Fig. 1. Initial right carotid arteriogram shows severe stenosis at the origin of the right internal carotid artery and moderate stenosis at the origin of the external carotid artery.   Case Reference No. CC-0398-07   A 77-year-old woman presented with neurological symptoms to the left side of the body lasting over a few hours that were suggestive of a transient ischemic attack. Duplex ultrasound and arteriography both demonstrated severe narrowing at the origin of the right internal carotid artery (ICA) (Fig. 1). The patient underwent right ICA endarterectomy that was technically difficult, so postoperative carotid arteriography was ordered to verify the operative result. The arteriogram demonstrated a pseudoaneurysm above the take-off of the right ICA (Fig. 2). It was thought that the pseudoaneurysm should be treated because of the risks of embolism and possible expansion and rupture. A compassionate-use IRB approval was obtained to treat the lesion with a covered stent. One week after the postoperative arteriogram, the lesion had almost doubled in size (Fig. 3). Through a 10-F sheath, a 90-cm delivery system was used to deliver a 10-mm x 50-mm Wallgraft (PET covered) into the ICA, excluding the pseudoaneurysm (Figs. 4, 5). The stent was dilated to 7 mm using a 7-mm x 4-cm angioplasty balloon. The neurosurgeons specifically requested that the stent be deployed over a long distance of the ICA to treat additional lesions (not shown). The patient tolerated the procedure well and was discharged from the hospital the next day. A follow-up ultrasound examination showed a widely patent reconstruction. The patient remains asymptomatic at 2 months of follow-up.   Questions 1) What is the natural history of an ICA pseudoaneurysm? 2) Would it be prudent to insert a balloon-expandable rather than a self-expandable covered stent in the ICA? 3) Were bridges burned by placing the stent so high in the ICA? 4) Would coils be appropriate in a case like this?

Fig. 2. Arteriogram following endarterectomy shows resolution of the ICA stenotic lesion; however, a 3.1-mm pseudoaneurysm is seen in the ICA above the endarterectomy site. The ECA is now occluded. Fig. 3. One week later the pseudoaneurysm has almost doubled in size. Fig. 4. Anatomic landmarks of the deployed covered stent. Fig. 5. Digital subtraction arteriogram of the area of stent placement shows exclusion of the pseudoaneurysm.