PMC8267006_01
Patient 5 (A,B) (magnified), lateral (A) and oblique (B) views of right ICA angiogram showing the traumatic carotid-cavernous fistula (CCF, indicated by black arrow) as well as one pseudoaneurysm (indicated by black arrow head) located at cavernous segment of ICA. (C) Intra-procedural road map during stent graft (white arrows) positioning for occluding the CCF, with white arrow head indicating the pseudoaneurysm. (D,E) Oblique views of right ICA angiogram showing the complete occlusion of the CCF and the remained pseudoaneurysm (indicated by black arrow head). (F) Post-treatment radioscopic anteroposterior view of the placed coils (white arrow head) and stent (white arrow) for the stent-assisted coiling procedures. (G,H) Anteroposterior (G) and lateral (H) views of a right ICA angiogram showing the completely occluded traumatic pseudoaneurysm (black arrow head). (I) post-treatment radioscopic lateral view of the placed coils (black arrow head) and the stent (white arrow) for stent-assisted coiling, as well as the covered- stent (black double-arrow heads) for treating CCF.
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F1
A pseudoaneurysm 6.4 x 8.7 mm was also identified at the cavernous segment of the right ICA (Figures 1A-C). Using the methods described for patient 13, a Willis covered stent (4 x 16 mm, MicroPort) was first placed over the orifice of the fistula (Figures 1A-C,I), and immediate angiography confirmed correct placement of the stent, intact blood flow of the ICA and satisfactory occlusion of the fistula (Figures 1D,E). AB-6-20, ev3) was positioned with a microcatheter and released to fully cover the aneurysm neck (Figures 1F,I). After that, further aneurysm occlusion with detachable coils was then performed using standard procedures. Immediate angiography confirmed the complete embolization of the pseudoaneurysm (Figures 1G,H), and after the procedure, the patient was given heparin for 2 days followed by oral administration of aspirin (100 mg/day) and clopidogrel (75 mg/day) for 3 months.
Patient 12 (A,B) anteroposterior (A) and lateral (B) views of the right ICA angiogram for initial diagnosis, showing a traumatic cavernous pseudoaneurysm (black arrow head). (C) The second time of right ICA angiogram before the embolization, showing the formation of the thrombus in the false cavity of the pseudoaneurysm. (D,E) Anteroposterior (A) and oblique (B) views of the right ICA angiogram, showing the placement of endovascular coils in the pseudoaneurysm (black arrows), with the embolization microcatheter directing toward the pseudoaneurysm's cavity. (F) Balloon inflation (black arrows) was accomplished with the saline/contrast mixture. (G) Intraprocedural road map during the injection of the onyx (black arrow) into the pseudoaneurysm's cavity, after the complete cover of the pseudoaneurysm's ostium by the inflated balloon. (H,I) Anteroposterior (A) and oblique (B) views of the right ICA angiogram, showing the traumatic pseudoaneurysm completely occluded by the coils and onyx embolization (black arrow heads).
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F2
The patient then recovered, but 1 month later, he was admitted to our hospital due to repeated epistaxis, and a pseudoaneurysm 6.4 x 11.9 mm located at the cavernous sinus segment of the right ICA was found by initial DSA (Figures 2A,B). Three days later, a second DSA performed before embolization showed the formation of a thrombus in the false cavity of the pseudoaneurysm (Figure 2C). Then, an aneurysm embolization microcatheter (EchelonTM-10, ev3) was carefully placed into the aneurysm cavity with the guidance of a 0.014-in microguidewire (Traxcess 14EX), and aneurysm occlusion with detachable coils was performed using standard procedures (Figures 2D,E). Immediate angiography showed a significant reduction in blood flow in the cavity of the pseudoaneurysm (Figures 2D,E). Then, balloon inflation was accomplished with a 50:50 mixture of saline/contrast, and repeated angiography confirmed the correct placement of the balloon to completely cover the ostium of the pseudoaneurysm (Figure 2F). After that, 2.5 ml of Onyx glue (OnyxTM 18) was injected into the cavity of the pseudoaneurysm via the embolization microcatheter (Figure 2G), and complete embolization of the pseudoaneurysm was confirmed by final angiography (Figures 2H,I).
Patient 13 (A) oblique views of a left ICA angiogram showing the traumatic OphA aneurysm. (B,C) radioscopic anteroposterior (B) and oblique (C) views of the implanted stent during the left ICA angiogram. Black arrow heads indicate the pseudoaneurysm close to the ophthalamic artery in (A-C), black arrows indicate the stent in (B-G), oblique (E), anteroposterior (F) and lateral (G) views of a left ICA angiogram showing the complete occlusion of the pseudoaneurysm, with black arrow head indicating the absence of the pseudoaneurysm as well as ophthalamic artery. (H) Lateral (G) view of a left ECA angiogram showing the presence of the collateral flow from ECA to OphA (black arrow head).
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F3
One month later, the patient was admitted to our department because of the recurrence of severe epistaxis, and DSA confirmed a pseudoaneurysm 7.6 mm x 8.2 mm located at the OphA (ophthalmic artery) segment of the left ICA (Figures 3A-C). With a tapered 0.014-in microguidewire (TransendTM-300, Boston Scientific) navigated into a distal branch of the middle cerebral artery, a Willis covered stent (4 x 10 mm, MicroPort) was navigated over the microguidewire until it bridged the ostium of the pseudoaneurysm with the ostium in the center of the stent under roadmap guidance (Figures 3C,D). Then, the stent was deployed with a balloon expanded by 5 atm pressure lasting for 5 s, and multiple control angiograms were performed immediately after balloon de?ation to confirm the correct placement of the stent and satisfactory exclusion of the pseudoaneurysm (Figures 3E,F). For the left OphA, which was occluded after stent placement (Figures 3E,G), additional angiography of the left ECA (external cranial artery) was conducted and collateral flow from the ECA to the retina was observed (Figure 3H) and the patient manifested no change in vision postoperatively.