Treatment of a surgically inaccessible grade III blunt internal carotid artery injury using the transcervical carotid approach with flow reversal and covered stent placement

Abstract

Background: Standardized treatment for blunt cerebrovascular injury (BCVI) has not been defined. Surgically inaccessible blunt carotid artery injuries pose a significant challenge and, when associated with symptoms, have significant morbidity and mortality. Methods: We present the case of an expanding grade III blunt carotid injury following a motor vehicle collision. The patient presented with a right distal internal carotid artery (ICA) dissection with left hemiparesis. He was initially managed with heparin anti-thrombotic therapy and surveillance imaging. Follow-up CT angiogram (CTA) demonstrated expansion of a distal pseudoaneurysm and extension of dissection into the petrous portion of the ICA. Treatment was indicated given the rapid expansion of this pseudoaneurysm and concern for stroke. Due to the anatomic location of the injury, carotid stenting was selected. We elected to use the transcervical approach with flow reversal given our concern for thrombus within the pseudoaneurysm. Results: The patient underwent successful placement of a covered stent within the distal ICA. The flow reversal filtration system demonstrated a significant amount of thrombus. Early post-operative CTA revealed a patent ICA stent and maintenance of cerebral perfusion. At 6-month follow-up the patient had regained use of his left side and the ICA stent remained patent. He was maintained on dual antiplatelet therapy. Conclusion: The treatment of high grade blunt carotid injuries using a transcervical approach with flow reversal and covered stenting is a viable and safe option for patients with surgically inaccessible injuries. Long-term follow-up of covered stents within the ICA is warranted to support continued use of this treatment approach.