Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 80-82

Endovascular repair of spontaneous common carotid pseudoaneurysm with covered stent graft


Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Date of Submission13-Aug-2019
Date of Acceptance11-Sep-2019
Date of Web Publication16-Mar-2020

Correspondence Address:
Dr. Hemant Kadu Chaudhari
Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_52_19

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  Abstract 


Extracranial carotid pseudoaneurysms are rare. They commonly occur secondary to blunt or penetrating trauma and rarely of spontaneous etiology. Rupture is one of the fatal complications; hence, surgical or endovascular treatment is warranted. We report a case of spontaneous common carotid pseudoaneurysm in a middle-aged female, which was successfully treated with a covered stent-graft.

Keywords: Covered stent-graft, extracranial carotid, pseudoaneurysm, spontaneous


How to cite this article:
Chaudhari HK, Motukuru V, Anand V, Sumanthraj K B, Rodney S R. Endovascular repair of spontaneous common carotid pseudoaneurysm with covered stent graft. Indian J Vasc Endovasc Surg 2020;7:80-2

How to cite this URL:
Chaudhari HK, Motukuru V, Anand V, Sumanthraj K B, Rodney S R. Endovascular repair of spontaneous common carotid pseudoaneurysm with covered stent graft. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 14];7:80-2. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/80/280674




  Introduction Top


Pseudoaneurysms of the extracranial carotid arteries account for <1% of all aneurysms.[1] Most commonly, they are associated with blunt or penetrating trauma. Other causes are of iatrogenic origin (prior endarterectomy), radiation, inflammation, infection, vasculitis, and rarely spontaneous or idiopathic.[2] Clinically, it presents as painless pulsatile neck mass, thrill on physical examination with or without compression symptoms such as cranial nerve palsy, dysphagia, and dyspnea. The majority of complications are neurologic in nature either due to embolic events or extrinsic cranial nerve compression.[3] Although uncommon, it may lead to rupture, which can be fatal, so surgical or endovascular treatment is necessary.[4],[5] We report a successful case of endovascular repair of a spontaneous right common carotid artery (CCA) pseudoaneurysm with a covered stent graft.


  Case Report Top


A 45-year-old female without any comorbidities, presented with a complaints of pulsatile swelling on the right side of neck [Figure 1], insidious in onset and gradually progressing in size over previous 2 months. No history of neck trauma or other etiology. No stridor or dysphagia was present. A history of the right upper limb acute ischemia cat III secondary to subclavian artery to distal complete thrombotic occlusion was present; for which she underwent right above elbow amputation 1 month back in outside hospital. The right above elbow amputation stump was healed at the time of presentation.
Figure 1: Clinical picture showing right-sided neck swelling

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Physical examination revealed 8 cm × 6 cm pulsatile swelling on the anterolateral aspect of the right side of the neck with ill-defined lower border. Bruit was present over the swelling. No signs of cranial nerve palsy or any neurological deficit, and her vital signs were stable. Computed tomography angiography showed 2.3 cm × 2 cm pseudoaneurysm of CCA with 8 cm × 5.3 cm contained hematoma with 7 mm neck, arising 11 mm from CCA origin [Figure 2] and [Figure 3]. Her right upper limb blood pressure was not recordable with feeble axillary and subclavian signals.
Figure 2: Preoperative computed tomography angiography of neck and upper thorax showing. (a) Coronal and (b) sagittal view. The right common carotid pseudoaneurysm with retrosternal extension and mass effect on trachea

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Figure 3: Three dimensional computed tomography reconstruction of the right common carotid pseudoaneurysm

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Technique

Under general anesthesia, the right common femoral artery retrograde access was obtained. Innominate was selectively cannulated. The left anterior oblique angiogram with catheter tip in innominate showed, 2.3 cm × 2 cm pseudoaneurysm of CCA with 7 mm neck arising from posteromedial aspect of CCA 11 mm distal to its origin [Figure 4]a. 9 mm × 60 mm FLUENCY stent graft was deployed centered on the neck of the aneurysm. In this particular case, distal innominate is covered so as to achieve 2 cm proximal sealing zone.
Figure 4: (a) Intraoperative left anterior oblique digital subtraction angiogram showing common carotid artery pseudoaneurysm (b) completion digital subtraction angiogram showing pseudoaneurysm exclusion by stent-graft

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Postprocedure on table check angiogram showed good flow across stent graft with the exclusion of the pseudoaneurysm sac with no endoleak [Figure 4]b. The patient tolerated the procedure well without any complications.

Postoperative

Postoperative period was uneventful; subclavian and axillary signals were the same as preoperative with no signs of ischemia of the right above elbow amputation stump. She was discharged home on postoperative day 2 with dual antiplatelet therapy.

Follow-up

At 6th month follow-up, she was asymptomatic, and a neck ultrasound revealed no blood flow to the pseudoaneurysm with good flow across stent graft [Figure 5].
Figure 5: Follow-up 6 months' Doppler scan showing good flow in stent-graft with thrombosed pseudoaneurysm sac

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  Discussion Top


The conventional treatment of carotid pseudoaneurysm has been primarily open surgical repair in the form of primary repair, pseudoaneurysm resection, and placement of a prosthetic or an autogenous vein graft and rarely carotid artery ligation. Although surgery is an effective treatment modality, it is a technically challenging especially in those with pseudoaneurysm extension to skull base or with retrosternal extension and carries a high risk for complications such as rupture and cranial nerve injury with transient cranial nerve dysfunction reported in up to 20% of patients. It is associated with increased mortality and morbidity mainly due to the extensive exposure required.[5]

In the last decade, endovascular repair of carotid pseudoaneurysms has been emerged as an alternative treatment modality with less morbidity and mortality. Available endovascular options include bare-metal stent placement with or without coil embolization, coil embolization alone or, more recently, sac exclusion with covered stent-grafts. The data on the use of covered stent-grafts in the treatment of carotid pseudoaneurysm are limited to small case reports and series.

The selection of surgical versus an endovascular treatment approach depends on multiple etiologic-, anatomic-, and patient-related factors. Open surgical repair is preferred for infected and ruptured aneurysms. The endovascular management of the aneurysm is preferred in pseudoaneurysms related to trauma, and in those with surgically inaccessible lesions such as extending up to base of skull or retrosternal area, and in patients with hostile neck anatomy.[6]

In our patient, there is no history of trauma or any other specific etiology, and thus, the cause of the pseudoaneurysm was unknown (spontaneous). Although our patients are young healthy, in view of large size of pseudoaneurysm with retrosternal extension which would have required midline sternotomy and at increased risked of cranial nerve palsy so we decided to exclude carotid pseudoaneurysm with a stent-graft. The other important points to note in the present case is that, pseudoaneurysm is arising 11 mm from CCA origin, so distal innominate (subclavian ostia) is covered with stent-graft so as to achieve 2 cm sealing zone. As subclavian and axillary arteries were already occluded and she had undergone right above elbow amputation with healed stump, there was no threat of acute ischemia after covering subclavian ostia with the stent-graft.


  Conclusion Top


The possibility of a pseudoaneurysm must be considered when a patient complains of a pulsating neck mass, even if there is no history of trauma. Covered stent grafts can be considered as the primary treatment modality for carotid pseudoaneurysms, especially in high surgical risk or in those with surgically inaccessible lesions as it offers a less morbid alternative.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
El-Sabrout R, Cooley DA. Extracranial carotid artery aneurysms: Texas heart institute experience. J Vasc Surg 2000;31:702-12.  Back to cited text no. 1
    
2.
Nadig S, Barnwell S, Wax MK. Pseudoaneurysm of the external carotid artery – Review of literature. Head Neck 2009;31:136-9.  Back to cited text no. 2
    
3.
Srivastava SD, Eagleton MJ, O'Hara P, Kashyap VS, Sarac T, Clair D, et al. Surgical repair of carotid artery aneurysms: A 10-year, single-center experience. Ann Vasc Surg 2010;24:100-5.  Back to cited text no. 3
    
4.
Prendergast H, Kuo D. Spontaneous rupture of the common carotid artery with pseudoaneurysm formation. Ann Emerg Med 1997;30:230-3.  Back to cited text no. 4
    
5.
Rancic Z, Pecoraro F, Nigro G, Simon R, Frauenfelder T, Mayer D. Branch ligatures and blood aspiration for post-traumatic superficial temporal artery pseudoaneurysm: Surgical technique. Gen Thorac Cardiovasc Surg 2014;62:68-70.  Back to cited text no. 5
    
6.
Li Z, Chang G, Yao C, Guo L, Liu Y, Wang M. Endovascular stenting of extracranial carotid artery aneurysm: A systematic review. Eur J Vasc Endovasc Surg 2011;42:419-26.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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