Endoluminal Reconstruction of Complex Cervical Internal Carotid Artery Dissections Using the Surpass Elite Flow Diverter: A Technical Report

Most cervical internal carotid artery (ICA) dissections heal with antithrombotic therapy. Complex lesions with flow-limiting stenosis, multisegment involvement, or persistent wide-necked pseudoaneurysms may fail medical management and require endovascular reconstruction, the indications for which remain individualized. Conventional carotid stents conform poorly to acute curves. Flow diverters reconstruct the parent lumen and accommodate angulation, but cervical use is off-label and experience with current-generation devices is limited. To our knowledge, we report the first use of the Surpass Elite flow diverter (Stryker Neurovascular, Fremont, CA) for cervical ICA dissection, in two patients, as the primary scaffold within hybrid constructs supported by coil embolization, angioplasty, and carotid stenting. An 18-year-old female with a Biffl grade III blunt injury had a right cervical dissection with critical narrowing of the true lumen and two large wide-necked pseudoaneurysms persisting despite antiplatelet therapy; coil embolization of both sacs, a single flow diverter, angioplasty, and telescoped carotid stents restored luminal caliber, with six-month angiography showing complete resolution without coil compaction. A 72-year-old male with a prior left middle cerebral artery infarct had a 6-cm chronic dissection of the cervical left ICA with dense distal calcification, aneurysmal dilatation, 70% stenosis, and angiographic hypoperfusion; two telescoped flow diverters and a carotid stent reconstructed the lumen without residual stenosis. Both patients received dual antiplatelet therapy starting seven days preoperatively, with P2Y12 reaction units verified within the target range, and neither had periprocedural complications. Reconstruction with the Surpass Elite within a hybrid construct was technically feasible in these two contrasting morphologies; two cases cannot establish efficacy, and the independent contribution of the device cannot be determined.