Introduction Endovascular stenting is a common treatment modality for intravascular stenosis. Current intracranial devices are relatively atraumatic and flexible to allow for navigation through tortuous anatomy such as the carotid siphon to reach its intended target. At times, large vessel diameters preclude the use of intracranial stents. Larger carotid or wall stents are limited in their ability to navigate tortuous anatomy due to their stiffness. We present two cases where vessel size demanded a larger stent but vascular tortuosity prevented primary navigation to the target lesion.
Case presentation The first patient was found to have symptomatic sagittal sinus stenosis with venous outflow obstruction due to compression from a posterior interhemispheric fissure meningioma. She presented with blurred vision and papilledema. The second patient had symptomatic right internal carotid stenosis and stroke symptoms.
Results In both cases, severe tortuosity was present proximal to the target location. In each case, a 070 Neuron (Alameda, California, USA) was able to navigate through the tortuosity and across the intended lesions. In the first patient, a 8 mm×40 mm Cordis Precise (Miami Lakes, Florida, USA) stent tracked through the Neuron, which was then withdrawn and the stent was successfully deployed in the superior sagittal sinus. The patient had the second stent placed using the same technique from the torcula to the right transverse sinus. In the other patient, attempts to primarily navigate through the tortuous carotid artery to reach the target location failed. The 070 Neuron was able to safely and successfully navigate through the tortuosity over an 038 glide wire and cross the target lesion. Two Cordis Precise stents (6 mm×20 mm and 5 mm×20 mm) were able to successfully navigate through the Neuron and deploy across the lesion in the internal carotid artery petrous segment. Control angiography did not demonstrate any evidence of vascular injury or stroke.
Conclusion Severe tortuosity can preclude successful primary navigation of larger, non-intracranial stents due to stent inflexibility. Use of a flexible guide catheter can provide a conduit to deliver these devices to their intended targets successfully.
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Competing interests RT—Mindframe, Microvention, Micrus.