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 ex tracranial-intracranial (EC-IC) bypass surgery is required in some pat ients. The reported incidence of thromboembolic and ischemic complicat ions remains significant for these patients, despite a variety of advo cated management strategies. We present our treatment paradigm. METHOD S: Between April 1992 and March 1997, nine patients with inoperable IC A aneurysms were treated using EC-IC bypass surgery and then permanent endovascular ICA occlusion, All of the patients except one had been s elected 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 perfor med by a mean of 6 days (range, 2-20 d). All patients were managed in the intensive care unit after ICA occlusion. RESULTS: Clinical improve ment was noted in all patients (mean follow-up, 21 mo; range, 3-42 mo) . There were no major complications. Aneurysmal thrombosis was confirm ed in all patients. Although ICA occlusion was delayed after bypass su rgery, only one bypass was noted to be occluded. The occluded bypass o ccurred in a patient who subsequently underwent successful ICA occlusi on. This patient was thought to have been improperly selected for bypa ss surgery. CONCLUSION: Certain carotid aneurysms can be effectively m anaged with hunterian ICA ligation. After preliminary identification o f patients with borderline cerebrovascular reserve as candidates for E C-IC bypass surgery, close attention to the following points may help enhance clinical outcome: 1) excellence in surgical technique for EC-I C bypass surgery, 2) occlusion of the parent vessel as close to the an eurysm neck as possible by endovascular means, and 3) judicious postop erative combination of anticoagulation, fluid, and pressure management .