**2.1. CASE 1**

A 52-year-old female with a pulsatile palpable mass in the left retromandibular space was referred to our hospital. Computed tomography angiography revealed a giant false aneurysm of the left cervical segment of the internal carotid artery (ICA) that was probably due to arterial injury caused by an elongated Styloid process. CTA revealed significant elongation and tortuosity of the left and right proximal ICA and a large supra-ophthalmic aneurysm of the right ICA (Figure 2).

252 Aneurysm

conventional angiography. Promiment factors that emphasize superiority of MRA to arteriography are that it excludes the risk of stroke associated with angiography and also possible access site complications and it gives information about the surrounding tissues. MRA also provides reconstruction and rotation of images of intracranial circulation and

The current treatment options include surgical treatment and endovascular treatment, but these are not without significant problems [6]. For instance, a randomised, multicentre trial compared the safety and efficacy of endovascular coiling with standard neurosurgical clipping for intracranial aneurysms found that the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling [7]. In addition, neurosurgery is associated with significantly longer length of stay and significantly higher total hospital charges [8]. Surgical treatment of extracranial internal carotid artery aneurysms located near skull base is technically challenging with high morbidity and mortality rates. In addition, surgical approach often requires an extended cervicotomy, mandibular subluxation, resection of the styloid process, and sometimes a transection of the external auditory canal with resection of the mastoid and vaginal process of the styloid bone to expose the first vertical intrapetrous segment of the ICA and risk of cranial nerve injury. Over the past decades, with advances in technologies, endovascular therapy is becoming the first-line treatment in the treatment of internal carotid and vertebral artery aneurysms and

Endovascular treatment options includes covered stent placement, flow diverting device (FDD) placement, parent vessel sacrifice with detachable balloons and coils, coil embolisation of the aneurysm with or without a stent placement. Endovascular techniques are usually performed via a femoral access route with placement of either covered stent, FDD or stent extending from the normal artery site to the distal vessel beyond the aneurysm. Despite the trend toward endovascular treatment the rate of recurrence and

This article describes current possibilities in endovascular treatment of vertebral and internal carotid artery aneurysms, with special focus on covered stents with our experience and description of used techniques in the treatment of internal carotid and vertebral artery

A 52-year-old female with a pulsatile palpable mass in the left retromandibular space was referred to our hospital. Computed tomography angiography revealed a giant false aneurysm of the left cervical segment of the internal carotid artery (ICA) that was probably due to arterial injury caused by an elongated Styloid process. CTA revealed significant

evaluation of collateral circulation better than angiography.

offers a minimally invasive alternative to open surgery.

**1.3. Endovascular treatment** 

complications can be high.

aneurysms.

**2. Body** 

**2.1. CASE 1** 

**Figure 2.** CTA finding of a styloid process causing a false aneurysm of the left ICA, elongation of both proximal parts of the ICA and a large aneurysm of the supra-ophthalmic part of the right ICA (A, B).

A four-step, multidisciplinary therapeutic plan combining surgical and endovascular modalities was selected: (i) resection and straightening of proximal tortuosity of the right ICA; (ii) endovascular coiling of intracranial aneurysms (Figure 3); (iii) resection and straightening of the proximal left ICA; and (iv) endovascular treatment of the false aneurysms in the left retromandibular space using covered stent.

**Figure 3.** DSA before coiling of the aneurysm of the supra-ophthalmic part of the right ICA (A) and after endovascular treatment (B).

Before implantation of the pericardium civered stent (PCS), the patient was given 100 mg aspirin and 300 mg clopidogrel. Right femoral access was used and digital subtraction angiography (DSA) of the left carotid artery confirmed the findings of the CTA (Figure 4A, 4B). A 6-F guiding catheter (Guider Softip™ XF, Boston Scientific Corp., Fremont, CA, USA) was advanced in the distal part of the common carotid artery (CCA). A 0.014 guidewire (Synchro, Boston Scientific Corp., Fremont, CA, USA) was then passed distal to the neck of the aneurysm. The length of the aneurysm neck necessitated two PCS, and resulted in complete exclusion of the aneurysm demonstrated on post-procedure angiography (Figure 4C).

**Figure 4.** CTA (A) and DSA (B) of a giant false aneurysm of the cervical segment of the left ICA and post-procedure angiography after placement of a covered stent (C).

#### **2.2. CASE 2**

A 44-year-old female was referred to our hospital after suffering a subarachnoid hemorrhage. Coiling of a small aneurysm of the communicating segment of the left ICA had been done. A giant (20 18 mm), large-neck aneurysm was discovered on CTA at the intradural fourth segment of the left vertebral artery (VA) proximal to the posterior inferior cerebellar artery (PICA). Endovascular treatment was considered to be first-line treatment for this VA aneurysm. The patient received 100 mg aspirin and 75 mg clopidogrel for 3 days before the procedure. Right femoral access was used and a 6-F guiding catheter (Neuron, Penumbra Inc, San Leandro, California, USA) advanced to the V3 segment of the left VA. DSA showed a giant, large-neck aneurysm of the V4 segment of the VA (Figure 5A). After passage of a 0.014 guidewire (Synchro, Boston Scientific Corp., Fremont, CA, USA) distal to the aneurysm neck, a 4 27 mm PCS was deployed and inflated to 12 atm. The aneurysm was completely excluded and this was demonstrated at control angiography (Figure 5B). Follow-up CTA at 3 months demonstrated complete exclusion and shrinkage of the aneurysm to 18 16 mm (Figure 6).

Endovascular Treatment of Internal Carotid and Vertebral Artery Aneurysms Using Covered Stents 255

**Figure 5.** Preoperative DSA of a giant aneurysm of the V4 segment of the left VA (A) and DSA after placement of a covered stent with no filling of the aneurysm (B).

**Figure 6.** Three-month follow-up CTA showing aneurysm exclusion, a patent covered stent with no intimal hyperplasia, and aneurysm shrinkage.

#### **2.3. CASE 3**

254 Aneurysm

**2.2. CASE 2** 

aneurysm to 18 16 mm (Figure 6).

Before implantation of the pericardium civered stent (PCS), the patient was given 100 mg aspirin and 300 mg clopidogrel. Right femoral access was used and digital subtraction angiography (DSA) of the left carotid artery confirmed the findings of the CTA (Figure 4A, 4B). A 6-F guiding catheter (Guider Softip™ XF, Boston Scientific Corp., Fremont, CA, USA) was advanced in the distal part of the common carotid artery (CCA). A 0.014 guidewire (Synchro, Boston Scientific Corp., Fremont, CA, USA) was then passed distal to the neck of the aneurysm. The length of the aneurysm neck necessitated two PCS, and resulted in complete

exclusion of the aneurysm demonstrated on post-procedure angiography (Figure 4C).

**Figure 4.** CTA (A) and DSA (B) of a giant false aneurysm of the cervical segment of the left ICA and

A 44-year-old female was referred to our hospital after suffering a subarachnoid hemorrhage. Coiling of a small aneurysm of the communicating segment of the left ICA had been done. A giant (20 18 mm), large-neck aneurysm was discovered on CTA at the intradural fourth segment of the left vertebral artery (VA) proximal to the posterior inferior cerebellar artery (PICA). Endovascular treatment was considered to be first-line treatment for this VA aneurysm. The patient received 100 mg aspirin and 75 mg clopidogrel for 3 days before the procedure. Right femoral access was used and a 6-F guiding catheter (Neuron, Penumbra Inc, San Leandro, California, USA) advanced to the V3 segment of the left VA. DSA showed a giant, large-neck aneurysm of the V4 segment of the VA (Figure 5A). After passage of a 0.014 guidewire (Synchro, Boston Scientific Corp., Fremont, CA, USA) distal to the aneurysm neck, a 4 27 mm PCS was deployed and inflated to 12 atm. The aneurysm was completely excluded and this was demonstrated at control angiography (Figure 5B). Follow-up CTA at 3 months demonstrated complete exclusion and shrinkage of the

post-procedure angiography after placement of a covered stent (C).

An 85-year-old female was admitted to our hospital for endovascular therapy of a symptomatic large-neck aneurysm of the cervical segment of the ICA subsequent to a stroke in the left middle cerebral artery (MCA). The patient was pre-medicated with 100 mg aspirin and 75 mg clopidogrel for 3 days before the procedure. Endovascular treatment was undertaken after gaining access via the femoral artery and placement of a 6-F guiding sheath (Guider Softip™ XF, Boston Scientific Corp., Fremont, CA, USA) in the CCA. DSA confirmed the CTA findings of an aneurysm of the cervical segment of the ICA (Figure 7A, 7B). A 0.014 guidewire (Synchro, Boston Scientific Corp., Fremont, CA, USA) was passed distal to the aneurysm and a PCS (4 27 mm) advanced over the wire and placed in the optimal position. The balloon was slowly inflated to 10 atm and the PCS successfully deployed. Control DSA confirmed complete exclusion of the aneurysm with preservation of ICA patency (Figure 7C).

**Figure 7.** CTA (A) and DSA (B) before endovascular treatment of an aneurysm of the left cervical segment of the ICA and final angiogram after implantation of a covered stent (C).

#### **2.4. CASE 4**

An 55-year-old male was admitted to our centre for endovascular treatment of a symptomatic dissecting aneurysm of the cervical segment of the ICA subsequent to a stroke. The patient was pre-medicated with 100 mg aspirin and 75 mg clopidogrel for 3 days before the endovascular procedure. Endovascular treatment was performed after gaining access via the right femoral artery and placement of a 6-F guiding sheath (Guider Softip™ XF, Boston Scientific Corp., Fremont, CA, USA) in the CCA. DSA confirmed the CTA findings of an aneurysm of the cervical segment of the ICA (Figure 8A). A 0.014 guidewire (Synchro, Boston Scientific Corp., Fremont, CA, USA) was passed distal to the aneurysm and a 5x26mm Jostent Graftmaster (Abbott Vascular, Abbott Park, Ill, USA) advanced over the wire and successfully deployed after balloon inflation. Control DSA confirmed exclusion of the aneurysm with patent ICA (Figure 8B).

**Figure 8.** DSA before (A) endovascular treatment of an aneurysm of the left cervical segment of the ICA and angiogram after endovascular treatment with implantation of a covered stent (B).
