in a staged fashion. A 6-french sheath was placed from right common carotid artery to right internal carotid artery by a vascular surgeon and was confined with digital subtraction angiography. An intermediate catheter was navigated to the internal carotid artery beyond the internal carotid artery dissecting pseudoaneurysm and surpass streamline flow diversion was achieved with 3 devices; 4x50 mm x2 and 5x40 mm. Carotid artery cutdown site was sutured by vascular surgeon. Patient was extubated and discharged home in 48 hours with NIHSS 0 and mRS1 at his baseline. The left internal carotid artery dissecting pseudoaneurysm was repaired after 3 month using similar technique as described above with two 5x50 mm flow diverters. For the second procedure, angioplasties were required for better appositions of flow diverters. Patient was discharged home in 24 hours. Patient’s symptoms resolved and resumed baseline activities. Prescribed to continued 325 mg aspirin and 75 mg clopidogrel for six months followed by 162 mg aspirin and 75 mg of clopidogrel. Patient maintained mRS 0 in follow-up visits but refused to have a computed tomographic angiography, which finally performed in 24 months, demonstrates complete obligations of the left internal carotid artery dissecting pseudoaneurysm but occlusion of right internal carotid artery with robust collaterals from left internal carotid artery through collaterals. Patient admits premature discontinuation of antiplatelets when he learned about his computed tomographic angiography results. Conclusion: This is the first report of treatment of bilateral internal carotid artery dissecting pseudoaneurysm repaired by direct carotid artery cutdown approach. This is also the first report of a patient with an aortic arch stent, who developed bilateral internal carotid artery dissecting pseudoaneurysm and direct carotid artery cutdown required for treatment. Additionally, antiplatelets must be continued to prevent device occlusion.