Open versus endovascular repair for extracranial carotid aneurysms

Incidental neck mass in a young adult: A case report

INTRODUCTION

While true extracranial internal carotid aneurysms (tECAAs) are extremely rare and often asymptomatic, they can lead to serious complications including rupture, thrombosis or embolization. Surgery has been the standard, even in asymptomatic patients, due to safety and long-term outcomes. However, advancements in technology have introduced endovascular interventions and observation as options.

PRESENTATION OF CASE

A 32-year-old obese man presented with sudden right-sided facial numbness lasting 3 h. Personal, family, social and trauma history were unremarkable. Cardiac and neurological examinations were normal. Imaging revealed a non-flow-limiting stenosis and a left internal carotid saccular artery aneurysm (15 × 16 mm). After considering the pros and cons of each treatment and thorough shared decision-making, left carotid stenting (6 × 25 mm ViabahnGORE) was performed. The postoperative course was uneventful. Patient was discharged on the postoperative day 2 with Clopidogrel.

DISCUSSION

The choice of treatment approach for tECAAs depends on various factors, including patient characteristics, surgeon experience, and equipment availability. In general, symptomatic aneurysms (regardless of diameter), expanding aneurysms, and larger aneurysms (>20 mm), and those with identified thrombus are typically indications for repair.

CONCLUSION

Endovascular techniques are gaining traction due to their potential advantages, including avoidance of cranial nerve injury and general anesthesia, enhanced access and control of lesions that may be difficult to navigate surgically, and lower rates of perioperative morbidity and mortality.

Advancements in Endovascular Treatment of Extracranial Carotid Artery Aneurysms

OBJECTIVE

Traditionally, extracranial carotid artery aneurysms or pseudoaneurysms (ECCAs) have been managed through open surgical repair. Recent literature highlights the increasing success of endovascular techniques in treating ECCAs. Our study explores our center's experience with endovascular management of ECCAs, including the innovative use of Transcarotid Artery Revascularization (TCAR) at a tertiary care center.

METHODS

We performed a retrospective analysis of patients with ECCAs who underwent endovascular intervention at a single institution. We examined our database from the period of 2010 to 2024. Our treatment modalities have expanded to include covered stenting, stent-assisted coil embolization, braided stents, overlapping closed-cell stents, and most recently Transcarotid Artery Revascularization (TCAR).

RESULTS

There were 29 extracranial carotid artery aneurysms in 27 patients treated with various endovascular modalities. The average age was 67.6 years, with 17 (63.0%) males and 10 (37.0%) females. 8 (29.6%) patients had prior ipsilateral carotid intervention. 9 (31.0%) aneurysms were symptomatic. The most common etiology was idiopathic, with 16 (55.2%) aneurysms being spontaneous. Treatment modalities included: 2 (6.9%) treated with covered stents, 2 (6.9%) with stent-assisted embolization, 3 (10.3%) with flow-diverting braided stents, 3 (10.3%) with embolization or ligation alone, 17 (58.6%) with overlapping bare metal stents via femoral or radial access, and 2 (6.9%) with overlapping bare metal stents via TCAR. Technical success was achieved in all patients. The mean follow-up duration was 236 days (range: 2 to 3039 days). No perioperative or post-operative complications occurred, including no neurological deficits or embolic events. All patients were discharged on post-operative day 1 or 2. All 29 (100%) stents maintained vessel patency on follow-up imaging, and exclusion of ECCAs was confirmed on post-procedure surveillance imaging.

CONCLUSION

Our study highlights that endovascular therapy is effective in managing ECCAs, with high patency rates and a favorable procedural safety profile.

Extracranial internal carotid artery aneurysm: Surgical approach to a rare entity

BACKGROUND

Extracranial internal carotid artery aneurysms are rare entities that arise within the carotid triangle. Although rare, they are clinically significant due to the risk of neurologic thromboembolic events, compression of cranial nerves and vasculature, rupture, and ischemia.

OBJECTIVE

Surgery is the gold-standard treatment for symptomatic patients of all ages with extracranial internal carotid artery aneurysm.

METHOD

A 26-year-old female patient was admitted to our institution with complaints of left auricular pain, hoarseness, and uncontrollable hypertension. She had a pulsatile mass located at the left cervical region. After diagnosing the extracranial internal carotid artery aneurysm, it was decided that surgery was necessary to relieve the patient's discomfort and prevent possible complications from the aneurysm in the left carotid artery.

RESULT

In the operation, the aneurysmatic segment was resected and sent for histopathological evaluation. Saphenous vein graft was interposed as end to end anastomosis to the proximal and distal healthy segments of the internal carotid artery.

CONCLUSION

This case report highlights the surgical management of a 26-year-old female patient who presented to our institution with complaints of left auricular pain, hoarseness, uncontrolled hypertension, and a pulsatile mass localized at the left cervical region and diagnosed extracranial internal carotid artery aneurysm.

Giant cell arteritis as a cause of extracranial internal carotid artery aneurysm: a case report

BACKGROUND

This report presents the management of patient with extracranial internal carotid artery pseudoaneurysm due to giant cell arteritis.

CASE PRESENTATION

Left internal carotid artery pseudoaneurysm was diagnosed in a 57-year-old Ukrainian woman, which became a direct indication for surgical treatment involving aneurysm resection and internal carotid artery reimplantation. The used reconstruction technique with oblique cutting of internal carotid artery, aneurysm resection, ellipse-form anastomosis formation, and distal intima fixation prevents the dissection, restenosis, and aneurysm of anastomosis in the long-term postoperative period. Histopathological examination revealed the giant cell arteritis of the internal carotid artery.

CONCLUSION

This case emphasizes the importance of open surgical treatment of extracranial carotid artery aneurysms, which allows to perform optimal carotid artery reconstruction and also define the rare etiology of disease.

Trans-Cervical Endovascular Management of Saccular Aneurysm of the Extracranial Internal Carotid Artery Using a Self-Expanding Nitinol Base ePTFE Covered Stent

Saccular aneurysm of the extracranial internal carotid artery is rare. We present a 56-year-old lady presented with a progressively enlarging pulsatile swelling over the right neck, and the right internal carotid artery aneurysm was successfully treated with trans-carotid endovascular stenting of right common to right carotid artery using a self-expanding nitinol base ePTFE covered stent (COVERA Plus™ stent, Bard, Tempe, USA). The external carotid artery was prophylactically embolised to prevent back bleeding. New generation covered stents have consistently improved flexibility and conformability, and this is to our knowledge the first reported case in the world's literature of using this type of self-expanding nitinol base ePTFE covered stent in endovascular stenting of carotid artery aneurysms, with excellent short-term results.

Viabahn™-assisted sutureless anastomosis (VASA) repair of a complex internal carotid artery aneurysm

Extracranial carotid artery aneurysms (CAAs) are extremely rare and often require surgical intervention to avoid complications such as local compression symptoms and thrombo-embolization. We present the case of a 63-year-old man with a history of hypertension, meningioma, and an incidental finding of a right saccular internal carotid artery aneurysm at the base of the skull. He underwent open surgical repair; nonetheless, end-to-end anastomosis was not feasible. As bailout, the internal carotid artery was successfully reconstructed with a novel Viabahn-assisted sutureless anastomosis technique (GORE, Viabahn). Postoperative clinical assessment revealed no complications, postoperative computed tomography angiography revealed a patent reconstruction, and the patient was discharged home uneventfully with 1-year clinical and computed tomography angiography follow-up without remarks. Hybrid procedure is a viable option for technically challenging carotid anastomoses near the skull base.

Extracranial Carotid Artery Aneurysms: 20-Year Experience of Surgical Management

Extracranial carotid artery aneurysm (ECAA) is a rare vascularpathology with reported incidence of 0.2-5.0% of all carotid artery surgical interventions. Most of ECAAs remain clinically asymptomatic, however, they can manifest in neurological symptoms as transient ischemic attack or stroke. The presence of a pulsating formation, swallowing disorders, signs of compression of cranial nerves may beindicative of the aneurysm growth, which is associated with higher risk of thromboembolic complications and less oftenwith rupture. Surgical treatment is a method of choice in symptomatic patients or in cases of the aneurysm growth and includes resection with arterial reconstruction, ligation of the artery or endovascular intervention. The aim. To improve the results of surgical treatment of ECAAs. Materials and methods. The results of clinical examination, laboratory, instrumental, intraoperative observations were analyzed in 39 patients (35 [89.7%] men and 4 [10.3%] women) with 44 ECAAs, who were admitted to the Vascular Surgery Department of Lviv Regional Clinical Hospital for the period from 2003 to 2022. To conϐirm the diagnosis of ECAA, preoperative instrumental examination included duplex ultrasonography and multispiral computed tomography angiography. Results. Etiological causes of ECAAs included: atherosclerosis (79.5%),ϐibromuscular dysplasia (7.7%), trauma (5.1%), previous operations in the neck region (5.1%) and infection (2.6%). The justiϐication of the choice of surgical tactics depended on the localization of aneurysm, concomitant carotid occlusive disease or pathological deviation of carotid arteries. Early results of surgical treatment were evaluated up to 30 days of the postoperative period. The postoperative complications included: transient ischemic attack in 1 (2.6%), ischemic stroke in 2 (5.1%), cranial nerve damages in 4 (10.3%), thrombosis of arterial reconstruction in 2 (5.1%), hematoma of postoperative wound in 4 (10.3%), infection of postoperative wound in 1 (2.6%) cases. Postoperative mortality was 2.6%. Conclusion. ECAA is a rare clinical disease that requires an active surgical approach to reduce the risk of ischemic stroke. Reconstructive surgery of ECAAs is a highly effective method of treatment that allows to achieve satisfactory results and prevent the development of severe complications.