Neurofibromatosis-associated massive right internal carotid artery aneurysm with a coexisting arteriovenous fistula Marlin Wayne Causey, MD, Daniel M.

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Presentation transcript:

Neurofibromatosis-associated massive right internal carotid artery aneurysm with a coexisting arteriovenous fistula Marlin Wayne Causey, MD, Daniel M. Balkin, MD, PhD, Bala Ramanan, MD, Christopher F. Dowd, MD, Charles M. Eichler, MD Journal of Vascular Surgery Cases and Innovative Techniques Volume 2, Issue 4, Pages 165-168 (December 2016) DOI: 10.1016/j.jvscit.2016.04.006 Copyright © 2016 Terms and Conditions

Fig 1 A, Preoperative computed tomography angiography three-dimensional reconstruction demonstrating a partially thrombosed 8-cm right internal carotid artery (ICA) aneurysm with coexistent vertebrojugular fistula between the distal right vertebral artery and the right internal jugular vein. B, Arch angiography demonstrated significant lateral displacement of the right ICA (white arrow) as well as the right vertebral artery to right internal jugular vein fistula (black arrow). C, Frontal view of the aneurysm with filling and turbulent flow/partial thrombosis within the aneurysm (visualization of the distal right ICA is difficult, given the large amount of contrast material within the aneurysm). D, Lateral view of the ICA aneurysm. E, Selective catheterization of the right vertebral artery demonstrating the direct fistulous connection to the right internal jugular vein (arrow). F, Selective catheterization of the left vertebral artery demonstrating retrograde flow in the right vertebral artery and vertebrojugular fistula (arrow). G, Three-dimensional reconstruction of the left vertebral artery selective catheterization demonstrating the bilateral vertebral arteries, which enhance well owing to flow into the low-pressure right internal jugular vein and the fistulous connection (arrow). Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 165-168DOI: (10.1016/j.jvscit.2016.04.006) Copyright © 2016 Terms and Conditions

Fig 2 Operative repair (stage 1). A, Preoperative image of the patient demonstrating the large right-sided neck mass as well as the cutaneous neurofibromas. B, Right internal carotid artery (ICA) aneurysm with retractors removed. Vessel loops are placed around the right common and external carotid arteries. C, The patient underwent resection of the right ICA aneurysm with a right common carotid artery to ICA bypass using a 7-mm Dacron graft. Because of the large size and high location of the aneurysm, a clamp was used to control the proximal common carotid artery, and a balloon was employed for control of the distal ICA. D, Completed reconstruction of the right common carotid artery to ICA interposition graft. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 165-168DOI: (10.1016/j.jvscit.2016.04.006) Copyright © 2016 Terms and Conditions

Fig 3 Endovascular repair (stage 2). A, Initial angiogram demonstrating resection of the internal carotid artery (ICA) aneurysm with interposition graft. B, Right vertebral artery selective catheterization. C, Vertebrojugular fistula embolization. D, Selective left vertebral artery catheterization. The distal right vertebral artery and vertebrojugular fistula are cannulated (arrow). E, Coil embolization of the right vertebrojugular fistula (arrow) through the left vertebral approach. Note that completion angiography from the left vertebral artery demonstrates prograde basilar flow without retrograde right vertebral artery flow. Journal of Vascular Surgery Cases and Innovative Techniques 2016 2, 165-168DOI: (10.1016/j.jvscit.2016.04.006) Copyright © 2016 Terms and Conditions