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134
failure of CEA (or whatever surgical technique used) is best
evaluated by angiography and expeditiously treated
(Fig.
6.14 ).
Aneurysm of the cervical ICA can be conveniently treated
by endograft insertion and exclusion of the aneurysm. This
represents a good alternative to conventional surgery
(Fig. 6.15 ).
Concomitant ICA stenosis (extra- and intracranial) plus
intracranial aneurysm can be treated in a single procedure:
CAS and aneurysm embolization (Fig. 6.16 ).
One of the major advantages of angiographic examination
is diagnosing near occlusion of the ICA and differentiating it
from total occlusion, with eventual recuperation of the
carotid system. In the example shown in Fig. 6.16 , the gen-
eral aspect was that of ICA occlusion. The patient had a
symptomatic aneurysm of the MCA and angiography
revealed an almost occluded ICA on the same side.
Revascularization of the ECA in patients with bilateral
occlusion of the ICA (Fig. 6.17 ). This procedure can be per-
formed either by endovascular route or surgically (the surgi-
cal approach is presented in Chap.
13 ). These patients are
symptomatic (dizziness, unstable gait, pre-syncope and syncope, and so forth), either with previous strokes or not.
Angiography probably offers the best details regarding the
total occlusion of the ICA, the status of the VAs (and possible lesions in the vertebrobasilar system), the intracerebral
hemodynamics, and, not least, the status of collateral circulation between the extra- and intracranial vessels. Such data
are best correlated with transcranial Doppler examination (as
this later technique is used for patient follow-up also). The
side with less collateral fl ow is selected fi rst.
Speediest and precise diagnosis of critical clinical condi-
tions represents another major, unparalleled attribute of angiography. We are illustrating here the case of a 28-year-old
female patient with SAH, in whom 4-vessel angiogram (arterial, parenchymal, and venous phases) was negative: no
intracerebral aneurysm or any other type of vascular malformation was found (Fig.
6.18 ). A quick angiographic evalua-
tion of the spinal vascularization revealed the presence of
vascular malformation as the cause of SAH.
H. Muresian and B. Dorobat
135
Fig. 6.1 Treatment of lesions at the level of the CCA – surgery.
Atherosclerotic lesion of the CCA can present and become signifi cant, in various modes. On the one hand, stenosis can appear signifi cant or serial stenoses can add their hemodynamic impact; on the
other hand, plaques on the CCA can be ulcerated or with a conspicuous lipid core. Not infrequently, both conditions may associate.
Panel ( a ): angiographic aspect of stenosis of the ICA and of the
CCA. Note the tight, severe lesion on the ICA and the lengthier stenosis of the CCA. Panel ( b ): an intraoperative demonstration of the
signifi cance of such lesions of the CCA. In this particular case, a
wider exposure of the CCA, ICA, and ECA was performed. Panel
( c ): because of the extensive and severe lesions of the almost entire
right CCA, a resection of the vessel was performed, followed by
graft (G) interposition. Panel ( d ): macroscopic aspect of the excised
arterial segments. From the ICA, the plaque was excised by using
the eversion technique. The ICA plaque and the segment of the CCA
excised were both sliced, to demonstrate the extension and the
severity of the lesions
CCA
a
CCA
ICA
ICA
Image Gallery
6 Endovascular Approach: From Diagnosis to Therapy
136
CCA
ICA
ECA
ICA
ECA
c
b
G
Fig. 6.1 (continued)
H. Muresian and B. Dorobat
137
CCAICA
CCAICA
d
Fig. 6.1 (continued)
6 Endovascular Approach: From Diagnosis to Therapy
138
PATCH
CCA
a
b
Fig. 6.2 Treatment of the lesions at the level of the CCA – combined.
Panel ( a ): angiographic aspect of the left carotid bifurcation in a patient
who underwent CEA and patching of the bifurcation. Note the long and
tight stenosis of the CCA. A stent was placed into the CCA from the
femoral route. Panel ( b ): the severe stenosis required post-dilatation.
On the right side, note the fi nal result
H. Muresian and B. Dorobat
139
Fig. 6.3 Angiographic evaluation of the diseased ECA. Panel ( a ):
angiographic aspect of the left carotid. The origin of the ECA is not
visible. Only the superior thyroid artery origin is visible ( white arrow ).
Panel ( b ): intraoperative aspect of the opened carotid bifurcation. The
origin of the ECA is occluded ( white arrow ). Note also the highly irreg-
ular and ulcerated plaques at the level of the bifurcation. Panel
( c ): following the data offered by angiography, and the intraoperative
aspect, endarterectomy of the origin of the ECA was complementary
performed. The origin of the ICA was enlarged with a PTFE patch (the
patch is partially visible). Note the enlarged caliber of the ECA. Panel
( d ): the excised plaque at the origin of the ICA and ECA. Note the
extension of the plaque into the ECA (scale in cm and inch, above)
CCA CCA
ICA
a
ICA
ECA
b
ICA
CCA
6 Endovascular Approach: From Diagnosis to Therapy
140
ECA
CCA
PATCH
c
ECA
CCA
ICA
d
Fig. 6.3 (continued)
H. Muresian and B. Dorobat
141
Fig. 6.4 Angiographic evaluation of particular lesions (stenosis + aneu-
rysm). Angiography offers valid data on particular conditions such as
coexistence of stenosis and aneurysm. The height of the lesion can be
best assessed, while osseous artifacts will not distort the fi nal image (as,
e.g., during CT-angio). 3-D reconstruction offers particulars comparable with CT-angio
6 Endovascular Approach: From Diagnosis to Therapy
142
VERTEBRAL
VERTEBRAL
CCA
CCA
ICA
a
b
ICA
ECA
Left carotid bifurcation
enlarged
ACA ACA
MCA
ICA
VERTEBRAL
BASILAR
PCA
PCA
ACA
MCA
ICA
Fig. 6.5 Evaluation of arterial reconstructions. Panel ( a ): angiographic
demonstration of the result of arterial reconstruction consisting of CEA
and patching of the carotid bifurcation + VA reimplantation into the
CCA. Besides the anatomical data, angiography offers important details
on the direction of fl ow, fl ow velocity, and intracranial distribution,
including the hemodynamics of the CoW (Panel ( b ) )
H. Muresian and B. Dorobat
143
Fig. 6.6 Completion angiogram. The paradigm is offered by a patient
operated and who developed cerebral ischemia. Angiography performed as emergency procedure reveals thrombosis of the operated
zone; the diseased zone was stented with reversal of clinical signs and
complete recovery of the patient
6 Endovascular Approach: From Diagnosis to Therapy