Endovascular Treatment of Vertebral Artery Dissection Using Stents and Coils: Its Pitfall and Technical Considerations

Abstract

Objective: There are various options for the treatment of vertebral artery dissection aneurysms (VADA). Treatment with stents may be an effective method to treat VADA involving the posterior inferior cerebellar artery (PICA) and dissection of the dominant vertebral artery (VA). In this article, our personal experience of the treatment of VADAs by using stents and coils is reported.

Methods: Since 1998, 26 cases of VADA have been treated by endovascular surgery by the first author. Of these cases, 6 cases were treated using stents, 3 of which were treated using stent and coils, 2 patients were treated using double overlapping stents, and the remaining one patient was treated using a single stent.

Results: In all patients, dissection aneurysms were successfully covered by stents. There was one complication: an intraprocedural rupture during additional coil insertion without neurological deterioration. Follow-up angiography was performed in all 5 surviving patients except for one patient who died due to the severity of his original subarachnoid hemorrhage (mean duration of follow-up angiography 22.8 months, range 15–57 months). Total or subtotal disappearance of the VADA was achieved in all 5 cases. At one year after the treatment, all 5 surviving patients remained clinically stable without any neurological deficit.

Conclusions: Treatment using stents is an effective alternative for the treatment of VA dissecting aneurysms, especially for lesions of the dominant VA or involving the PICA. However, additional coil insertion should be performed very carefully and may be avoided if stagnation of contrast material is achieved after overlapping stenting.

Key words

vertebral artery - dissecting aneurysm - stent - coil

References

• 1 Albuquerque FC, Fiorella DJ, Han PP. et al . Endovascular management of intracranial vertebral artery dissecting aneurysms.  Neurosurg Focus. 2005;  18 E3
• 2 Anxionnat R, de Melo Neto JF, Bracard S. et al . Treatment of hemorrhagic intracranial dissections.  Neurosurgery. 2008;  62 (6 Suppl 3) 1525-1531
• 3 Kurata A, Ohmono T, Miyasaka Y. et al . Coil embolization for the treatment of ruptured dissecting vertebral aneurysms.  AJNR Am J Neuroradiol. 2001;  22 11-18
• 4 Otawara Y, Ogasawara K, Ogawa A. et al . Dissecting aneurysms of the bilateral vertebral arteries with subarachnoid hemorrhage: report of three cases.  Neurosurgery. 2002;  50 1372-1374
• 5 Rabinov JD, Hellinger FR, Morris PP. et al . Endovascular management of vertebrobasilar dissecting aneurysms.  AJNR Am J Neuroradiol. 2003;  24 1421-1428
• 6 Yuki I, Murayama Y, Viñuela F. Endovascular management of dissecting vertebrobasilar artery aneurysms in patients presenting with acute subarachnoid hemorrhage.  J Neurosurg. 2005;  103 649-655
• 7 Ahn JY, Han IB, Kim TG. et al . Endovascular treatment of intracranial vertebral artery dissections with stent placement or stent-assisted coiling.  AJNR Am J Neuroradiol. 2006;  27 1514-1520
• 8 Ansari SA, Thompson BG, Gemmete JJ. et al . Endovascular treatment of distal cervical and intracranial dissections with the neuroform stent.  Neurosurgery. 2008;  62 636-646
• 9 Lylyk P, Cohen JE, Ceratto R. et al . Combined endovascular treatment of dissecting vertebral artery aneurysms by using stents and coils.  J Neurosurg. 2001;  94 427-432
• 10 Mehta B, Burke T, Kole M. et al . Stent-within-a-stent technique for the treatment of dissecting vertebral artery aneurysms.  AJNR Am J Neuroradiol. 2003;  24 1814-1818
• 11 Naito I, Takatama S, Shimaguchi H. et al . Endovascular treatment of vertebral artery dissecting aneurysms using stents.  Intervent Neuroradiol. 2004;  10 (S 01) 181-186
• 12 Shin YS, Kim HS, Kim SY. Stenting for vertebrobasilar dissection: a possible treatment option for nonhemorrhagic vertebrobasilar dissection.  Neuroradiology. 2007;  49 149-156
• 13 Sugiu K, Tokunaga K, Watanabe K. et al . Emergent endovascular treatment of ruptured vertebral artery dissecting aneurysms.  Neuroradiology. 2005;  47 158-164
• 14 Suzuki S, Kurata A, Iwamoto K. et al . Endovascular surgery using stents for vertebral artery dissecting aneurysms and a review of the literature.  Minim Invas Neurosurg. 2008;  51 193-198
• 15 Zenteno MA, Murillo-Bonilla LM, Guinto G. et al . Sole stenting bypass for the treatment of vertebral artery aneurysms: technical case report.  Neurosurgery. 2005;  57 (1 Suppl) E208
• 16 Iihara K, Sakai N, Murao K. et al . Dissecting aneurysms of the vertebral artery: a management strategy.  J Neurosurg. 2002;  97 259-267
• 17 Ro A, Kageyama N, Abe N. et al . Intracranial vertebral artery dissection resulting in fatal subarachnoid hemorrhage: clinical and histopathological investigations from a medicolegal perspective.  J Neurosurg. 2009;  110 948-954
• 18 Katsuno M, Mizunari T, Kobayashi S. et al . Rupture of a vertebral artery dissecting aneurysm developing immediately after trapping of a dissecting aneurysm on the contralateral vertebral artery: case report.  Neurol Med Chir (Tokyo). 2009;  49 468-470
• 19 Komotar RJ, Mocco J, Samuelson RM. et al . Rapidly successive, symptomatic, bilateral, spontaneous vertebral artery dissections: treatment with stent reconstruction.  Surg Neurol. 2009;  72 300-305
• 20 Benndorf G, Herbon U, Sollmann WP. et al . Treatment of a ruptured dissecting vertebral artery aneurysm with double stent placement: Case report.  AJNR Am J Neuroradiol. 2001;  22 1844-1848
• 21 Lieber BB, Stancampiano AP, Wakhloo AK. Alteration of hemodynamics in aneurysm models by stenting: Influence of stent porosity.  Ann Biomed Eng. 1997;  25 460-469
• 22 Kim TK, Seo SI, Seol HY. et al . Mechanically-induced proximal artery occlusion and stent-within-a-stent technique for the treatment of bilateral vertebral artery dissecting aneurysms.  Br J Radiol. 2006;  79 166-170
• 23 Masuo O, Terada T, Walker G. et al . Patency of perforating arteries after stent placement? A study using an in vivo experimental atherosclerosis-induced model.  AJNR Am J Neuroradiol. 2005;  26 543-548
• 24 Lopes DK, Ringer AJ, Boulos AS. et al . Fate of branch arteries after intracranial stenting.  Neurosurgery. 2003;  52 1275-1278
• 25 Lanzino G, Wakhloo AK, Fessler RD. et al . Efficacy and current limitations of intravascular stents for intracranial internal carotid, vertebral, and basilar artery aneurysms.  J Neurosurg. 1999;  91 538-546
• 26 Chiaradio JC, Guzman L, Padilla L. et al . Intravascular graft stent treatment of a ruptured fusiform dissecting aneurysm of the intracranial vertebral artery: technical case report.  Neurosurgery. 2002;  50 213-217
• 27 Felber S, Henkes H, Weber W. et al . Treatment of extracranial and intracranial aneurysms and arteriovenous fistulae using stent grafts.  Neurosurgery. 2004;  55 631-638
• 28 He M, Zhang H, Lei D. et al . Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms.  J Neurosurg. 2009;  110 418-426

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