Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 150-153

Open surgical reconstruction of the extracranial internal carotid artery aneurysm at the base of the skull: An experience of five cases in a tertiary vascular surgery center


Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir Jamshedjee Jeejeebhoy Group of Hospitals, Mumbai, Maharashtra, India

Date of Submission14-Feb-2020
Date of Decision11-Mar-2020
Date of Acceptance13-Apr-2020
Date of Web Publication17-Jun-2020

Correspondence Address:
Dr. Saptarshi Paul
Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir Jamshedjee Jeejeebhoy Group of Hospitals, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_20_20

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  Abstract 


Aim: Aneurysms of the internal carotid artery (ICA) at the base of the skull are uncommon dangerous lesions whose management remains unclear. The aim of this retrospective study is to report the short term results of open surgical repair done in our center to formulate a standardized surgical technique of ICA reconstruction with best results. Subjects and Methods: From 2017 to 2019, totally five ICA reconstructions were performed for extracranial internal carotid artery (EICA): two male patients and three female patients (mean age, 34 years). The cause was atherosclerosis (n = 3 patients), trauma (n = 1 patient), and syndromic (associated with a complex congenital cardiac condition, n = 1 patient). The symptoms were mainly swelling and pain, in one case. Results: All patients underwent open extracranial surgical reconstruction at the skull base; interposition grafting using reverse saphenous vein graft was used in three cases, after resection of the aneurysm, and direct end to end anastomosis was employed in two cases of saccular aneurysms. The ICA was patent on the postoperative angiogram in all cases. All patients are doing well on follow-up. Conclusion: Venous graft bypass and direct ICA to ICA anastomosis for EICA can be performed safely with an open surgical approach and produces durable satisfactory results.

Keywords: Extracranial internal carotid artery aneurysm, interposition grafting, open surgical reconstruction


How to cite this article:
Nagre SW, Paul S. Open surgical reconstruction of the extracranial internal carotid artery aneurysm at the base of the skull: An experience of five cases in a tertiary vascular surgery center. Indian J Vasc Endovasc Surg 2020;7:150-3

How to cite this URL:
Nagre SW, Paul S. Open surgical reconstruction of the extracranial internal carotid artery aneurysm at the base of the skull: An experience of five cases in a tertiary vascular surgery center. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 4];7:150-3. Available from: http://www.indjvascsurg.org/text.asp?2020/7/2/150/286902




  Introduction Top


Aneurysms of the extracranial internal carotid artery (EICA) are defined as localized increases of caliber of more than 50% as compared with the reference values, which are 0.55 ± 0.06 cm in men and 0.49 ± 0.07 in women at the level of the internal carotid artery (ICA) and 0.99 ± 0.10 in men and 0.92 ± 0.10 in women at the level of the carotid bulb.[1],[2] Although atherosclerosis is the main cause of stenotic lesions of the ICA, the causes of aneurysms are multiple and include atherosclerosis and dysplastic, traumatic, and infectious lesions.[3] Surgical management of such aneurysms remains unclear. The aim of this retrospective study is to report the results of open surgical repair done in our center in order to establish the feasibility and effectivity of open surgical technique of ICA reconstruction with long-term results.


  Subjects and Methods Top


From 2017 to 2019, totally five open ICA reconstructions were performed for EICA: two male patients and three female patients (mean age, 34 years). The cause was atherosclerosis (n = 3 patients), trauma (n = 1 patient), and syndromic (associated with a complex congenital cardiac condition, n = 1 patient). Two patients had transient ischemic attacks, one had stroke, and the last two had swelling and pain, respectively. The aneurysms were all located in the cervical (extracranial) part of the ICA. The youngest patient was 15 years old and the oldest was 51.

Case 1

A 32-year-old female reported with repeated attacks of transient ischemic attacks; computed tomography (CT) angiography of the neck and head vessels revealed a fusiform right ICA (C1 cervical segment) aneurysm, of 3 cm × 4 cm × 1.8 cm size, at a distance of 2 cm distal to the carotid bifurcation and 4 cm proximal to the petrous temporal bone [Figure 1]. The vessels showed extensive atherosclerotic changes.
Figure 1: Fusiform aneurysm as seen by us in cases 1, 2, and 4

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Case 2

A 24-year-old female came with a history of trauma to the neck in a road traffic accident with complaints of pain and swelling; CT angiography of the neck and head vessels revealed a left ICA dissecting aneurysm (C1), of 1.5 cm × 1.3 cm × 2.1 cm size, at a distance of 4.5 cm distal to the carotid bifurcation and 3 cm proximal to the petrous temporal bone.

Case 3

A 15-year-old male came with a history of pain and swelling on the right side the neck for 1 month. He was a known case of supracardiac total anomalous pulmonary venous connection, operated 7 years back; also a known case of the right lateral rectus palsy with congenital ptosis, and white hair lock too. Magnetic resonance imaging (MRI) angiography of the neck and brain revealed a right ICA (C1 cervical part) pseudoaneurysm of the saccular type, of size 2.1 cm × 1.9 cm × 2.4 cm, at a distance of 3 cm distal to the carotid bifurcation and 3 cm proximal to the petrous temporal bone. A wide neck measuring 9 mm was present [Figure 2]. Clinical signs suggested a syndromic association. Workup for vasculitis was done; the reports turned out to be normal.
Figure 2: Saccular internal carotid artery aneurysm as seen by us in cases 3 and 5

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Case 4

A 48-year-old female came with a history of a cerebrovascular accident leading to left-sided hemiplegia; CT angiography of the neck and head vessels revealed a right ICA fusiform aneurysm in its cervical part (C1), of size 2 cm × 2.5 cm × 1.7 cm, at a distance of 4 cm distal to the carotid bifurcation and 3.5 cm proximal to the petrous temporal bone, with extensive atherosclerotic changes.

Case 5

A 51-year-old male came with complaints of multiple episodes of transient ischemic attacks; CT angiography of the neck and head vessels revealed a right ICA saccular aneurysm (cervical part C1), of size 2 cm × 2 cm × 1.6 cm, at a distance of 3.7 cm distal to the carotid bifurcation and 4 cm proximal to the petrous temporal bone, with extensive atherosclerotic changes.

Observed anatomy of the cervical portion of internal carotid artery

This portion of the internal carotid begins at the bifurcation of the common carotid, passes in front of the transverse processes of the upper three cervical vertebræ, to enter the carotid canal in the petrous portion of the temporal bone.[4] In the observed cases, two cases had hairpin turns of the proximal ICA. Aneurysms were fusiform in two cases, saccular in one, spontaneous dissecting in one and pseudoaneurysm in one.

Imaging and other investigations

All patients underwent bilateral carotid artery duplex-scan examination and CT carotid arteriography along with cerebral angiography [Figure 3], except one patient who underwent MRI angiography of the neck and brain. Routine blood investigations and chest imaging and electrocardiogram were done. Additional two-dimensional echo and coronary angiography was done for patients with stroke and transient ischemic attack, in order to rule out concomitant coronary artery lesions.
Figure 3: Preoperative computed tomography angiogram of saccular right internal carotid artery aneurysm as seen in case 3

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Surgical technique employed

Although initially endovascular repair was given as an option, the patients opted for open surgery after being explained to the potential complications of endovascular repair such as thromboembolism, aneurysm rupture, patent artery occlusion, coil migration, and vasospasm[5] and also that its long-term durability is questionable. Transcervical approach under general anesthesia was chosen [Figure 4]. Adequate exposure could be achieved for lesions located in the lower parapharyngeal space. All the lesions were present in the bicarotid region (region containing both external and internal carotid arteries), below the Blaisdell line (line between the tip of the mastoid process and the angle of the jaw). A longitudinal incision was placed on the neck on the medial aspect of the sternocleidomastoid and after carefully dissecting the tissue layers, the internal carotid was exposed [Figure 5]. The aneurysms were resected after placing deBakey clamps proximal and distal to the same. Three cases required placement of great saphenous vein interposition grafts, while in 2 cases of saccular aneurysms, direct end to end anastomosis was possible. All patients were extubated on table.
Figure 4: Preoperative photograph showing the operative position; inspection reveals a swelling on the right side of the neck with neck extended

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Figure 5: Intraoperative photograph showing the saccular aneurysm, with the proximal and distal segments of the cervical part of internal carotid artery

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  Results Top


Postoperative angiograms showed a patent ICA in all cases. All patients were followed up for a minimal period of 1 year postsurgery. No mortality has been recorded till date. One patient who was operatied in 2017 developed atherosclerotic aneurysm of the abdominal aorta later. No incidence of stroke or cranial nerve injuries was reported. We are presenting this study after a minimal follow-up of 1 year postsurgery.


  Discussion Top


Aneurysms of the EICA are infrequent lesions, accounting for 1% of peripheral aneurysms. The most common underlying cause of extracranial carotid artery (ECCA) is atherosclerosis which is seen in 37%–42% of aneurysms followed by trauma which is the second-most common cause of ECCA (35%–51%).[6],[7] If the young patients have ECAA, then the infective etiology should be looked at like tuberculosis or human immunodeficiency virus. Mycotic aneurysms usually are caused by  Salmonella More Details or syphilis. Other etiologies are collagen vascular disease, fibromuscular dysplasia, irradiation, Behcet's disease, Takayasu's arteritis, or Cogan syndrome. Connective diseases that can affect the carotid arteries include Marfan syndrome, Ehlers–Danlos syndrome, osteogenesis imperfecta, and pseudoxanthoma elasticum.[8] The most common clinical presentation is pulsatile cervical mass and local pain, but if an aneurysm is in distal ECCA, it can cause dysfunction of postganglionic sympathetic nerve fibers and cranial nerves due to compression or distension leading to swallowing difficulties, hoarseness or even Horner syndrome.[9] Routine investigation includes Doppler ultrasonography of the neck. Gold standard diagnostic tool is digital subtraction angiography.[10] Enhanced CT scanning with three-dimensional reconstruction allows analysis of the aneurysm (appreciating the upstream and downstream ICA) and assesses the possible existence of a false lumen channel, representing the existence of a previous dysplastic or traumatic dissection.[2] de Jong et al. suggested an ECCA should be diagnosed when the diameter of the carotid bulb was 1.5 times that of the CCA.[11] The spontaneous progression of ICA aneurysms is associated with a higher risk of mainly thromboembolic neurologic complications. Conservative treatment is based on anticoagulation.[2] Currently, surgical reconstructions and endovascular aneurysm exclusion are the two preferred treatments, and ligation is reserved for particular cases.[10],[12] Garg et al. point out the five basic options of surgical management of the ECCA as aneurysm clipping, excision with primary anastomosis, excision with interposition graft, extracranial–intracranial bypass, and carotid ligation.[7] Primary anastomosis and excision with interposition grafting were the two techniques employed by us. Another modality of management is endovascular approach. This technique excludes an aneurysm from the circulation with subsequent thrombosis within the sac while maintaining intraarterial blood flow. Garg et al. reported a series of open surgical intervention with a 0% rate of stroke and death at 30 days and 7% rate of cranial nerve injuries.[7] Li et al. reviewed 113 studies involving 224 patients submitted to endovascular repair of ECAA and reported a stroke rate of 1.8%, a cranial nerve injury rate of 0.5%, and an inhospital mortality rate of 4.1%.[13]


  Conclusion Top


EICA is uncommon and may be manifested with varying or no symptoms. Surgical treatment is feasible, with an acceptable rate of stroke and cranial nerve injuries, especially when an aneurysm is located on the common carotid artery and carotid bulb.[9] The review of literature proves that open surgical aneurysmectomy and reconstruction of the EICA remains a viable and strong surgical option. We aim at intervening suitable future cases of EICA aneurysms by open surgical reconstruction technique with the documentation of long-term outcomes.

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.
Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC. Suggested standards for reporting on arterial aneurysms. Subcommittee on reporting standards for arterial aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991;13:452-8.  Back to cited text no. 1
    
2.
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McCann RL. Basic data related to peripheral artery aneurysms. Ann Vasc Surg 1990;4:411-4.  Back to cited text no. 3
    
4.
Desai M, Rolls A, Girish G, Baker DM. Surgical approaches to the internal carotid artery at the extracranial middle skull base. Clin Surg 2017;2:1551.  Back to cited text no. 4
    
5.
Seibert B, Tummala RP, Chow R, Faridar A, Mousavi SA, Divani AA. Intracranial aneurysms: Review of current treatment options and outcomes. Front Neurol 2011;2:45.  Back to cited text no. 5
    
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Srivastava SD, Eagleton MJ, O'Hara P, Kashyap VS, Sarac T, Clair D. Surgical repair of carotid artery aneurysms: A 10-year, single-center experience. Ann Vasc Surg 2010;24:100-5.  Back to cited text no. 6
    
7.
Garg K, Rockman CB, Lee V, Maldonado TS, Jacobowitz GR, Adelman MA, et al. Presentation and management of carotid artery aneurysms and pseudoaneurysms. J Vasc Surg 2012;55:1618-22.  Back to cited text no. 7
    
8.
Royce PM, Steinmann BU. Connective Tissue and its Heritable Disorders: Molecular, Genetic, and Medical Aspects. NewYork: Wiley-Liss; 1993.  Back to cited text no. 8
    
9.
McCollum CH, Wheeler WG, Noon GP, DeBakey ME. Aneurysms of the extracranial carotid artery. Twenty-one years' experience. Am J Surg 1979;137:196-200.  Back to cited text no. 9
    
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Sharma RK, Asiri AM, Yamada Y, Kawase T, Kato Y. Extracranial internal carotid artery aneurysm – Challenges in the management: A case report and review literature. Asian J Neurosurg 2019;14:970-4.  Back to cited text no. 10
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11.
de Jong KP, Zondervan PE, van Urk H. A new method of quantifying extracranial carotid artery aneurysms. J Vasc Surg 1989;10:103-4.  Back to cited text no. 11
    
12.
Jong KP, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC. Suggested standards for reporting on arterial aneurysms. Eur J Vasc Surg 1989;3:557-62.  Back to cited text no. 12
    
13.
Li Z, Chang G, Yao C, Guo L, Liu Y, Wang M, et al. Endovascular stenting of extracranial carotid artery aneurysm: A systematic review. Eur J Vasc Endovasc Surg 2011;42:419-26.  Back to cited text no. 13
    


    Figures

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



 

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