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

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.

Treatment Dilemma of Latrogenic Pseudoaneurysm of the Intracavernous Internal Carotid Artery in Young Girl Following Transnasal Transsphenoidal Surgery: A Case Report

Epistaxis following transnasal transsphenoidal (TNTS) removal of pituitary adenoma can be massive and life-threatening. The intracranial source of bleeding is usually the intracavernous segment of the internal carotid artery (ICA) or adjacent branches. Injury to the cavernous ICA can lead to pseudoaneurysm (PA) or fistula formation. Management of PA is different from saccular aneurysms. A timely diagnosis and adequate management can restore vessel integrity and prevent associated morbidity. A young patient of growth hormone-secreting pituitary adenoma, who underwent microscopic TNTS excision of the tumour, presented with massive epistaxis. Pseudoaneurysm of the cavernous ICA was initially not seen on computed tomography angiography and was later diagnosed on digital subtraction angiography. The attempted management of PA with coils without stent could not stop aneurysm recurrence. The management of such complicated PAs is discussed, and a literature review is done regarding epistaxis in growth hormone secreting adenoma.

Covered Stenting Is an Effective Option for Traumatic Carotid Pseudoaneurysm with Promising Long-Term Outcome

Objective

Covered stenting is an optional strategy for traumatic carotid pseudoaneurysm, especially in malignant conditions of potential rupture, but the long-term outcomes are not clear. Our aim was to determine if covered stenting is an effective option for traumatic carotid pseudoaneurysm with promising long-term outcomes.

Methods

Self-expanding Viabahn and balloon-expandable Willis covered stents were separately implanted for extra- and intracranial traumatic carotid pseudoaneurysm. The covered stent was placed across the distal and proximal pseudoaneurysm leakage under roadmap guidance. Procedural success was defined as technical success (complete exclusion of the pseudoaneurysm and patency of the parent artery) without a primary end point (any stroke or death within 30 days after the procedure). Long-term outcomes were evaluated as ischemic stroke in the territory of the qualifying artery by clinical follow-up through outpatient or telephone consultation and as the exclusion of the pseudoaneurysm and patency of the parent artery by imaging follow-up through angiography.

Results

Five patients with traumatic carotid pseudoaneurysm who underwent covered stenting were enrolled. The procedural success rate was 100%. No ischemic stroke in the territory of the qualifying artery was recorded in any of the five patients during a mean clinical follow-up of 44±16 months. Complete exclusion of the pseudoaneurysm and patency of the parent artery were maintained in all five patients during a mean imaging follow-up of 39±16 months.

Conclusion

Satisfactory procedural and long-term outcomes were obtained, suggesting that covered stenting is an effective option for traumatic carotid pseudoaneurysm.

Successful management with 2 overlapping bare stents for post-carotid endarterectomy carotid pseudoaneurysm secondary to carotid shunt

Pseudoaneurysms are a rare complication of carotid endarterectomy. We successfully excluded with 2 overlapping bare stents a distal carotid artery pseudoaneurysm very likely induced by a Pruitt-Inahara shunt 2 months after carotid endarterectomy.

Covered stent-graft treatment of a postoperative common carotid artery pseudoaneurysm

BACKGROUND

Extracranial carotid artery pseudoaneurysms are rare cases resulting from trauma, mycotic infection, head and neck carcinomas or complications related to their treatment. Trauma is the most common cause of carotid artery pseudoaneurysms. They can also present after surgery, most commonly following endarterectomy, which is a rare cause with an estimated incidence of 0.3-0.6%.

CASE REPORT

A 26-year-old male patient was admitted with swelling in his left neck after left carotid endarterectomy. Angiography confirmed pseudoaneursym in the left carotid bulb and it was treated successfully with two heparin-bonded covered stent grafts.

CONCLUSIONS

Endovascular treatment of carotid pseudoaneurysms with covered stent-grafts is a safe and efficient method providing definitive arterial reconstruction. But series with longer follow-up periods are needed to evaluate patient compatibility to lifelong antiplatelet theraphy.

Endovascular management of radiotherapy-induced injury to brachiocephalic artery using covered stents

Actinic vascular lesions tend to be stenotic-occlusive lesions. In this article, we present 2 exceptional cases of pseudoaneurysms caused by radionecrosis of the supra-aortic trunks. Both patients were treated by a retrograde carotid approach and deployment of a self-expanding covered stent. Proper exclusion of the pseudoaneurysm was attained in both cases; the first patient remained asymptomatic 12 months later; the second patient died of mediastinitis. Compared with conventional surgery, endovascular management is a viable, less invasive alternative in select patients, especially in life-threatening cases.

Endovascular Management of Vascular Injury during Transsphenoidal Surgery

Vascular injury is an unusual and serious complication of transsphenoidal surgery. We aimed to define the role of angiography and endovascular treatment in patients with vascular injuries occurring during transsphenoidal surgery. During the last ten-year period, we retrospectively evaluated nine patients with vascular injury after transsphenoidal surgery. Eight patients were symptomatic due to vascular injury, while one had only suspicion of vascular injury during surgery. Four patients presented with epistaxis, two with subarachnoid hemorrhage, one with exophthalmos, and one with hemiparesia. Emergency angiography revealed a pseudoaneurysm in four patients, contrast extravasation in two, vessel dissection in one, vessel wall irregularity in one, and arteriovenous fistula in one. All patients but one were treated successfully with parent artery occlusion, with one covered stent implantation, one stent-assisted coiling method, while one patient was managed conservatively. One patient died due to complications related to the primary insult without rebleeding. Vascular injuries suspected intra or postoperatively must be investigated rapidly after transsphenoidal surgery. Endovascular treatment with parent artery occlusion is feasible with acceptable morbidity and mortality rates in the treatment of vascular injuries occurring in transsphenoidal surgery.

Cavernous carotid pseudoaneurysm following transsphenoidal surgery

Pseudoaneurysm of the internal carotid artery (ICA) as a result of injury during transsphenoidal surgery is a rare but serious complication. We present a review of this subject, identifying 22 such cases in the literature, and contribute an unusual case of our own. Among our cohort, 23% of patients had no evidence of vascular injury or hemorrhage during the initial transsphenoidal operation, and presented at an average of 83 days after surgery. The average time to diagnosis for patients with intraoperative bleeding was 64 days after surgery. Epistaxis was the most common initial presenting symptom, seen in 41% of patients, and traditional angiography was employed in every case to make the diagnosis of pseudoaneurysm. Though complete occlusion of the ICA was ultimately required in 41% of patients, the remainder were treated with a variety of modalities. While intraoperative hemorrhage is certainly the most predictive indicator of iatrogenic vascular damage, in its absence, other signs such as postoperative bruits may be predictive of pseudoaneurysm formation as well. The continued accumulation of these unique cases will hopefully provide definitive recommendations on the early recognition and treatment of this serious condition, especially regarding the emerging role of endovascular therapy in its management.

Cervical carotid pseudoaneurysm: A carotid artery stenting complication

Background:

As carotid artery stenting becomes increasingly used, more complications are likely to occur. We present a case of Staphylococcus septicemia and pseudoaneurysm arising in the neck portion of the carotid artery after stenting.

Case Description:

A 51-year-old man was admitted with mild left hemiparesis. CT and MRI showed right hemisphere ischemia. Duplex Scan and MRA showed bilateral severe stenosis of the carotid arteries in the neck. A percutaneous angioplasty with stenting of the left carotid artery was performed. Two weeks after the procedure, he developed fever and swelling in the right leg and shoulder. An abscess, near where the groin had been punctured for the angioplasty was surgically drained. Blood samples were positive for S. aureus. After treatment the patient complained of a painful bulky pulsatile left cervical mass. Duplex scan and MRA showed a pseudoaneurysm of the left carotid artery. We excised the pseudoaneurysm and rebuilt the carotid artery with a saphenous vein graft. The postoperative period was uneventful, and the MRA revealed a patent saphenous graft.

Conclusion:

Mycotic pseudoaneurysm of the carotid artery is a rare complication of percutaneous angioplasty and stenting. Surgical treatment with saphenous vein graft is the treatment of choice.

Covered stent treatment for an aneurysm of a saphenous vein graft to the common carotid artery

Aneurysmal degeneration of a saphenous vein graft is a rare complication and, so far, only three cases involving a carotid artery have been described. We report the case of a patient with a cervical neoplasm presenting carotid invasion, who underwent en bloc tumor resection and carotid reconstruction with a saphenous vein graft. Six years later, during follow-up, an aneurysm of the carotid graft was detected. Endovascular intervention was performed using a covered stent. Three years after this intervention, the patient was found to be asymptomatic, and computed tomography showed that the covered stent was patent, without complications.

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.

Intracranial pseudoaneurysms, fusiform aneurysms and carotid-cavernous fistulas. Repair with percutaneous implantation of endovascular covered stents

The study assessed the effectiveness and safety of endovascular covered stents in the management of intracranial pseudoaneurysms, fusiform aneurysms and direct carotid-cavernous fistulas. Fourteen endovascular covered stents were used to repair three pseudoaneurysms, six fusiform aneurysms and six direct carotid-cavernous fistulas. Aneurysms were in the carotid artery in seven cases, in the vertebral artery two cases. It was not possible to treat two additional cases transcutaneously for technical reasons (2/15). Percutaneous closure of the lesions with an endovascular covered stent was successful in 13 of 15 cases. Initial follow-up showed good stent patency. No complications were observed after stent implantation. During follow-up, stent thromboses were detected in two of nine patients with follow-up digital subtracted angiography. One carotid-cavernous fistula of Barrow Type A transformed into Barrow Type D at nine month follow-up study was cured with a procudure of Onyx-18 injection. Endovascular covered stents may be an option for percutaneous closure of intracranial pseudoaneurysms, fusiform aneurysms and direct carotid-cavernous fistulas. Endoluminal vascular repair with covered stents offers an alternative therapeutic approach to conventional modalities.

Endovascular trapping for a giant aneurysm of the cervical internal carotid artery: a case report

SUMMARY

We describe a case of giant cervical internal carotid aneurysm successfully treated by endovascular trapping. A 57-year-old woman with a history of maxillary contusion seven years before presented with pharyngeal discomfort during swallowing. MRI revealed a 4 cm mass in the right parapharyngeal space. A common carotid angiogram revealed a giant aneurysm with a wide neck originating from the cervical internal carotid artery; kinking of the internal carotid artery was noted at a point distal to the carotid bifurcation. Analysis of cerebral blood flow by SPECT during a balloon occlusion test showed no hypoperfusion areas, and the patient underwent endovascular trapping. There were no neurological or other complications after the procedure. A follow-up MRI revealed complete thrombosis of the aneurysm. Our results show that endovascular trapping for pseudoaneurysm of the cervical internal carotid artery can be a reliable and effective treatment in patients who tolerate a balloon occlusion test.