Stenting-assisted coiling of an artery dissecting ...
Our case
History
· Male, 55 years old· Main complaint: Sudden onset of unsteady gait and distortion of commissure six months ago.· Medical history: Brain stem infarction 8 years ago. No hypertension or diabetes.· PE: (-)· Medication: Clopidogrel, Atorvastatin.· 男性，55岁· 主诉：突发行走不稳、口角歪斜6个月· 既往史：8年前脑干梗死。否认高血压或糖尿病病史。· 药物：氯吡格雷，阿托伐他汀。
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Pre-operative
Figure 1. Angiodysplasia.CTA shows left vertebral-basilar artery dissection (A). HR-MRI shows intimal flap and abnormal enhancement of left vertebral artery wall (B) , enlarged left ICA (C). 血管发育不良。CTA可见左侧椎基底动脉夹层(A)。HR-MRI可见内膜瓣及左侧椎动脉壁异常强化(B)，左侧颈内动脉扩张(C)。
Figure 3. Left ICA angiography confirms left ICA irregular dilatation without primitive posterior communicating artery. 左侧颈内动脉血管造影证实左侧颈内动脉不规则扩张，无原始后交通动脉。
Figure 4. Angiography shows the occlusion of right VA and segmental stenosis of right CCA, brachiocephalic trunk and subclavian artery, indicating the diagnosis of dissection. 血管造影提示右椎动脉闭塞，右颈总动脉、头臂干和锁骨下动脉节段性狭窄，提示多发夹层。
Video 1.Angiography confirms the dissection of left VA and BA, showing segmental stenosis of BA and aneurysmal dilatation of left VA. Right SCA arose from the stenotic segment of BA. 血管造影证实左侧椎动脉、基底动脉夹层，可见基底动脉节段性狭窄，左椎动脉动脉瘤样扩张，右侧小脑上动脉发自基底动脉狭窄段。
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Strategy
BA dissection: Stent angioplasty. Since right SCA arises from stenotic segment of BA, balloon dilation was not selected.Left VA aneurysmal dilatation: reconstruct the vessel wall with large coils assisted stenting technique.基底动脉夹层：支架成形术。右侧小脑上动脉自基底动脉狭窄段发出，故不选择球囊扩张。左侧椎动脉动脉瘤样扩张：行大圈辅助支架成形术重构血管壁。
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Operation
Figure 5. Measurement. 测量。
Figure 6. General heparinization. 8F guidecatheter and Navien (115cm) catheter were placed in V4 segment of left VA. Headway-21 microcatheter was navigated to P2 segment of right PCA. 全身肝素化。将8F导引管和Navien(115cm)导管置于左侧椎动脉V4段，Headway-21微导管到达右侧大脑后动脉P2段。
Video 2.LVIS 5.5mm*20mm was placed in the proximalsegment of the BA stenotic lesion .LVIS 5.5mm*20 mm放置于基底动脉狭窄段近端。
Figure 7. Post stent angiography. 支架置入后血管造影。
Figure 8. Measurement of segmental dilatation and stenosis of left VA V4 segment. 左椎动脉V4段节段性狭窄和扩张的测量。
Figure 9. Echelon-10 was placed in the proximal segment of the target lesion. Keep the coil loops loose and even. Echelon-10放置在目标病变的近端。保持弹簧圈襻疏松和均匀。
Figure 10. Microplex 10mm*30cm (2) and 9mm*30cm (1) were inserted. 填入Microplex 10mm*30cm 2枚和9mm*30cm 一枚。
Video 3.LVIS 5.5mm*25mm was deployed in the left V4 segment , pressing coils to the vessel walls and keeping the patent of parent artery. 在左椎动脉V4段放置LVIS 5.5mm*25mm支架，使弹簧圈贴壁，保持载瘤动脉通畅。
Figure 13. Tirofiban(Xinweining) 14ml was given via the guiding catheter. 经导引管给予替罗非班(欣维宁)14ml。
Figure 14 GIF. Post-operative angiography shows occlusion of the aneurysm with the patent of parent artery. 术后血管造影提示动脉瘤栓塞，载瘤动脉通畅。
Figure 15. 3D reconstruction of the vessels, coils and stents. 血管、弹簧圈、支架三维重建。
Figure 16. DynaCT shows no hemorrhage or infarction. DynaCT未见出血或梗死。
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Summery
· Early treatment for the left vertebral-basilar artery dissecting aneurysm can avoid subsequent complicated treatment and mass effect of brain stem.· Proper coil selection by the diameter of the segment, loosely pack the left VA dissecting aneurysm and push the stent while deploying can make the LVIS stent fully deployed. Further more, Solitaire stent providing good radial support can reinforce the prior LVIS stent.· Right CCA, brachiocephalic trunk and subclavian artery dissections with stenosis can be followed up or treated if necessary.· Flow diverter can be chosen if the dissecting aneurysm recurred in follow-up angiography.· 早期治疗左椎基底动脉夹层动脉瘤可避免后续复杂的治疗和脑干占位效应。· 根据病变段直径选择合适的弹簧圈，疏松填塞左椎动脉夹层动脉瘤，在释放支架时推动支架，可以使LVIS支架充分打开。此外，Solitaire支架提供良好的径向支撑力，可加固先前的LVIS支架。· 右侧颈总动脉、头臂干和锁骨下动脉夹层狭窄可随访，或在必要时进行治疗。· 如果夹层动脉瘤在后续造影中发现复发，可以选择血流导向装置治疗。
