Surgical Treatment of Post-Carotid Endarterectomy Carotid Pseudoaneurysm

Successful treatment of iatrogenic internal carotid artery pseudoaneurysm following carotid endarterectomy with thrombin injection: a case report

BACKGROUND

Iatrogenic pseudoaneurysms arising from the internal carotid artery subsequent to carotid endarterectomy are exceptionally infrequent. Herein, we present a case detailing an internal carotid artery pseudoaneurysm that manifested subsequent to a hybrid carotid endarterectomy and endovascular therapy intervention. Our approach to managing this condition involved a novel technique wherein thrombin was directly injected into the luminal cavity of the pseudoaneurysm under the guidance of a C-arm.

CASE PRESENTATION

A 66-year-old male patient of Chinese ethnicity exhibited a 4-month history of headache and a 20-day history of gait disturbance. Digital subtraction angiography revealed occlusion in the cervical region of the left carotid artery. Following a hybrid surgical procedure, the patient reported mild pain and bruising surrounding the incision site of the left internal carotid artery endarterectomy. Subsequent angiography identified the presence of a carotid artery pseudoaneurysm. Utilizing C-arm guidance, thrombin was then directly injected into the luminal cavity of the pseudoaneurysm, resulting in complete healing during follow-up.

CONCLUSION

For the management of pseudoaneurysms arising post carotid endarterectomy, the direct injection of thrombin into the aneurysm cavity under the guidance of a C-arm is deemed both safe and efficacious.

Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications

Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.

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.

Acquired Carotid-Jugular Fistula Secondary to a Pseudoaneurysm Following Carotid Endarterectomy

Acquired arteriovenous fistulas involving the carotid artery are most frequently the result of trauma and iatrogenic causes such as central venous catheterisation. Occasionally, they may develop spontaneously due to erosion of an aneurysm into an adjacent vein. We report a rare case of an acquired carotid-jugular fistula secondary to a pseudoaneurysm that occurred four months following carotid endarterectomy.