Treatment of inoperable carotid aneurysms with endovascular carotid occlusion after extracranial-intracranial bypass surgery.
OBJECTIVE
Hunterian ligation of the internal carotid artery (ICA) is an accepted treatment for inoperable carotid aneurysms. Preliminary extracranial-intracranial (EC-IC) bypass surgery is required in some patients. The reported incidence of thromboembolic and ischemic complications remains significant for these patients, despite a variety of advocated management strategies. We present our treatment paradigm.


METHODS
Between April 1992 and March 1997, nine patients with inoperable ICA aneurysms were treated using EC-IC bypass surgery and then permanent endovascular ICA occlusion. All of the patients except one had been selected for bypass surgery on the basis of failing results of the ICA test occlusion with hypotensive challenge. ICA occlusion was performed by endovascular means and was delayed after bypass surgery was performed by a mean of 6 days (range, 2-20 d). All patients were managed in the intensive care unit after ICA occlusion.


RESULTS
Clinical improvement was noted in all patients (mean follow-up, 21 mo; range, 3-42 mo). There were no major complications. Aneurysmal thrombosis was confirmed in all patients. Although ICA occlusion was delayed after bypass surgery, only one bypass was noted to be occluded. The occluded bypass occurred in a patient who subsequently underwent successful ICA occlusion. This patient was thought to have been improperly selected for bypass surgery.


CONCLUSIONS
Certain carotid aneurysms can be effectively managed with hunterian ICA ligation. After preliminary identification of patients with borderline cerebrovascular reserve as candidates for EC-IC bypass surgery, close attention to the following points may help enhance clinical outcome: 1) excellence in surgical technique for EC-IC bypass surgery, 2) occlusion of the parent vessel as close to the aneurysm neck as possible by endovascular means, and 3) judicious postoperative combination of anticoagulation, fluid, and pressure management.
Hacein-Bey
L
L
Department of Radiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA.
Connolly
E S
ES
Duong
H
H
Vang
M C
MC
Lazar
R M
RM
Marshall
R S
RS
Young
W L
WL
Solomon
R A
RA
Pile-Spellman
J
J
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002340:Carotid Artery Diseases / Q000175:diagnosis / Q000601:surgery / Q000628:therapy*; D002404:Catheterization; D002533:Cerebral Angiography; D002548:Cerebral Revascularization; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis / Q000601:surgery / Q000628:therapy*; D008026:Ligation; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D014654:Vascular Patency