Open Retrograde Endovascular Stenting for Left Common Carotid Artery Dissection Secondary to Surgical Repair of Acute Aortic Dissection: A Case Report and Review of the Literature Peng Gao,1 Yabing Wang,2 Yanfei Chen,2 and Liqun Jiao,1 Beijing, China
A 30-year-old male presented with an acute aortic artery dissection (Stanford type A) and underwent total arch replacement using a stented elephant trunk technique. One month later, the patient developed dissections in the innominate and left common carotid artery (CCA). The innominate artery dissection caused occlusion in the right internal carotid artery (ICA) and a major stroke. Dissection of the left CCA progressed and extended to the bifurcation site. Antegrade access for a left carotid intervention was deemed as difficult because of the previously implanted stent and the additional risks of embolic events and dissection enlargement. Hybrid procedures combining left carotid bifurcation exposure and retrograde endovascular stenting were successfully completed. This report is a rare case of retrograde endovascular reconstruction for the left CCA dissection following surgical repair of an aortic artery dissection. Here, we also review previous cases of iatrogenic carotid dissections following surgical intervention.
Dissection of the extracranial carotid artery can be spontaneous,1 secondary to trauma2 or an acute aortic dissection involving supra-aortic branches3 or iatrogenic dissection. Spontaneous or traumatic dissections can be treated with endovascular therapy (EVT) in patients with recurrent cerebral ischemia despite medical therapy4e6; however, patients with aortic dissections can be managed by cardiothoracic surgical repair with acceptable immediate and long-term outcomes.7 Recently, there have been new reports on iatrogenic carotid dissections following surgical repair of aortic
The authors declare no conflict of interests. 1 Department of Interventional Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China. 2 Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
Correspondence to: Liqun Jiao, Department of Interventional Radiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing 100053, China; E-mail: [email protected] Ann Vasc Surg 2015; 29: 1019.e11–1019.e15 http://dx.doi.org/10.1016/j.avsg.2015.01.017 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: August 7, 2014; manuscript accepted: January 10, 2015; published online: March 9, 2015.
dissection3,8,9 or carotid endarterectomy (CEA).10 Here, we report a rare case of dissections in the innominate and left common carotid arteries after a total arch replacement that was successfully treated with open retrograde EVT reconstruction in the left common carotid artery (CCA). We also address previous similar reports.
CASE REPORTS A previously healthy 30-year-old man without history of Marfan’s syndrome, hypertension, or arteritis presented with a sudden severe tearing pain in the chest. Thoracic computed tomography (CT) angiogram showed an acute aortic dissection involving the ascending aorta, aortic arch, descending aorta, and supra-aortic branches, and the tear originated at the root of the ascending aorta (Stanford type A, Fig. 1A, B). The patient underwent an emergency total aortic arch replacement using a stented elephant trunk technique (Sun’s procedure7,11) at another hospital. He was discharged without any apparent postsurgical morbidity. One month later, the patient suddenly developed dizziness and left extremity weakness. Cranial CT showed cerebral infarction in the right tempo-occipital lobe (Fig. 1C). Cervical CT angiogram showed dissections in the 1019.e11
1019.e12 Case reports
Fig. 1. The anteroposterior view (A) and posteroanterior view (B) of the three-dimensional CT angiogram demonstrated an aortic dissection involving the ascending aorta, aortic arch, descending aorta, and supra-aortic branches. The cranial CT showed cerebral infarctions in the right
innominate artery and left CCA. The innominate artery and CCA dissection extended distally and caused right internal carotid artery (ICA) occlusion (Fig. 1D, E), while the left CCA dissection originated from the surgical anastomosis site and extended distally to the bifurcation (Fig. 1F). The patient underwent transcervical open retrograde endovascular stenting in an integrated hybrid operating room. Concomitant CEA was deemed unnecessary because of the absence of apparent atheromatous plaque in the left CCA bifurcation. Briefly, a modified transverse mini-incision was made to access the left carotid bifurcation. The left ICA, CCA, and external carotid artery (ECA) were mobilized and isolated. After systemic heparinization, the left ICA and ECA were temporarily clamped without an apparent decrease in ipsilateral middle cerebral artery flow based on the transcranial Doppler monitoring throughout the procedure. A 6-French sheath using a Seldinger approach was introduced into the left ICA under ultrasound guidance and then retrogradely moved from the ICA into the
Annals of Vascular Surgery
tempo-occipital lobe (C). The three-dimensional CT angiogram showed a right ICA occlusion (D, E) and left CCA dissection (F). Asterix indicates the dissecting originating point.
Fig. 2. The intraoperative photograph showing retrograde cannulation of a 6-French sheath into the left ICA. proximal CCA (Fig. 2). After ultrasound confirmation that the sheath was in the true lumen, angiography revealed an intimal flap dissection originating at the site
Vol. 29, No. 5, July 2015
Case reports 1019.e13
Fig. 3. The preoperative left CCA angiogram showed an intimal flap that originated from the surgical anastomosis site and extended to the left CCA bifurcation with an apparent extravasation of contrast into the pseudolumen, and the true lumen was severely compressed by the pseudolumen (A). The angiogram after delivery of the
first WallStent showed an improvement in the pseudolumen (B). The second WallStent was placed in tandem with the first stent, and the angiogram revealed an almost complete restoration of proximal (C) and distal intracranial (D) flow.
of anastomosis between the artificial graft and proximal CCA wall. The false lumen extended, compressed, and nearly occluded the true lumen in the distal CCA. A microguidewire was then carefully positioned across the dissection to the normal lumen under fluoroscopic control. One WallStent (9e50 mm; Boston Scientific, Natick, MA) was placed over the guidewire covering the dissection origination point. Angiogram revealed unsatisfactory stent apposition, and the intimal flap did not adhere well to the vessel wall and the pseudolumen persisted. Another WallStent (9e50 mm) was then delivered in tandem with the first one to cover the entire dissection. A repeated angiogram demonstrated appropriate stent apposition without apparent extravasation of contrast into the pseudolumen (Fig. 3). The artery at the puncture site was closed with 6-0 Prolene sutures. Definite hemostasis was achieved and overlying layers were closed. The procedure was successful without complications. The patient was followed up for 6 months, and no neurological deficits were reported.
condition, and its natural history remains unknown. Based on a review of the literature, iatrogenic carotid dissection may be associated with the surgical repair of aortic dissections3,8,9 or CEA10 (see Table I for review of the literature). Iatrogenic dissections related to the surgical repair of aortic dissections rarely occur and may be secondary to repaired wall fragility and suture line-related secondary trauma.9 The only documented large series reported a 15% incidence of postoperative CCA dissection with the majority of cases showing no progression and patients remaining asymptomatic during a 2-year follow-up by carotid ultrasound.12 However, the present patient suffered a major stroke caused by right ICA occlusion 30 days after surgical repair. We were disinclined to reconstruct the right CCA because of the occlusion, and the left CCA dissection with extension to the branch was considered at high risk for malperfusion syndrome. Although there are limited publications on the treatment of symptomatic iatrogenic CCA dissections,3,8e10 antegrade EVT via femoral artery as an alternative to surgical therapy appears to be frequently used (Table I). Katoh et al. reported a 71-year-old woman who developed an iatrogenic dissection from the brachiocephalic trunk to the right ICA 6 days after an operation for an ascending aortic dissection. For this case, a successful EVT via the left femoral artery was performed.9 In a case report by Cardaioli et al., a 67-year-old male
DISCUSSION Dissection of the extracranial carotid arteries has been increasingly recognized as a cause of transient ischemic attack or stroke in young patients. The dissection can be spontaneous, secondary to trauma or an acute aortic dissection or iatrogenic dissection. Most extracranial dissections usually heal over time with antithrombotic therapy. EVT is only considered when patients with recurrent ischemia fail medical therapy.6 Iatrogenic carotid dissection is a rare
1019.e14 Case reports
Annals of Vascular Surgery
Table I. Previous studies of iatrogenic CCA dissections after surgical repair
Study
Year of Sex and Side of publication age dissections
Cardaioli et al.8 2007
M/67
Stella et al.10
2010
M/83
Casana et al.3
2011
F/66
Right CCA
Katoh et al.9
2013
F/71
Right CCA
Previous history of surgery and current condition
Bilateral CCA Presented with acute aortic type A dissection and was treated with a 28-mm Vasculteck prosthesis Left CCA Left CCA dissection secondary to carotid endarterectomy
Endovascular treatment with antegrade or retrograde approach
Antegrade approach
Access route
Right femoral artery
Superficial Retrograde approach temporal because of a partially artery compromised aortobifemoral bypass graft Antegrade approach Femoral artery
Underwent a composite repair with a valve sparing technique for type A aortic dissection and presented with episodes of ‘‘drop attack’’ Antegrade approach Developed dissection from brachiocephalic trunk to right ICA 6 days after the operation of ascending aortic dissection
Left femoral and right brachial artery
F, female; M, male.
presented with progressive bilateral CCA dissections within the early postoperative days following surgical repair of an acute aortic type A dissection with a 28-mm Vasculteck prosthesis. The dissections were treated via the right femoral artery.8 Casana et al. described a case involving a 66-year-woman who underwent a composite repair with a valve-sparing technique for a type A aortic dissection and then presented with episodes of ‘‘drop attack.’’ An ultrasound revealed a right CCA dissection, which was successfully treated with an antegrade approach.3 However, transfemoral antegrade access may not be applicable for all patients with iatrogenic carotid dissections because of either inaccessible routes (severe aortoiliac occlusive diseases) or implantation of an elephant trunk within the aorta (this case). In the study by Stella et al., a patient suffered from a left CCA dissection post-CEA. Retrograde EVT via the superficial temporal artery instead of the femoral artery was performed because of a partially compromised aortobifemoral bypass graft.10 A deformed arch anatomy caused by total arch replacement or a stented elephant trunk implantation may prevent
a conventional antegrade approach for intervention because of additional challenges. For example, the study by Tsai and Shen reported a patient who developed symptomatic left CCA restenosis 2 weeks after total arch rerouting and elephant trunk repair for an acute aortic dissection with left CCA malperfusion. The patient underwent emergent CCA stenting via a sternal reentry with restoration of cerebral perfusion.13 In our case, an open and retrograde approach was chosen instead of an antegrade or open reentry for multiple reasons: (1) the left CCA antegrade catheterization was rendered technically difficult by the previously implanted elephant stent, and this method posed additional risks of embolic events and dissection enlargement because of pseudolumen proximity to the aortic arch; (2) surgical exposure of the carotid bifurcation would help choose an appropriate puncture site and achieve hemostasis, while the intraoperative ultrasound would provide real-time information to avoid sheath malposition into the pseudolumen; (3) stenting may carry the risk of embolic events, and distal ICA and ECA
Vol. 29, No. 5, July 2015
temporary occlusion would provide distal protection from embolic events during stent delivery; and (4) retrograde EVT with arteriotomy for the atherosclerotic lesions of the proximal CCA,14,15 ICA,16 innominate artery,16e18 or the lesions in tandem17,19 was a safe and effective alternative in selected patients. The hybrid operating room served as an important platform allowing for both surgical and endovascular procedures.10,13 Therefore, we were encouraged to treat this rare condition for the first time using hybrid procedures combining carotid exposure, arteriotomy, and retrograde endovascular angioplasty.
Case reports 1019.e15
7.
8.
9.
10.
CONCLUSION
11.
A retrograde approach with arteriotomy may represent a valid alternative approach for the endovascular treatment of iatrogenic carotid dissections following surgical repair.
12.
13.
The authors thank Dr. Yang Hua, MD, Department of Vascular Ultrasonography, for her assistance with the intraoperative ultrasound.
14.
REFERENCES 1. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001;344:898e906. 2. Alimi YS, Di Mauro P, Fiacre E, et al. Blunt injury to the internal carotid artery at the base of the skull: six cases of venous graft restoration. J Vasc Surg 1996;24:249e57. 3. Casana R, Tolva V, Majnardi AR, et al. Endovascular management of symptomatic cerebral malperfusion due to carotid dissection after type A aortic dissection repair. Vasc Endovasc Surg 2011;45:641e5. 4. Ohta H, Natarajan SK, Hauck EF, et al. Endovascular stent therapy for extracranial and intracranial carotid artery dissection: single-center experience. J Neurosurg 2011;115: 91e100. 5. Asif KS, Lazzaro MA, Teleb MS, et al. Endovascular reconstruction for progressively worsening carotid artery dissection. J Neurointerv Surg 2015;7:32e9. 6. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals
15.
16.
17.
18.
19.
from the American Heart Association/American Stroke Association. Stroke 2014;45:2160e236. Ma WG, Zheng J, Dong SB, et al. Sun’s procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection. Ann Cardiothorac Surg 2013;2:621e8. Cardaioli P, Rigatelli G, Giordan M, et al. Multiple carotid stenting for extended thoracic aorta dissection after initial aortic surgical repair. Cardiovasc Revasc Med 2007;8:213e5. Katoh H, Nozue T, Nagamine H, et al. A case of carotid artery dissection after surgical repair of aortic dissection successfully treated with endovascular therapy using intravascular ultrasound. Cardiovasc Interv Ther 2014;29:237e42. Stella N, Palombo G, Filippi F, et al. Endovascular treatment of common carotid artery dissection via the superficial temporal artery. J Endovasc Ther 2010;17:569e73. Ma WG, Zhu JM, Zheng J, et al. Sun’s procedure for complex aortic arch repair: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg 2013;2:642e8. Zielinski T, Wolkanin-Bartnik J, Janaszek-Sitkowska H, et al. Persistent dissection of carotid artery in patients operated on for type A acute aortic dissectiondcarotid ultrasound follow-up. Int J Cardiol 1999;70:133e9. Tsai KT, Shen TC. Challenging carotid intervention after total arch rerouting and hybrid zone 0 elephant trunk repair for a complicated type A aortic dissection. J Endovasc Ther 2014;21:306e11. Tsutsumi M, Kazekawa K, Onizuka M, et al. Cerebral protection during retrograde carotid artery stenting for proximal carotid artery stenosis: technical note. Neurol Med Chir (Tokyo) 2007;47:285e7. discussion 287e288. Garg N, Oderich GS, Duncan AA, et al. Retrograde supraaortic stent placement combined with open carotid or subclavian artery revascularization. Vasc Endovascular Surg 2011;45:527e35. Christopoulos DC, Kardakis C, Pitoulias GA, et al. Simultaneous transcervical angioplasty and stenting of innominate and right internal carotid arteries. Ann Vasc Surg 2014;28: 492.e11e5. Iihara K, Satow T, Matsushige T, et al. Hybrid operating room for the treatment of complex neurovascular and brachiocephalic lesions. J Stroke Cerebrovasc Dis 2013;22: e277e85. Mordasini P, Gralla J, Do DD, et al. Percutaneous and open retrograde endovascular stenting of symptomatic high-grade innominate artery stenosis: technique and follow-up. AJNR Am J Neuroradiol 2011;32:1726e31. Vermeulen T, Hendriks JM, Baeten M, et al. Endarterectomy combined with retrograde stenting for tandem lesions of the carotid artery. Acta Chir Belg 2011;111:312e4.
A 30-year-old male presented with an acute aortic artery dissection (Stanford type A) and underwent total arch replacement using a stented elephant trunk technique. One month later, the patient developed dissections in the innominate and left common carotid artery (CCA). The innominate artery dissection caused occlusion in the right internal carotid artery (ICA) and a major stroke. Dissection of the left CCA progressed and extended to the bifurcation site. Antegrade access for a left carotid intervention was deemed as difficult because of the previously implanted stent and the additional risks of embolic events and dissection enlargement. Hybrid procedures combining left carotid bifurcation exposure and retrograde endovascular stenting were successfully completed. This report is a rare case of retrograde endovascular reconstruction for the left CCA dissection following surgical repair of an aortic artery dissection. Here, we also review previous cases of iatrogenic carotid dissections following surgical intervention.
Dissection of the extracranial carotid artery can be spontaneous,1 secondary to trauma2 or an acute aortic dissection involving supra-aortic branches3 or iatrogenic dissection. Spontaneous or traumatic dissections can be treated with endovascular therapy (EVT) in patients with recurrent cerebral ischemia despite medical therapy4e6; however, patients with aortic dissections can be managed by cardiothoracic surgical repair with acceptable immediate and long-term outcomes.7 Recently, there have been new reports on iatrogenic carotid dissections following surgical repair of aortic
The authors declare no conflict of interests. 1 Department of Interventional Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China. 2 Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
Correspondence to: Liqun Jiao, Department of Interventional Radiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing 100053, China; E-mail: [email protected] Ann Vasc Surg 2015; 29: 1019.e11–1019.e15 http://dx.doi.org/10.1016/j.avsg.2015.01.017 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: August 7, 2014; manuscript accepted: January 10, 2015; published online: March 9, 2015.
dissection3,8,9 or carotid endarterectomy (CEA).10 Here, we report a rare case of dissections in the innominate and left common carotid arteries after a total arch replacement that was successfully treated with open retrograde EVT reconstruction in the left common carotid artery (CCA). We also address previous similar reports.
CASE REPORTS A previously healthy 30-year-old man without history of Marfan’s syndrome, hypertension, or arteritis presented with a sudden severe tearing pain in the chest. Thoracic computed tomography (CT) angiogram showed an acute aortic dissection involving the ascending aorta, aortic arch, descending aorta, and supra-aortic branches, and the tear originated at the root of the ascending aorta (Stanford type A, Fig. 1A, B). The patient underwent an emergency total aortic arch replacement using a stented elephant trunk technique (Sun’s procedure7,11) at another hospital. He was discharged without any apparent postsurgical morbidity. One month later, the patient suddenly developed dizziness and left extremity weakness. Cranial CT showed cerebral infarction in the right tempo-occipital lobe (Fig. 1C). Cervical CT angiogram showed dissections in the 1019.e11
1019.e12 Case reports
Fig. 1. The anteroposterior view (A) and posteroanterior view (B) of the three-dimensional CT angiogram demonstrated an aortic dissection involving the ascending aorta, aortic arch, descending aorta, and supra-aortic branches. The cranial CT showed cerebral infarctions in the right
innominate artery and left CCA. The innominate artery and CCA dissection extended distally and caused right internal carotid artery (ICA) occlusion (Fig. 1D, E), while the left CCA dissection originated from the surgical anastomosis site and extended distally to the bifurcation (Fig. 1F). The patient underwent transcervical open retrograde endovascular stenting in an integrated hybrid operating room. Concomitant CEA was deemed unnecessary because of the absence of apparent atheromatous plaque in the left CCA bifurcation. Briefly, a modified transverse mini-incision was made to access the left carotid bifurcation. The left ICA, CCA, and external carotid artery (ECA) were mobilized and isolated. After systemic heparinization, the left ICA and ECA were temporarily clamped without an apparent decrease in ipsilateral middle cerebral artery flow based on the transcranial Doppler monitoring throughout the procedure. A 6-French sheath using a Seldinger approach was introduced into the left ICA under ultrasound guidance and then retrogradely moved from the ICA into the
Annals of Vascular Surgery
tempo-occipital lobe (C). The three-dimensional CT angiogram showed a right ICA occlusion (D, E) and left CCA dissection (F). Asterix indicates the dissecting originating point.
Fig. 2. The intraoperative photograph showing retrograde cannulation of a 6-French sheath into the left ICA. proximal CCA (Fig. 2). After ultrasound confirmation that the sheath was in the true lumen, angiography revealed an intimal flap dissection originating at the site
Vol. 29, No. 5, July 2015
Case reports 1019.e13
Fig. 3. The preoperative left CCA angiogram showed an intimal flap that originated from the surgical anastomosis site and extended to the left CCA bifurcation with an apparent extravasation of contrast into the pseudolumen, and the true lumen was severely compressed by the pseudolumen (A). The angiogram after delivery of the
first WallStent showed an improvement in the pseudolumen (B). The second WallStent was placed in tandem with the first stent, and the angiogram revealed an almost complete restoration of proximal (C) and distal intracranial (D) flow.
of anastomosis between the artificial graft and proximal CCA wall. The false lumen extended, compressed, and nearly occluded the true lumen in the distal CCA. A microguidewire was then carefully positioned across the dissection to the normal lumen under fluoroscopic control. One WallStent (9e50 mm; Boston Scientific, Natick, MA) was placed over the guidewire covering the dissection origination point. Angiogram revealed unsatisfactory stent apposition, and the intimal flap did not adhere well to the vessel wall and the pseudolumen persisted. Another WallStent (9e50 mm) was then delivered in tandem with the first one to cover the entire dissection. A repeated angiogram demonstrated appropriate stent apposition without apparent extravasation of contrast into the pseudolumen (Fig. 3). The artery at the puncture site was closed with 6-0 Prolene sutures. Definite hemostasis was achieved and overlying layers were closed. The procedure was successful without complications. The patient was followed up for 6 months, and no neurological deficits were reported.
condition, and its natural history remains unknown. Based on a review of the literature, iatrogenic carotid dissection may be associated with the surgical repair of aortic dissections3,8,9 or CEA10 (see Table I for review of the literature). Iatrogenic dissections related to the surgical repair of aortic dissections rarely occur and may be secondary to repaired wall fragility and suture line-related secondary trauma.9 The only documented large series reported a 15% incidence of postoperative CCA dissection with the majority of cases showing no progression and patients remaining asymptomatic during a 2-year follow-up by carotid ultrasound.12 However, the present patient suffered a major stroke caused by right ICA occlusion 30 days after surgical repair. We were disinclined to reconstruct the right CCA because of the occlusion, and the left CCA dissection with extension to the branch was considered at high risk for malperfusion syndrome. Although there are limited publications on the treatment of symptomatic iatrogenic CCA dissections,3,8e10 antegrade EVT via femoral artery as an alternative to surgical therapy appears to be frequently used (Table I). Katoh et al. reported a 71-year-old woman who developed an iatrogenic dissection from the brachiocephalic trunk to the right ICA 6 days after an operation for an ascending aortic dissection. For this case, a successful EVT via the left femoral artery was performed.9 In a case report by Cardaioli et al., a 67-year-old male
DISCUSSION Dissection of the extracranial carotid arteries has been increasingly recognized as a cause of transient ischemic attack or stroke in young patients. The dissection can be spontaneous, secondary to trauma or an acute aortic dissection or iatrogenic dissection. Most extracranial dissections usually heal over time with antithrombotic therapy. EVT is only considered when patients with recurrent ischemia fail medical therapy.6 Iatrogenic carotid dissection is a rare
1019.e14 Case reports
Annals of Vascular Surgery
Table I. Previous studies of iatrogenic CCA dissections after surgical repair
Study
Year of Sex and Side of publication age dissections
Cardaioli et al.8 2007
M/67
Stella et al.10
2010
M/83
Casana et al.3
2011
F/66
Right CCA
Katoh et al.9
2013
F/71
Right CCA
Previous history of surgery and current condition
Bilateral CCA Presented with acute aortic type A dissection and was treated with a 28-mm Vasculteck prosthesis Left CCA Left CCA dissection secondary to carotid endarterectomy
Endovascular treatment with antegrade or retrograde approach
Antegrade approach
Access route
Right femoral artery
Superficial Retrograde approach temporal because of a partially artery compromised aortobifemoral bypass graft Antegrade approach Femoral artery
Underwent a composite repair with a valve sparing technique for type A aortic dissection and presented with episodes of ‘‘drop attack’’ Antegrade approach Developed dissection from brachiocephalic trunk to right ICA 6 days after the operation of ascending aortic dissection
Left femoral and right brachial artery
F, female; M, male.
presented with progressive bilateral CCA dissections within the early postoperative days following surgical repair of an acute aortic type A dissection with a 28-mm Vasculteck prosthesis. The dissections were treated via the right femoral artery.8 Casana et al. described a case involving a 66-year-woman who underwent a composite repair with a valve-sparing technique for a type A aortic dissection and then presented with episodes of ‘‘drop attack.’’ An ultrasound revealed a right CCA dissection, which was successfully treated with an antegrade approach.3 However, transfemoral antegrade access may not be applicable for all patients with iatrogenic carotid dissections because of either inaccessible routes (severe aortoiliac occlusive diseases) or implantation of an elephant trunk within the aorta (this case). In the study by Stella et al., a patient suffered from a left CCA dissection post-CEA. Retrograde EVT via the superficial temporal artery instead of the femoral artery was performed because of a partially compromised aortobifemoral bypass graft.10 A deformed arch anatomy caused by total arch replacement or a stented elephant trunk implantation may prevent
a conventional antegrade approach for intervention because of additional challenges. For example, the study by Tsai and Shen reported a patient who developed symptomatic left CCA restenosis 2 weeks after total arch rerouting and elephant trunk repair for an acute aortic dissection with left CCA malperfusion. The patient underwent emergent CCA stenting via a sternal reentry with restoration of cerebral perfusion.13 In our case, an open and retrograde approach was chosen instead of an antegrade or open reentry for multiple reasons: (1) the left CCA antegrade catheterization was rendered technically difficult by the previously implanted elephant stent, and this method posed additional risks of embolic events and dissection enlargement because of pseudolumen proximity to the aortic arch; (2) surgical exposure of the carotid bifurcation would help choose an appropriate puncture site and achieve hemostasis, while the intraoperative ultrasound would provide real-time information to avoid sheath malposition into the pseudolumen; (3) stenting may carry the risk of embolic events, and distal ICA and ECA
Vol. 29, No. 5, July 2015
temporary occlusion would provide distal protection from embolic events during stent delivery; and (4) retrograde EVT with arteriotomy for the atherosclerotic lesions of the proximal CCA,14,15 ICA,16 innominate artery,16e18 or the lesions in tandem17,19 was a safe and effective alternative in selected patients. The hybrid operating room served as an important platform allowing for both surgical and endovascular procedures.10,13 Therefore, we were encouraged to treat this rare condition for the first time using hybrid procedures combining carotid exposure, arteriotomy, and retrograde endovascular angioplasty.
Case reports 1019.e15
7.
8.
9.
10.
CONCLUSION
11.
A retrograde approach with arteriotomy may represent a valid alternative approach for the endovascular treatment of iatrogenic carotid dissections following surgical repair.
12.
13.
The authors thank Dr. Yang Hua, MD, Department of Vascular Ultrasonography, for her assistance with the intraoperative ultrasound.
14.
REFERENCES 1. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001;344:898e906. 2. Alimi YS, Di Mauro P, Fiacre E, et al. Blunt injury to the internal carotid artery at the base of the skull: six cases of venous graft restoration. J Vasc Surg 1996;24:249e57. 3. Casana R, Tolva V, Majnardi AR, et al. Endovascular management of symptomatic cerebral malperfusion due to carotid dissection after type A aortic dissection repair. Vasc Endovasc Surg 2011;45:641e5. 4. Ohta H, Natarajan SK, Hauck EF, et al. Endovascular stent therapy for extracranial and intracranial carotid artery dissection: single-center experience. J Neurosurg 2011;115: 91e100. 5. Asif KS, Lazzaro MA, Teleb MS, et al. Endovascular reconstruction for progressively worsening carotid artery dissection. J Neurointerv Surg 2015;7:32e9. 6. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals
15.
16.
17.
18.
19.
from the American Heart Association/American Stroke Association. Stroke 2014;45:2160e236. Ma WG, Zheng J, Dong SB, et al. Sun’s procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection. Ann Cardiothorac Surg 2013;2:621e8. Cardaioli P, Rigatelli G, Giordan M, et al. Multiple carotid stenting for extended thoracic aorta dissection after initial aortic surgical repair. Cardiovasc Revasc Med 2007;8:213e5. Katoh H, Nozue T, Nagamine H, et al. A case of carotid artery dissection after surgical repair of aortic dissection successfully treated with endovascular therapy using intravascular ultrasound. Cardiovasc Interv Ther 2014;29:237e42. Stella N, Palombo G, Filippi F, et al. Endovascular treatment of common carotid artery dissection via the superficial temporal artery. J Endovasc Ther 2010;17:569e73. Ma WG, Zhu JM, Zheng J, et al. Sun’s procedure for complex aortic arch repair: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg 2013;2:642e8. Zielinski T, Wolkanin-Bartnik J, Janaszek-Sitkowska H, et al. Persistent dissection of carotid artery in patients operated on for type A acute aortic dissectiondcarotid ultrasound follow-up. Int J Cardiol 1999;70:133e9. Tsai KT, Shen TC. Challenging carotid intervention after total arch rerouting and hybrid zone 0 elephant trunk repair for a complicated type A aortic dissection. J Endovasc Ther 2014;21:306e11. Tsutsumi M, Kazekawa K, Onizuka M, et al. Cerebral protection during retrograde carotid artery stenting for proximal carotid artery stenosis: technical note. Neurol Med Chir (Tokyo) 2007;47:285e7. discussion 287e288. Garg N, Oderich GS, Duncan AA, et al. Retrograde supraaortic stent placement combined with open carotid or subclavian artery revascularization. Vasc Endovascular Surg 2011;45:527e35. Christopoulos DC, Kardakis C, Pitoulias GA, et al. Simultaneous transcervical angioplasty and stenting of innominate and right internal carotid arteries. Ann Vasc Surg 2014;28: 492.e11e5. Iihara K, Satow T, Matsushige T, et al. Hybrid operating room for the treatment of complex neurovascular and brachiocephalic lesions. J Stroke Cerebrovasc Dis 2013;22: e277e85. Mordasini P, Gralla J, Do DD, et al. Percutaneous and open retrograde endovascular stenting of symptomatic high-grade innominate artery stenosis: technique and follow-up. AJNR Am J Neuroradiol 2011;32:1726e31. Vermeulen T, Hendriks JM, Baeten M, et al. Endarterectomy combined with retrograde stenting for tandem lesions of the carotid artery. Acta Chir Belg 2011;111:312e4.
