Coexistence of cerebral aneurysm and carotid artery disease may be encountered in clinical practice. Theoretical increase in aneurysmal blood flow may increase risk of rupture if carotid artery disease is treated first. If aneurysm coiling is performed first, stroke risk may increase while repeatedly crossing the diseased artery. It is controversial which disease to treat first, and whether it is safe to treat both simultaneously via endovascular procedures. We document the safety and feasibility of such an approach. Review of collected neurointerventional database at our institution was performed for patients who underwent both carotid artery stenting (CAS) and aneurysm coil embolization (ACE) simultaneously. All patients underwent carotid stenting followed by aneurysm coiling in the same setting. Demographic, clinical data, and outcome measures including success rate and periprocedural complications were collected. Five hundred and ninety aneurysms coiling were screened for patients who underwent combined CAS and ACE. Ten patients were identified. Mean age was 67.7 years (range 51–89). The success rate for stenting and coiling was 100% with no immediate complications. The coiling procedure time was extended by an average of 45 min for performing both procedures jointly. No stroke, TIAs, or aneurysmal rebleeding was found on their most recent follow up. Our case series demonstrates that it is safe and feasible to perform CAS and ACE simultaneously as one procedure which may avoid unwanted risk of treating either disease at two separate time sessions

Aamir Badruddin

Michael G  Abraham

Mohamed S  Teleb

Muhammad A Taqi

Osama O Zaidat

English

PubMed

Background: Coexistence of cerebral aneurysm and carotid artery disease may be encountered in clinical practice. Theoretical increase in aneurysmal blood flow may increase risk of rupture if carotid artery disease is treated first.  If aneurysm coiling is performed first, stroke risk may increase while repeatedly crossing the diseased artery. It is controversial which disease to treat first, and whether it is safe to treat both simultaneously via endovascular procedures. We document the safety and feasibility of such an approach.    Methods: Review of collected neurointerventional database at our institution was performed for patients who underwent both Carotid artery stenting (CAS) and aneurysm coil embolization (ACE) simultaneously. All patients underwent carotid stenting followed by aneurysm coiling in the same setting. Demographic, clinical data and outcome measures including success rate and periprocedural complications were collected.    Results: 590 aneurysms coiling were screened for patients who underwent combined CAS and ACE. Ten patients were identified. Mean age was 67.7 years (range 51 to 89).  The success rate for stenting and coiling was 100% with no immediate complications.  No stroke, TIAs, or aneurysmal rebleeding was found on their most recent follow up.    Conclusions: Our case series demonstrates that it is safe and feasible to perform CAS and ACE simultaneously as one procedure which may avoid unwanted risk of treating either disease at two separate time sessions

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Frontiers in Neurology

Safety and Feasibility of Simultaneous Ipsilateral Proximal Carotid Artery Stenting and Cerebral Aneurysm Coiling

Mohamed S. Teleb

Michael G. Abraham

Muhammad A. Taqi

Osama O. Zaidat

Frontiers - Publisher Connector

www.frontiersin.org October 2010 | Volume 1 | Article 120 | 1
Original research article
published: 12 October 2010
doi:10.3389/fneur.2010.00120
Safety and feasibility of simultaneous ipsilateral proximal 
carotid artery stenting and cerebral aneurysm coiling
Aamir Badruddin1,2, Mohamed S. Teleb1, Michael G. Abraham1, Muhammad A. Taqi1 and Osama O. Zaidat1,3,4*
1 Department of Neurology, Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
2 Daniel M. Soref Clinical Neuroscience Fellow at Froedtert Hospital, Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
3 Department of Neurosurgery, Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
4 Department of Radiology, Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
Coexistence of cerebral aneurysm and carotid artery disease may be encountered in clinical 
practice. Theoretical increase in aneurysmal blood flow may increase risk of rupture if carotid 
artery disease is treated first. If aneurysm coiling is performed first, stroke risk may increase 
while repeatedly crossing the diseased artery. It is controversial which disease to treat first, and 
whether it is safe to treat both simultaneously via endovascular procedures. We document the 
safety and feasibility of such an approach.  Review of collected neurointerventional database 
at our institution was performed for patients who underwent both carotid artery stenting 
(CAS) and aneurysm coil embolization (ACE) simultaneously. All patients underwent carotid 
stenting followed by aneurysm coiling in the same setting. Demographic, clinical data, and 
outcome measures including success rate and periprocedural complications were collected. 
Five hundred and ninety aneurysms coiling were screened for patients who underwent 
combined CAS and ACE. Ten patients were identified. Mean age was 67.7 years (range 51–89). 
The success rate for stenting and coiling was 100% with no immediate complications. The 
coiling procedure time was extended by an average of 45 min for performing both procedures 
jointly. No stroke, TIAs, or aneurysmal rebleeding was found on their most recent follow 
up.  Our case series demonstrates that it is safe and feasible to perform CAS and ACE 
simultaneously as one procedure which may avoid unwanted risk of treating either disease 
at two separate time sessions.
Keywords: carotid stenting, aneurysm, coil embolization
Edited by:
Syed I. Hussain, Michigan State 
University, USA
Reviewed by:
Syed I. Hussain, Michigan State 
University, USA
Shazam Hussain, Cleveland Clinic 
Foundation, USA
*Correspondence:
Osama O. Zaidat, Neurointerventional 
Program, Medical College of Wisconsin 
and Froedtert Hospital West, 9200 W. 
Wisconsin Ave, Milwaukee, WI 53226, 
USA.
e-mail: szaidat@mcw.edu
Materials and Methods
We reviewed a neurointerventional database at our institution for 
patients who underwent carotid artery stenting (CAS) and aneu-
rysm coil embolization (ACE) in one operative session. Carotid 
artery stenosis was measured using the NASCET criteria. Aneurysm 
dimensions were measured using automatically calibrated software 
available with the angiographic equipment. During the proce-
dure, the blood pressure was strictly monitored and treated and 
all patients were anticoagulated intra-procedurally using unfrac-
tionated heparin was administered to achieve activated clotting 
time (ACT) of 250–300 s. All patients were treated with aspirin 
and clopidogrel perioperatively and the antiplatelet treatment was 
continued for a minimum of 3 months.
Patient with subarachnoid hemorrhage (SAH) were treated with 
antiplatelet agents after securing the aneurysm. In these cases as 
soon as the first coil was placed, unfractionated heparin was admin-
istered intravenously to achieve ACT of 250–300 s.
In all cases the carotid artery was treated first. A 6 French sheath 
was placed in the common carotid artery while the carotid artery 
lesion was crossed with a microwire and a microcatheter. A distal 
emboli protection device was placed in the distal cervical segment 
of the internal carotid artery. Carotid artery stent was placed across 
the lesion and post stenting angioplasty was performed if needed. 
After stenting the distal emboli protection was removed and the 
introduction
The simultaneous occurrence of intracranial aneurysm and carotid 
artery stenosis is around 3% (Pappada et al., 1997; Kappelle et al., 
2000). Certain risk factors are shared between carotid atheroscle-
rosis and cerebral aneurysms. These include age, hypertension, 
and tobacco use (NASCET Trial Investigators, 1991; Wiebers 
et al., 2003).
Theoretical increase in aneurysmal blood flow may increase 
risk of rupture if carotid artery disease is treated first. If aneurysm 
coiling is performed first, stroke risk may increase while repeat-
edly crossing the diseased artery. This brings an important man-
agement and clinical decision approach. Are we putting patients 
at risk by treating each disease in isolation? When aneurysm and 
proximal large vessel stenosis occur in the same arterial tree, it 
may be feasible to treat both lesions via endovascular technique 
without added morbidity.
There are few case series documenting open surgical approach 
to the treatment of concomitant lesions (Pappada et al., 1996; 
Porter et al., 1997). And, our review found only one case report 
documenting endovascular treatment of both lesions in one ses-
sion (Navaneethan et al., 2006). This article aims to discuss safety 
and feasibility of endovascular treatment of unruptured cerebral 
aneurysms and ipsilateral carotid artery stenosis. Some surgical 
considerations are also reviewed.
Frontiers in Neurology | Endovascular and Interventional Neurology  October 2010 | Volume 1 | Article 120 | 2
Badruddin et al. Concomitant carotid stenting and aneurysm coiling
 coiling. The mean age was 67.7 ± 12.2 years (range 51–89), all were 
Caucasian, and one was male. Carotid artery stenosis was always 
present at the level of the bulb and was at least 75% in all cases. Mean 
stenosis was 79 ± 6.3% (range 75–95). In seven patients the aneu-
rysms were discovered after undergoing imaging for complaints 
of headache or TIA. Two patients presented with SAH and one 
patient had symptomatic re-stenosis of ICA after a previous carotid 
endarterectomy. There were no procedure related complications 
during either of the treatments or in the perioperative period. All 
but one patient had imaging follow-up. Mean time to follow-up was 
7.5 ± 5.5 months (range 3–22 months). Follow up imaging of these 
patients did not reveal any re-stenosis, aneurysm expansion, or coil 
guide catheter was advanced distally into the internal carotid 
artery traversing the stent once. A microcatheter was introduced 
into the aneurysm with the aid of a microwire and the coiling 
was performed with angiographically satisfactory outcome. The 
microcatheter and guide catheter were subsequently removed from 
the body. (see Figure 1).
results
Ten cases were treated between July 2005 and May 2010 (Table 1). 
Patients underwent CAS ipsilateral to the site of aneurysm or in 
the case of anterior communicating artery, internal carotid artery 
with the dominant anterior cerebral artery prior to aneurysm 
Table 1 | Demographic and angiographic data.
Age Sex Stenosis Stenosis  Aneurysm Aneurysm Complications Presenting 
  location (%) size (mm) location  symptom
56 F L ICA 95 5 × 4 L MCA None TIA
54 F R ICA 79 7 × 6 R MCA None Headache
62 F R ICA 75 6.5 × 4.5 A Comm None Headache
79 F L ICA 75 7 × 5 Supraclinoid ICA None Headache
51 F L ICA 80 5.5 × 5 Supraclinoid ICA None TIA
89 M L ICA 76 7 × 5 A Comm None SAH
67 F R ICA 81 8 × 5 Supraclinoid ICA None Incidental
72 F L ICA 76 8 × 6 A Comm None Headache
78 F L ICA 83 5 × 6 L MCA None SAH
69 F L ICA 75 4.5 × 5.5 L MCA None Headache
Figure 1 | Digital subtraction angiography of pre and post treatment internal carotid arteries is seen in (A,B) respectively. Pre and post treatment 
aneurysms are seen in the same arterial tree in (C,D). A digitally reconstructed CT angiogram demonstrated the carotid atherosclerotic disease (solid arrow) and the 
unsecured aneurysm (dashed arrow) distal to it in (e). 
www.frontiersin.org October 2010 | Volume 1 | Article 120 | 3
Badruddin et al. Concomitant carotid stenting and aneurysm coiling
Received: 21 May 2010; paper pending 
published: 20 July 2010; accepted: 10 
August 2010; published online: 12 October 
2010.
Citation: Badruddin A, Teleb MS, Abraham 
MG, Taqi MA and Zaidat OO (2010) 
Safety and feasibility of simultaneous 
ipsilateral proximal carotid artery stenting 
and cerebral aneurysm coiling. Front. Neur. 
1:120. doi:10.3389/fneur.2010.00120
This article was submitted to Frontiers in 
Endovascular and Interventional Neurology, 
a specialty of Frontiers in Neurology.
Copyright © 2010 Badruddin, Teleb, 
Abraham, Taqi and Zaidat. This is an 
open-access article subject to an exclusive 
license agreement between the authors and 
the Frontiers Research Foundation, which 
permits unrestricted use, distribution, and 
reproduction in any medium, provided the 
original authors and source are credited.
Endarterectomy Trial (NASCET) inves-
tigators. Stroke 22, 816–817.
Navaneethan, S. D., Kannan, V. S., Osowo, 
A., Shrivastava, R., and Singh, S. (2006). 
Concomitant Intracranial Aneurysm 
and Carotid Artery Stenosis: A 
Therapeutic Dilemma. South. Med. J. 
99, 757–758.
Pappada, G., Fiori, L., Marina, R., Citerio, 
G., Vaiani, S., and Gaini, S. M. (1997). 
Incidence of asymptomatic berry 
aneurysms among patients under-
going carotid endarterectomy. J. 
Neurosurg. Sci. 41, 257–262.
Pappada, G., Fiori, L., Marina, R., Vaiani, S., 
and Gaini, S. M. (1996). Management of 
symptomatic carotid stenoses with coin-
cidental intracranial aneurysms. Acta 
Neurochir. (Wien) 138, 1386–1390.
Porter, R. W., Lawton, M. T., Hamilton, 
M. G., and Spetzler, R. F. (1997). 
references
ACAS Trial investigators. (1995). 
Endarterectomy for asymptomatic 
carotid artery stenosis. Executive 
Committee for the Asymptomatic 
Carotid Atherosclerosis Study. JAMA 
273, 1421–1428.
Kappelle, L. J., Eliasziw, M., Fox, A. J., and 
Barnett, H. J. (2000). Small, unrup-
tured intracranial aneurysms and 
management of symptomatic carotid 
artery stenosis. North American 
Symptomatic Carotid Endarterectomy 
Trial Group. Neurology 55, 307–309.
NASCET Trial Investigators. (1991). Clinical 
alert: benefit of carotid endarterectomy 
for patients with high-grade stenosis 
of the internal carotid artery. National 
Institute of Neurological Disorders 
and Stroke and Trauma Division. 
North American Symptomatic Carotid 
Concurrent aneurysm rupture and 
thrombosis of high grade internal 
carotid artery stenosis: Report of two 
cases. Surg. Neurol. 47, 532–539.
Wiebers, D. O., Whisnant, J. P., Huston, J. III., 
Meissner, I., Brown, R. D. Jr., Piepgras, 
D. G., Forbes, G. S., Thielen, K., Nichols, 
D., O’Fallon, W. M., Peacock, J., Jaeger, 
L., Kassell,  N. F., Kongable-Beckman, G. 
L., and Torner, J. C. (2003). Unruptured 
intracranial aneurysms: natural history, 
clinical outcome, and risks of surgical 
and endovascular treatment. Lancet 
362, 103–110.
Conflict of Interest Statement: The 
authors declare that the research was 
conducted in the absence of any com-
mercial or financial relationships that 
could be construed as a potential conflict 
of interest.
and location as shown by the ISUIA study (Wiebers et al., 2003). 
ISUIA data has its strength and weaknesses. However, general 
consensus among neuro-interventionalists is that most aneurysms 
>3 mm should be treated if it can be done safely. Second, treatment 
of asymptomatic carotid artery stenosis is shown to be benefi-
cial in ACAS trial (ACAS Trial investigators, 1995). Although no 
such trial for stenting versus medical therapy in asymptomatic 
carotid atherosclerosis exists. In some cases, the reason for CAS 
is not necessarily to treat the lesion for stroke risk reduction, but 
for surgical planning and access to the distal aneurysm. Third, 
an aneurysm in the anterior circulation with severe ipsilateral 
carotid stenosis may be partially protected due to reduce blood 
flow and in turn reduced pressure head. Recanalization of the 
carotid artery may increase the flow and in theory may increase 
the rupture risk. Therefore, once the decision has been made to 
treat a carotid artery stenosis, any distal aneurysms in its territory 
should also be secured.
Possible complications with such a treatment include displace-
ment of the stent caused by traversing the guide catheter or other 
devices across a freshly laid stent. The carotid stent placement com-
mits the patient to immediate and long-term use of antiplatelet 
agents. In a setting of a ruptured aneurysm, this may add addi-
tional risk. Extra radiation exposure is also an additional point 
to consider.
This series demonstrates that concomitant or single-session coil-
ing of a cerebral aneurysm and ipsilateral CAS is safe and feasible 
and may even be mandated in cases where improved endovascular 
surgical access is required.
conclusion
In our case series of 10 patients, there were no immediate com-
plications. All but one patient have had clinical and imaging fol-
low up, showing no new symptoms and no re-stenosis, aneurysm 
enlargement, or coil compaction. We conclude that this approach 
is safe and reduces the inherent risks of performing the proce-
dures separately. Treating the stenosis first avoids the repeated 
insertion and removal of microwires and microcatheters through 
a stenosed segment.
compaction. Eight patients had digital  subtraction  angiography 
performed within 12 months of treatment. One patient had MRA 
only follow up at 5 months.
One patient who had presented with SAH died 1 week after 
treatment due to complications of SAH and family’s decision to 
withdraw care.
discussion
When clinician and interventionalist encounter ipsilateral carotid 
disease and cerebral aneurysm, they face a very critical patient safety 
issue of which one to treat first. Treatment decision for a carotid 
stenosis and an intracranial cerebral aneurysm simultaneously is 
complex as the treatment poses several risks. It is important to 
note that in this series all treated carotid lesions were ipsilateral. 
This fact has surgical implications as traversing a stenosed and 
diseased segment repeatedly would add to the complication risk. 
Therefore, in most cases the rationale for treating the lesion was to 
afford improved access to the aneurysm and reduce the procedural 
risk. In this group the aneurysm was found incidentally due to 
headache or a TIA located in the territory of the untreated vessel; 
and aneurysm was the primary discovery and the carotid disease 
was a secondary one.
The other group of patients was in whom the stenosis was dis-
covered first due to a TIA or an ischemic stroke, and the aneurysm 
was found incidentally. If the aneurysm was discovered first then the 
ipsilateral carotid had to be treated (even if it is asymptomatic) for 
endovascular surgical access to the aneurysm. If the patient under-
went carotid stenting for a symptomatic carotid lesion then the 
distal aneurysm in its territory could not be left unprotected due to 
increased flow and increased theoretical risk of rupture. Therefore, 
regardless of the lesion of primary concern and manner of presenta-
tion, concomitant treatment of the lesions would be prudent.
From a safety point of view, the risk of hematoma, stroke, TIA, 
or infection from a second procedure is consolidated by performing 
a single procedure rather than two.
Certain issues complicate simultaneous treatment of these 
lesions. First, treatment of an unruptured aneurysm is dictated by 
its risk of rupture, which in turn is dictated by the aneurysm’s size 


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Safety and Feasibility of Simultaneous Ipsilateral Proximal Carotid Artery Stenting and Cerebral Aneurysm Coiling

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