Endovascular Exclusion of a Postendarterectomy Carotid Pseudoaneurysm

Stenting for Traumatic Pseudoaneurysms of the Cervical Internal Carotid Artery: Case Report and Systematic Review

BACKGROUND

The optimal stenting approach for traumatic pseudoaneurysms (PSA) of the extracranial internal carotid artery (ICA) remains underinvestigated. We present a case of a traumatic pseudoaneurysm of the extracranial ICA managed with stenting and review of prior published similar cases.

METHODS

The systematic review followed PRISMA-S guidelines and included studies that investigated traumatic pseudoaneurysms of the extracranial ICA managed by stent placement. Statistical analysis assessed the association between the type of injury and stent type, dual antiplatelet therapy (DAPT) duration, and clinical presentation, and the association between stent type and DAPT duration.

RESULTS

Our search yielded 82 publications with 135 patients with extracranial ICA PSA treated with stenting. The odds of neck hematoma presentation was 12.2 times greater for patients with penetrating rather than blunt injuries (P = 0.000002). Covered stents had 2.02 times higher odds of use for penetrating rather than blunt injuries compared to bare metal stents. (P = 0.0029). Shorter duration DAPT was seen with bare metal stents having 1.25 higher odds of DAPT duration less than one month compared to covered (P = 0.001).

CONCLUSIONS

In traumatic extracranial ICA pseudoaneurysms, covered stents are used more commonly for penetrating injuries compared to blunt injuries. Penetrating injuries are more strongly associated with the presentation of a hematoma compared to blunt injuries. Stent type may influence the recommended DAPT duration. Surgeons should consider these findings when selecting stent type and DAPT duration with patients presenting with traumatic extracranial ICA pseudoaneurysm.

Adjunctive techniques in endovascular repair of postcarotid endarterectomy pseudoaneurysm: Case report and literature review

Pseudoaneurysm (PA) following carotid endarterectomy (CEA) is a rare and dangerous complication. In recent years endovascular approach has been preferred to open surgery as it is less invasive and reduces complications in an already operated neck, especially cranial nerve injuries. We report a case of large post-CEA PA causing dysphagia, successfully treated by deployment of two balloon-expandable covered stents and coil embolization of the external carotid artery. A literature review dealing with all cases of post-CEA PAs since 2000 treated by endovascular means is also reported. The research was conducted on Pubmed database using keywords "carotid pseudoaneurysm after carotid endarterectomy," "false aneurysm after carotid endarterectomy," "postcarotid endarterectomy pseudoaneurysm," and "carotid pseudoaneurysm."

Treatment Options for Pseudoaneurysm After Carotid Endarterectomy: A Systematic Review and Illustrative Case

BACKGROUND

The goal of this study was to systematically review the management and outcomes of patients who developed pseudoaneurysm (PA) after carotid endarterectomy (postendarterectomy PA [PEPA]).

METHODS

Following the PRISMA guidelines, a systematic literature review was performed using PubMed, Scopus, and Web of Science databases from date of inception to June 2022. Studies were selected based on predetermined inclusion and exclusion criteria. Simultaneously, a retrospective review was conducted of patients who underwent neurosurgical evaluation of suspected PEPA at our institution.

RESULTS

Of the 321 articles in the original literature search, 62 were selected. A total of 143 patients (93 men, 27 women; mean age, 70.7 years) diagnosed with PEPA were included. Mean time from carotid endarterectomy to PA diagnosis was 41.8 months. Primary repair data were available for 135 patients, including 19 with primary closures, 112 with patch or graft repairs, and 4 with eversion procedures. Fifty-five patients with PA (39%) presented with infection. Staphylococcal species were the most common causative organism. Of infected PAs, 89.1% were treated with open procedures. Overall complication rates of PAs treated via open, endovascular, and hybrid methods were 31%, 15.4%, and 0%, respectively. Open ligation (42.9%) and aneurysmectomy with grafting (36.4%) resulted in the highest rates of complications.

CONCLUSIONS

Despite higher complication rates after open repair strategies, use of these techniques remains a viable option in situations requiring removal of infected patches or evacuation of large extravascular collections. Endovascular treatment options are associated with low numbers of complications and can be considered for primary PEPA treatment when infection is not present.

Transcervical Access for Endograft Exclusion of a Postendarterectomy Carotid Pseudoaneurysm in a Patient With Type III Aortic Arch

Postendarterectomy carotid pseudoaneurysms are infrequent. The endovascular treatment is less invasive, with a minor risk of complications. However, the presence of a highly angulated aortic arch (type III) is a challenge, since the navigation of endovascular devices is not favorable. Through transcervical access, it is possible to deliver the devices directly into the carotid artery. We herein present a case of a postendarterectomy carotid pseudoaneurysm in a patient with type III aortic arch that was successfully treated with transcervical endograft exclusion.

Stent-assisted Coil Embolization to Treat Extracranial Carotid Artery Aneurysm 13 Years after Endarterectomy: A Case Report

Development of extracranial carotid artery aneurysm (ECCA) after carotid endarterectomy (CEA) is a rare complication, occurring in connection with <1% of all CEAs. The main causes are infection, suture failure, and degeneration of arterial wall or patch. The traditional treatment has been operative repair, which can present a significant technical challenge owing to reoperative neck inflammation and potential cranial nerve injuries. Here, we report a case of successful stent-assisted coil embolization for right noninfectious ECCA. A 63-year-old female was admitted to our hospital for a 3-cm pulsating mass in her right midneck. Doppler examination and digital subtraction angiography revealed a large (15 mm) ECCA at the right common carotid artery (CCA). Thirteen years earlier, eversion CEA with patch angioplasty and abbreviation of the internal carotid artery (ICA) had been performed for a symptomatic 80% diameter stenosis with transient ischemic attack at another hospital. As the patient refused blood transfusion for religious reasons, we treated her with stent-assisted coil embolization, which achieved nearly complete obliteration of the aneurysm while preserving the parent artery patency. Three months after initial treatment, ultrasound revealed complete occlusion of the ECCA, but also showed stent shortening. Hence, we performed an additional stent placement so as to overlap the previous stent by 2.5 cm. Six months after initial treatment, carotid duplex ultrasound confirmed a good outcome. This procedure is an excellent choice for high-risk patients, and a larger case series is needed to establish this technique as the treatment of choice for ECCAs.

Postendarterectomy Common Carotid Artery Pseudoaneurysm

Pseudoaneurysm (PSA) formation is an uncommon complication in carotid surgery. PSA of the carotid artery requires surgical or endovascular treatment to prevent PSA thrombosis, embolization from the thrombotic material within the PSA, hemorrhage after rupture, or compression on the adjacent structures. We present a case of a symptomatic common carotid PSA that occurred 14 months after routinely performed eversion carotid endarterectomy.

Internal carotid pseudoaneurysm associated with tortuosity after tonsillectomy: a case report

We present a patient who was found to have an internal carotid pseudoaneurysm 3 years after tonsillectomy and chemoradiation for tonsillar cancer. Ha also had severe tortuosity of both internal carotid arteries. The lesion was in an anatomically challenging location, but an endoluminal approach was not feasible because of the extreme tortuosity. He underwent open repair with resection of the pseudoaneurysm and direct anastomosis with good results.

Endovascular implantation of covered stents in the extracranial carotid and vertebral arteries: Case series and review of the literature

Background:

Covered stents are used endovascularly to seal arterial wall defects while preserving vessel patency. This report describes our experience with the use of covered stents to treat cervical pathology, and a review of the literature in regards to this topic is presented.

Case Description:

Two patients presenting with the carotid blowout syndrome and one patient with a vertebrojugular fistula were treated with covered stents. This allowed for preservation of the vessel and was a treatment alternative to cerebral bypass.

Conclusion:

Covered stents provide a viable means of preserving the cervical vessels in selected patients; however, long-term follow-up is necessary to determine stent patency and permanency of hemostasis.

Radiotherapy-induced common carotid pseudoaneurysm presenting with initially occult upper airway hemorrhage and successfully treated by endovascular stent graft

Radiation induced carotid vasculopathy may present as steno-occlusive disease or less commonly as a pseudoaneurysm. The latter most often presents with a pulsatile mass but is a potential cause of life threatening hemorrhage. We present a case of a small common carotid artery (CCA) pseudoaneurysm that was initially dismissed as the cause of the patients presenting epistaxis given its small size and location. After standard bilateral internal maxillary artery embolizations failed to prevent significant subsequent pharyngeal and tracheal blood loss and serial imaging demonstrated a progressive enlargement of the pseudoaneurysm, a stent graft was successfully placed across the lesion. At five months post stenting, follow-up imaging of the neck showed a stable obliteration of the pseudoaneurysm, good arterial patency, and the patient remained free of recurrent hemorrhage. This case demonstrates that even a small carotid pseudoaneurysm, can present with pharyngeal hemorrhage and should be treated aggressively--with endovascular stent grafting being a preferred treatment modality for arterial lesions in the irradiated neck.

Management of a chronic carotid artery pseudoaneurysm

An 82-year-old female with a history of right carotid endarterectomy with patch closure 12 years prior presents with a pulsatile right neck mass with skin erosion and bleeding. The patient had been previously evaluated but refused the surgical intervention because a median sternotomy was recommended to obtain adequate proximal control. Her aneurysm was successfully repaired using a combination of open and endovascular method. The repair was performed through a right-hand side anterior sternocleidomastoid neck incision, and proximal vascular control was obtained with an 8.5-mm balloon positioned under fluoroscopic guidance via a femoral puncture.

Carotid Artery Pseudoaneurysm After Carotid Endarterectomy: Case Series and a Review of the Literature

Background: Pseudoaneurysm (PA) after carotid endarterectomy (CEA) is a rare complication with incidence less than 1%. There is a potential for rupture, embolization, thrombosis or compression of cranial nerves. Objective: We reviewed our experience and compare it to the literature to raise awareness of this rare though serious condition. It is crucial to treat these patients early to avoid the hazardous consequences. Methods: A review of the case records of patients who had CEA at University Hospital Birmingham (UHB) NHS Foundation Trust from 1990-2007, was undertaken. Information of patients including their aetiology, presenting features, treatment and results was collected. The English-language literature was searched using PubMed database for post CEA pseudoaneurysm. Results: Five patients developed post CEA PA. This represents 0.4% of the 1200 CEA performed at our hospital in the last 18 years. The timing of their presentation varied from three days to eight months after the original operation. All had patch reconstruction after CEA. Patches were intact at exploration of the PAs. There was one death and one stroke. The literature revealed 154 carotid PAs after CEA and two cases following carotid stenting 52 of these cases had infected PA. Patients with synthetic patches have the least incidence of infection. More than 80% had open surgery and 9% had endovascular repair. Conclusion: Post CEA surveillance is necessary to detect patients with PA early. Factors that favour infection must be avoided. Endovascular repair of carotid PA should be encouraged in specialised centres.

Resistência tensional do pericárdio bovino fixado em glutaraldeído comparada com a da veia safena magna

CONTEXTO: O uso do pericárdio bovino como remendo na endarterectomia de carótida é uma alternativa à veia safena magna. As vantagens do pericárdio incluem facilidade de obtenção, menor tempo operatório e principalmente menor índice de ruptura. OBJETIVO: Avaliar a resistência tensional do pericárdio bovino tratado com glutaraldeído e compará-la com a da veia safena magna. MÉTODOS: Os remendos de pericárdio bovino (grupo I, n = 20) e de veia safena magna (grupo II, n = 20) foram recortados em dimensões iguais (50 x 5 mm) e preparados de modo habitual a sua utilização. Os grupos foram submetidos a ensaio de tração e comparados em relação a força de ruptura, força máxima e tensão de ruptura utilizando-se o teste t de Student. A correlação da espessura do remendo com a força de ruptura também foi analisada utilizando-se o coeficiente de correlação linear de Pearson. RESULTADOS: Os parâmetros força de ruptura e força máxima foram significativamente maiores no grupo dos remendos de pericárdio bovino: 1,97 versus 1,36 kgf (p = 0,001230) e 2,27 versus 1,51 kgf (p = 0,0001087), respectivamente. A tensão de ruptura média para o material pericárdio bovino também foi maior (193,99±43,05 versus 49,19±22,96 kgf/cm², p = 7,603e-16) do que na veia safena. A correlação entre a espessura e a força de ruptura foi considerada moderada (r = 0,5032993) para o pericárdio bovino e baixa (r = 0,3062166) para o grupo da veia safena. CONCLUSÃO: Os autores concluem que a resistência do pericárdio bovino à ruptura foi considerada adequada neste estudo, e é significativamente maior que a da veia safena magna, retirada da região da coxa. Além disso, a espessura do remendo em ambos os grupos não apresenta boa correlação com sua resistência a ruptura.

Successful Covered Stent-Graft Exclusion of Carotid Artery Pseudo-aneurysm: Two Case Reports and Review of Literature

Postendarterectomy carotid artery pseudo-aneurysm (CPA) is a relatively infrequent complication with an estimated incidence of 0.3%-0.6%. A report from a single center experience on open-surgical repair of CPA has shown the associated high morbidity and mortality. Endovascular therapy is emerging as a safer alternative to open-surgical therapy. We describe two cases of CPA treated with commercially available Viabahn stent graft system (Gore AL, Flagstaff, AZ).

Tratamento endovascular de pseudo-aneurisma de carótida interna em criança

Relato de um caso de paciente feminina, com 6 anos de idade, que apresentou uma massa cervical, dolorosa e com características de processo infeccioso, que revelou ser um pseudo-aneurisma de carótida interna. Foi realizado o tratamento endovascular, com o uso de um balão destacável que determinou a oclusão e conseqüente trombose do pseudo-aneurisma, com excelente resultado.

Resolution of an Infectious Pseudoaneurysm in a Cervical Petrous Carotid Vein Bypass Graft after Covered Stent Placement: Case Report

OBJECTIVE AND IMPORTANCE

Covered stenting of the carotid artery has been used to treat aneurysms and dissections. We describe a unique case of covered stenting in the setting of an infected psuedoaneurysm in a previously placed cervical-to-petrous vein bypass graft. Operating in an infected field and reopening a surgical wound at the craniocervical junction that had previously been exposed to penetrating trauma created substantial risks to open surgical repair. We therefore chose an endovascular strategy to repair this lesion.

CLINICAL PRESENTATION

A 57-year-old diabetic man with a previously placed cervical-to-petrous vein bypass graft presented with chronic otitis media and acute hemorrhage from his right external auditory meatus. Evaluation revealed an infectious pseudoaneurysm of the vein graft at the skull base.

TECHNIQUE

The patient was treated with intravenous antibiotics and endovascular placement of an 8-mm x 25-mm polytetrafluoroethylene-covered stent across the pseudoaneurysm. Angiography obtained 8 months later confirmed successful obliteration of the lesion.

CONCLUSION

The patient's clinical outcome was excellent. Despite the active infection, covered stenting of the pseudoaneurysm was an effective treatment strategy, obviating the need for open debridement and graft revision.

Endoluminal repair of carotid artery pseudoaneurysms: A word of caution

This report describes our results with covered endoluminal stents in the management of 4 patients with carotid artery pseudoaneurysms (PSAs) following carotid endarterectomy (CEA). Two patients had symptomatic embolization of thrombus from the PSA's into branches of the middle cerebral arteries (MCA) during deployment of the stents. Endoluminal stents were deployed uneventfully in the other two. At 12 month follow-up, one patient had an occlusion of the stent. While endoluminal therapy of carotid PSAs in an effective method to exclude PSAs, embolization of thrombus is a potential hazard. The long-term patency of covered stents in the carotid artery is unknown.

Endovascular repair of an infected carotid artery pseudoaneurysm

Pseudoaneurysm formation after carotid endarterectomy is a rare but potentially lethal complication. The risks for embolization and continued expansion necessitate repair. Traditional surgical repair of carotid pseudoaneurysms is often technically demanding, and is associated with relatively high morbidity and mortality. Endovascular stent grafts have been used to treat both posttraumatic and postoperative carotid pseudoaneurysms. An endovascular approach to these pseudoaneurysms limits the risks for operative damage to surrounding structures and the potential for substantial blood loss. We present the case of an infected carotid pseudoaneurysm that was successfully treated with a covered stent graft.