Conjoined Stent Technique for Radiation Induced Long Segment Carotid Stenosis and Pseudoaneurysm
A 70-year-old man had history of carcinoma larynx (Stage I) treated with conventional radiotherapy with the dose of 70 Gy in the year 2000. In March 2013, he presented with complaint of recurrent transient episodes of left upper limb weakness. He had six such episodes during last three months. Each episode lasted for 2-3 minutes and used to improve on its own. He also complained small swelling in neck in right submandibular area and transient weakness on left side on pressing neck swelling. He had hypertension since 2008. He was nonsmoker and nonalcoholic. He had no known drug allergy. On examination, his left carotid artery was nonpalpable and right carotid artery was less palpable. On auscultation, carotid bruit was present on right side. Neurological examination was normal. Other systemic examination did not reveal any significant abnormality. Magnetic resonance imaging of brain did not reveal acute or old infarcts. Carotid Doppler revealed occlusion of left common carotid artery and significant long segment stenosis of right common and internal carotid artery. Diagnostic cerebral angiography was done which revealed long segment stenosis of right internal carotid artery (70 cms in length and 80-90% stenosis) with a pseudoaneurysm measuring 5.06×3.59 mm (). Left carotid angiogram revealed complete occlusion of left internal carotid artery. Left and right vertebral angiogram revealed good flow in vertebral and basilar arteries.\nIn view of long segment of stenosis, potential clot embolization from pseudoaneurysm and possible rupture of pseudoaneurysm in future, it was planned to cover the whole length of stenosis with stent and apposing distal end of first closed cell design stent (Absolute pro 8×60 mm; Abbott Vascular, Santa Clara, CA, USA) with proximal end of second stent (Acculink 6-8×40 mm; Abbott Vascular, Santa Clara, CA, USA). This was thought to provide extra metal coverage to vessel wall and reducing blood flow inside pseudoaneurysm to promote thrombosis in the aneurysm sac in corollary to flow diverter. After deploying the stent we inflated the balloon up to 10 atm for 10 seconds in each stent (). Post angioplasty right carotid angiogram revealed good flow across the stent with absent flow in pseudoaneurysm with complete circulation in right internal carotid artery territory ().\nOn follow up at three months, patient was asymptomatic with no recurrence of episodes of transient weakness of left upper limb.