The Difference of Each Angiographic Finding After Multiple Stent According to Stent Type in Bilateral Vertebral Artery Dissection
A 55-year-old female with stupor was admitted to our hospital. A computed tomography (CT) scan with CT angiography revealed thick SAH with associated hydrocephalus and fusiform dilation of bilateral V4 VAs (). The patient underwent cerebral angiography, which revealed the presence of a bilateral V4 segment dissecting aneurysm, and a double origin posterior inferior cerebellar artery (PICA) was observed on the left side (). Each vertebral artery was similar in size. Because the hematoma showed even distribution on CT, the ruptured side could not be specified. We planned on simultaneous treatment of the bilateral lesions using the overlapping stent-alone technique.\nThe procedure was performed under local anesthesia using standard neuro-endovascular techniques. Due to the risk of rebleeding, intravenous injection of heparin was not administered at the beginning of the procedure. In order to facilitate simultaneous treatment, we opted for a transfemoral approach. On the left-sided lesion, an SES was applied because the BMS could not be advanced into the left VA due to vascular tortuosity. Two SESs (Neuroform3 stent, Boston Scientific, Voisins-le-Bretonneux, France; 4.5×20 mm) were deployed across the dissecting lesion. The guiding catheter was then repositioned at the origin of the right VA. The first BMS (Driver RX, Medtronic, Minneapolis, MN, USA; 3.5×18 mm) was deployed at the proximal end of the dissection. A second BMS (Driver RX, Medtronic, Minneapolis, MN, USA; 3.5 × 15 mm) was placed distally within the previously placed stent with a telescoping overlap of approximately 10 mm. In this fashion, the dissecting segment was covered by the 2 stents. We did not perform stent-assisted coiling because an additional coiling procedure might have risked re-rupture of the dissecting aneurysm and led to a life-threatening situation. Final images confirmed the placement of the stents across the entire length of the aneurysms (). The patient received 100 mg of oral acetyl salicylic acid daily after the initial treatment. A follow-up right VA angiography 2 months after the initial treatment showed minimal contrast filling into the pseudo lumen through the stent and showed near-complete healing of the lesion (). In contrast, a left VA angiogram showed an increase in size of the dissecting aneurysm (). The angiographic result led us to believe that the lesion on the left side was ruptured and that the SESs used on this lesion were not sufficient to induce pseudo-luminal thrombosis.\nRetreatment was performed via a transbrachial approach in order to overcome VA tortuosity. The transradial or transbrachial approach, which is the preferred approach, offers a more direct route to the ipsilateral vertebral artery in cases where the vertebral artery has a more acute angle or tortuosity.\nTherefore, based on navigation of the stent into the lesion, the transbrachial method is considered superior to the transfemoral approach because the guiding catheter can be advanced distally without increasing the risk of flow arrest. Three BMSs (FlexMaster F1 stent, Abbott, Abbott Park, IL, USA) with commercially available lengths of 19 mm, 16 mm, and 12 mm and diameters of 3.5 mm were deployed using an overlapping technique (). Evaluation of CT angiography with maximum intensity projection on the first day after retreatment showed a marked reduction in the size of the pseudolumen. A follow-up left VA angiogram 5 months after retreatment showed complete healing of the aneurysm without in-stent stenosis (). The patient recovered without any neurological deficits.