Abstract 1122‐000076: Direct Carotid Artery Cutdown and Flow Diversions for the Bilateral Dissecting Pseudo‐Aneurysms

Introduction : flow diverters (FD) have been used for the treatment of the dissecting pseudo aneurysm (DSA) via trans femoral or transradial approach. Both trans femoral and transradial approaches require aortic arch as a relay to access the internal carotid artery (ICA). Presence of an aortic arch stent prevents navigating to the ICA. Therefore, alternative option such as direct Carotid artery Cutdown (DCAC) and FD for the treatment of the DSA in the ICA is not known. Methods : Case report and Retrospective chart review. Results : 67 years old man with history of hypertension, hyperlipidemia, smoking, and repair of the aortic arch aneurysm using a and aortic arch stenting. Patient was diagnosed with bilateral internal carotid artery DSA buy a CT angiogram when complained of neck pain, headaches and dizziness. Right ICA DSA was in multi‐level extending from cervical carotid artery to the skull base measured 19 × 15 × 20 mm and the left was 16 × 9 × 22 mm. An angiogram was attempted for the better evaluation of the DSA, which fail due to the presence of aortic arch stent. Considering the severity of the disease and the presence of symptoms, it was planned to have a DCAC by vascular surgeon followed by the repair of the aneurysms using FD by neurovascular surgeon (NES) in a staged fashion. Preparation: blood pressure was controlled and smoking was ceased. Patient was given 4 chewable baby aspirin and 300 mg clopidogrel on the day of the procedure. Activated coagulation time was kept 2 times of baseline. A 6F sheath was placed from right common carotid artery (CCA) to right ICA by a vascular surgeon and the placement was confined by NES by angiography. A CAT5 intermediate catheter was navigated to the ICA beyond DSA. FD was achieved using Surpass streamline measuring 4 × 50 mm x2 and a 5 × 40 mm to cover the entire DSA and disease ICA. The DCAC site was sutured by vascular surgeon and patient was extubated. Patient was discharged home in 48 hours with NIHSS 0 and mRS 1 as baseline. Using similar techniques, Left‐sided dissecting pseudoaneurysm repaired using 5 × 50 mm surpass streamline flow diverter. Patient was discharged in 24 hours. Patient continued 325 mg of aspirin and 75 mg of aspirin for six months followed by 81 mg baby aspirin and 75 mg of clopidogrel. Six‐month follow‐up MR angiogram demonstrate complete obligations of the bilateral DPA and remodeling of the internal carotid arteries. Conclusions : When transfemoral or transtibial approach is not feasible, DCACW could be an alternative option for the treatment of the symptomatic and life‐threatening DSA of the Internal carotid artery. Further studies are required.