Emergent Endovascular Management of Long-Segment and Flow-Limiting Carotid Artery Dissections in Acute Ischemic Stroke Intervention with Multiple Tandem Stents

Abstract

BACKGROUND AND PURPOSE:Although most cervical dissections are managed medically, emergent endovascular treatment may become necessary in the presence of intracranial large-vessel occlusions, flow-limiting and long-segment dissections with impending occlusion, and/or hypoperfusion-related ischemia at risk of infarction. We investigated the role of emergent endovascular stenting of long-segment carotid dissections in the acute ischemic stroke setting.

Primary stent implantation for bilateral spontaneous cervical ICA dissections with hypoperfusion after 72 h from onset: a case report

“…This was a typical case of bilateral spontaneous cICAD complicated with bi-hemispheric hypoperfusion that responded well to primary stent implantation at the critical flow-limiting site rather than covering the entire dissection. The lesions of cICAD are usually long segmented and the usual procedure of EVT uses a partial overlap technique to implant multiple stents in tandem to reconstruct the entire dissected segment (Cohen et al 2003 ; Ansari et al 2017 ). The advantages of this approach are: 1) to avoid residual dissection and then prevent secondary procedures in the future; 2) to cover the damaged intima to reduce the risk of thrombosis and thus lessen the chance of A-A embolism.…”

“…A very challenging task of EVT in cICAD is choosing the type of stent for deployment. Based on previous reports, specific types of intracranial/carotid self-expanding stents might be good choice (Moon et al 2017 ; Ansari et al 2017 ; Sedat et al 2003 ; Ishigami and Ota 2019 ). The main drawback of balloon expandable stents is the poor apposition to the vessel wall, especially after dissolution of the intramural hematoma.…”

“…Previous studies show that EVT is crucial for those patients who do not respond to antithrombotic treatment, have clinical deterioration due to hypoperfusion, or experience acute occlusion in an intracranial large vessel (Engelter et al 2015 ; Moon et al 2017 ; Engelter et al 2021 ). However, the EVT brings challenges: 1) to secure true lumen during the whole procedure; 2) to prevent downstream embolism from thrombus migration; 3) multiple stents are serially implanted using partially overlapping techniques to reconstruct the entire dissected segment, creating a restriction for the type of stent for deployment (Cohen et al 2003 ; Ansari et al 2017 ). Currently, the exact procedure for EVT remains ambiguous.…”

Stent Reconstruction of Carotid Tonsillar Loop Dissection Using Telescoping Peripheral Stents

“…Emergent endovascular treatment, including carotid revascularization and intracranial thrombectomy, is an increasingly popular and promising management strategy [1, 5-8]. A variety of techniques have been described for carotid revascularization in this setting, including the use of dedicated carotid artery stents with or without balloon angioplasty [2, 9, 10], the use of self-expanding intracranial or peripheral stents [11-13], and the use of an overlapping or telescoping stenting technique [9]. Recently, Murias Quintana et al [3] called attention to the importance of considering ectatic or tortuous ICA anatomy that could impact the choice of carotid revascularization technique.…”

Overlapping Stents-Assisted Coiling for Vertebral Artery Dissecting Aneurysm : LVIS Stent within Neuroform EZ Stent

“…Vertebral artery dissecting aneurysm (VADA) is a special subtype of intracranial aneurysms, which can cause subarachnoid hemorrhage (SAH) or acute ischemic stroke, particularly in middle-aged adults [ 1 , 24 ]. Stent-assisted coiling as a reconstructive treatment of VADAs has been proven effective in maintaining the parent artery patency.…”