Spontaneous carotid artery aneurysms

Infective Native Extracranial Carotid Artery Aneurysms: A Systematic Review

BACKGROUND

Infective native extracranial carotid artery aneurysms are rare, and their management is variable due to a lack of evidence assessing outcomes.

METHODS

We performed a systematic literature review following PRISMA guidelines to identify all reported cases of infective native extracranial carotid artery aneurysms between January 1970 and March 2021.

RESULTS

This study identified 193 infective native aneurysms of the extracranial carotid artery from 154 sources. Patients were predominantly male (71.4%), and age ranged from 6 months to 89 years old. The most common presenting features were a neck mass and fever, but also included hemorrhage, respiratory distress, and neurological symptoms. Most aneurysms were located in the internal carotid artery (47.4%). Staphylococcus (23.3%) was the most commonly identified causative pathogen, followed by Mycobacterium tuberculosis (20.9%). Most appeared to become infected by direct local spread. Treatment strategies involved open surgical methods in 101 cases and an endovascular approach in 41 cases. In 4 cases, a hybrid method involving concurrent endovascular and open surgical management was undertaken. In 5 cases, there was antibiotic treatment alone. In the open surgery-treated group, the complication rate was 20.8% compared to 13.2% in the endovascular group. Mortality rate was 5.6%.

CONCLUSIONS

Our review identified 193 cases of infective native extracranial carotid artery aneurysms. Direct local spread of a staphylococcus infection was the commonest cause. Endovascular management was associated with fewer early complications than open surgical management.

Etiology and treatment patterns of ruptured extracranial carotid artery aneurysm

OBJECTIVE

Rupture of an extracranial carotid artery aneurysm (ECAA) is a very rare and life-threatening condition. To obtain a comprehensive view of previous and current management of ruptured ECAAs (rECAAs), we analyzed all cases reported since 1940 and two of our own cases.

METHODS

We performed a comprehensive literature review of reports from the MEDLINE database on rECAAs and included two patients treated in our department.

RESULTS

A total 58 reports of 74 rECAAs in 74 patients were analyzed. Their mean age was 50 years, and the male/female ratio was 2.2:1. Infection was the most common reported etiology (19 of 74; 26%), followed by connective tissue disorder (13 of 74; 18%), atherosclerosis (9 of 74; 12%), and previous trauma (5 of 74; 7%). For 28 patients (38%), information on the etiology was not available. Of the 74 patients, 24 (32%) had undergone reconstructive surgery, 10 (14%) had undergone endovascular treatment, 17 (23%) had undergone ligation, 2 (3%) had been treated conservatively, and 1 (1%) had died before receiving definite treatment. For 20 patients (27%), information on the treatment received was not available. The complications after reconstruction included carotid blowout (3 of 24 patients; 13%) and cranial nerve deficit (3 of 24 patients; 13%). Two patients (8%) had died of unrelated ECAA causes during long-term follow-up, and one patient (4%) had died of an ECAA-related cause within 30 days. After an endovascular approach, 1 of the 10 patients had developed a cranial nerve deficit. After ligation, five patients (29%) had experienced stroke, three of which were fatal. One conservatively treated patient had experienced no complications and one had died of an ECAA-related cause.

CONCLUSIONS

The most common reported etiology for rECAA was infection. Reconstructive surgery was the most common approach and was safer than ligation, which carried a high risk of stroke. Endovascular treatment showed promising results, especially for distally located aneurysms; however, the number of patients has remained low.

Review of the neurological aspects of HIV infection

There are almost 40 million people in the world who live with the human immunodeficiency virus (HIV). The neurological manifestations associated with HIV contribute to significant morbidity and mortality despite the advances made with anti-retroviral therapy (ART). This review presents an approach to classification of neurological disorders in HIV, differentiating diseases due to the virus itself and those due to opportunistic infection. The effects of antiretroviral therapy are also discussed. The emphasis is on the developing world where advanced complications of HIV itself and infections such as tuberculosis (TB), toxoplasmosis and cryptococcal meningitis remain prevalent.

Management of extracranial carotid artery aneurysm

INTRODUCTION

Aneurysms of the extracranial carotid artery (ECAA) are rare. Several treatments have been developed over the last 20 years, yet the preferred method to treat ECAA remains unknown. This paper is a review of all available literature on the risk of complications and long-term outcome after conservative or invasive treatment of patients with ECAA.

METHODS

Reports on ECAA treatment until July 2014 were searched in PubMed and Embase using the key words aneurysm, carotid, extracranial, and therapy.

RESULTS

A total of 281 articles were identified. Selected articles were case reports (n = 179) or case series (n = 102). Papers with fewer than 10 patients were excluded, resulting in the final selection of 39 articles covering a total of 1,239 patients. Treatment consisted of either conservative treatment in 11% of the cases or invasive treatment in 89% of the cases. Invasive treatment comprised surgery in 94%, endovascular approach in 5%, and a hybrid approach in 1% of the patients. The most common complication described after invasive therapy was cranial nerve damage, which occurred in 11.8% of patients after surgery. The 30 day mortality rate and stroke rate in conservatively treated patients was 4.67% and 6.67%, after surgery 1.91% and 5.16%. Information on confounders in the present study was incomplete. Therefore, adjustments to correct for confounding by indication could not be done.

CONCLUSIONS

This review summarizes the largest available series in the literature on ECAA management. The number of ECAAs reported in current literature is scarce. The early and long-term outcome of invasive treatment in ECAA is favorable; however, cranial nerve damage after surgery occurs frequently. Unfortunately, due to limitations in reporting of results and confounding by indication in the available literature, it was not possible to determine the optimal treatment strategy. There is a need for a multicenter international registry to reveal the optimal treatment for ECAA.

HIV-associated large-vessel vasculopathy: a review of the current and emerging clinicopathological spectrum in vascular surgical practice

An established relationship exists between human immunodeficiency virus (HIV) and the vascular system, which is characterised by clinical expressions of aneurysmal and occlusive disease that emanate from a common pathological process. The exact pathogenesis is currently unknown; attempts to implicate opportunistic pathogens have been futile. Theories converge on leucocytoclastic vasculitis with the vaso vasora as the vasculopathic epicentre. It is thought that the virus itself or viral proteins trigger the release of inflammatory mediators that cause endothelial dysfunction and smooth muscle proliferation leading to vascular injury and thrombosis. The beneficial effects of highly active anti-retroviral therapy alter the natural history of the disease profile and promote longevity but are negated by cardiovascular complications. Atherosclerosis is an emerging challenge. Presently patients are managed by standard surgical protocols because of non-existent universal surgical interventional guidelines. Clinical response to treatment is variable and often compounded by complications of graft occlusion, sepsis and poor wound healing. The clinical, imaging and pathological observations position HIV-associated large-vessel vasculopathy as a unique entity. This review highlights the spectrum of HIV-associated large-vessel aneurysmal, occlusive and atherosclerotic disease in vascular surgical practice.

Ruptured large carotid artery aneurysm

Carotid artery aneurysms are rare [1]. Bifurcation of the common carotid artery is most frequently reported site of true aneurysm in the extracranial carotid system. Blunt injury of the neck involves high cervical portion of the internal carotid artery. Large aneurysms of the carotid artery can distort the anatomy and one can anticipate the intubation difficulties during anesthesia induction. A man aged 25 years, weighing 35 Kilograms was admitted in emergency with a large swelling (bleeding) on the right side of neck, covered with a bandage. In a rural hospital, biopsy was attempted, wounds were packed with gauze as there was profuse bleeding and referred the patient to our hospital. Spiral CT angiogram showed a large aneurysm arising from the bifurcation of the right common carotid artery. He complained of dysphagia for the past 20 days. In the CT scan the internal carotid artery was found to be occluded without neurological deficit. During surgery the common carotid, external carotid arteries were dissected out, clamped, ligated and thrombi were evacuated. The unhealthy and inflamed tissues were debrided. The wound was closed with a drain. Postoperative recovery was uneventful without neurological deficits.

Aneurysms of the Carotid Artery

Carotid artery aneurysms are an uncommon but important problem. The available data suggests that, untreated, these aneurysms lead to neurologic symptoms from embolization. Pseudoaneurysms of the carotid artery result from injury or may be the long-term sequelae of a spontaneous carotid dissection. While open surgery has been the primary mode of treatment, these aneurysms are being treated more commonly with endovascular approaches. This trend is partly the result of the increasing experience with the endovascular treatment of carotid artery stenosis. The endovascular approach offers advantages in other situations where open access to the distal extent of the aneurysm is difficult or neck radiation leads to concerns about wound healing. This article outlines the etiology, new diagnostic modalities, and treatment of aneurysms of the carotid artery.

Crohn's disease and Takayasu's arteritis

Takayasu's arteritis and inflammatory bowel disease are rarely found together in the reported literature. In particular, only one African-American patient with both Crohn's disease and Takayasu's arteritis has been reported. We present a case of an African-American patient previously diagnosed with Crohn's disease who subsequently developed Takayasu's arteritis and then presented with acute rectal bleeding. The differential diagnosis, diagnostic evaluation, and possible common pathophysiologic mechanism between the two diseases are discussed.