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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3643_Библиотеки_им_академика_М_И_Перельмана.pdf
144
BC
VA
ARSA
1
2
3
4
1
2
3
Fig. 6.7 Anatomical variations of the arch vessels. An example is
offered by the aberrant right subclavian artery (ARSA): this is probably
the most frequent anomaly of the arch vessels as its incidental fi nding
surpasses 5 %. Angiographic examination offers best and rapid data on
the anatomical variation and hemodynamics. In this particular case, the
right VA originated from the right CCA. Both carotid arteries originated
from a common trunk ( BC bicarotid trunk). The order of emergence
from the aortic arch is as follows: 1 = right CCA; 2 = left CCA (in this
case, actually 1 and 2 have a common aortic origin); 3 = left SCA;
4 = right SCA actually ARSA
H. Muresian and B. Dorobat
145
VA
VA
V1
V1
V2
V2
SCA
Fig. 6.8 Vertebral steal syndrome. Besides the “classical” vertebral
steal syndrome, there are also some “atypical” forms. The Doppler
examination in this particular patient revealed an occluded origin of the
left VA, while the fl ow in the V2 segment of the left VA was diffi cult to
ascertain. The patient experienced vertigo. Angiography shows an
atypical type of vertebral steal: in spite of the occluded V0 and V1,
blood is stolen from the VA through anastomoses with the SCA (deep
cervical and ascending cervical arteries). Note the good opacifi cation of
the left SCA, not directly through the VA but through collateral circulation. This patient had palpable distal pulse in the left hand
6 Endovascular Approach: From Diagnosis to Therapy
146
Fig. 6.9 Mega-dolicho ICA (1). Enormous dilatations of the ICA in a
younger patient, in whom the remainder cerebral arteries were normal.
A good collateral circulation developed, both from the opposite ICA
and from the vertebrobasilar system, allowing the exclusion of the
diseased left ICA from the circulation. Panel ( a ): anteroposterior view.
Panel ( b ): lateral view of the lesions. Panel ( c ) offers a 3-D reconstruc-
tion of the same. Panel ( d ): obliteration of the aneurysmatical segments
with distal coils and proximal balloon
ab
c
H. Muresian and B. Dorobat
147
d
Fig. 6.9 (continued)
PREPROCEDURAL STENTING COMPLETION ANGIO
Fig. 6.10 Mega-dolicho ICA (2). Kinking of the cervical ICA appears
very frequently associated to the stenotic lesions of the carotid bifurcation. In some patients, the excessive length is accompanied by
aneurysm- like dilatations. Many patients are symptomatic (TIAs
sometimes related to particular positions of the head). These lesions
may extend high in the neck making surgery cumbersome or impossible. The example in the fi gure demonstrates both the length of the lesion
and the result after stenting
6 Endovascular Approach: From Diagnosis to Therapy
148
LEFT
RIGHT
a
b
H. Muresian and B. Dorobat
149
CCA
ICA
VA
CCA
ICA
Fig. 6.12 Thrombosis at the origin of the ICA (2). Similar angiographic
aspect in an older patient with thrombosis of the right ICA at origin
( white arrow ). Note again the absence of any particular lesion of the
carotid and vertebral arterial axis. This patient was referred for surgery
while taking into account the longer time interval of symptomatology,
suggesting a longer evolution and the higher risks for an incomplete
thromboaspiration
Fig. 6.11 Thrombosis at the origin of the ICA (1). A spontaneous
thrombus formation at the level of the carotid bulb was encountered in
two patients. The patients had ischemic strokes of different ages, by
embolization. It is interesting to note that none of these two patients had
particular risk factors, no coagulation dysfunction, and no previous
trauma (and so forth). The carotid bifurcations appeared normal both on
eco and angio (Panel ( a )). Panel ( a ): younger patient with bilateral ICA
thrombosis, symptomatic on the left side. Panel ( b ): angiographic con-
trol after bilateral endovascular thrombectomy. Insert: thrombotic
material (scale in cm)
6 Endovascular Approach: From Diagnosis to Therapy
150
a
b
Fig. 6.13 Excessive kinking ( white arrow ) of the CCA and ICA – and
CAS. Angiography offers a dynamic picture of the carotid bifurcation
(over the CT-angio or MRA) and of the possibility of performing the
CAS or not in selected patients. Panel ( a ): excessive kinking of the
CCA that theoretically (and especially after CT-angio or MRA) would
contraindicate the CAS. Panel ( b ): progression with the sheath will
straighten the CCA but will transfer the excessive curve to the
ICA. However, in spite of these limitations, a good result was eventually obtained. Not least, note that the distal portion of the stent does not
angulate the ICA
H. Muresian and B. Dorobat
151
a
b
Fig. 6.14 Endovascular treatment of later restenosis after CEA. Panel ( a ):
stenosis of the ICA ( white arrow ) distal to the patch ( black arrow ). On the
right side, the fi nal result after stenting. Panel ( b ): stenosis of the ICA distal
to the patch ( black arrow ) and associated arterial spasm ( white arrow ). Note
that the ECA is occluded after surgery. On the right, angiographic aspect after
stenting; from the ECA only the superior thyroid artery patent ( yellow arrow )
6 Endovascular Approach: From Diagnosis to Therapy
152
Fig. 6.15 Endoprosthesis for exclusion of ICA aneurysm. Aneurysms
of the ICA can be elegantly treated without surgery, either by stenting
or by inserting and endoprosthesis (as in the case illustrated here). As in
the case of surgical treatment, the choice of the type of procedure is
dictated by numerous factors, among which are condition of the patient,
type and localization of the aneurysm, dimensions, presence of associated symptoms produced by compression, presence of infection, etc.
H. Muresian and B. Dorobat
153
Fig. 6.16 Intracerebral aneurysm + stenosis of the ICA ( white arrow ). The
case presented is of a patient with bleeding from an intracerebral aneurysm (of the MCA). Access appears diffi cult if not impossible due to an
almost occluded ICA. The case is particularly interesting and clinically
signifi cant because the ICA appeared in some angiographic images as
occluded, with a rich collateral circulation that eventually fi lled the distal
ICA (Panel ( a )). The ICA appears thin, from its origin up to its termina-
tion. Panel ( b ): the bifurcation and origin of the ICA were stented. Panel
( c ): access to the distal ICA and the aneurysm was obtained. Note that
even after CAS, the ICA appears diffusely diseased. The aneurysm was
coil embolized ( white arrow )
a
b
6 Endovascular Approach: From Diagnosis to Therapy