Εndovascular Repair of Extracranial Carotid Artery Aneurysms: A Systematic Review

Nonlinear biomechanical behaviour of extracranial carotid artery aneurysms in the framework of Windkessel effect via FSI technique

Extracranial carotid artery aneurysms (ECCA) lead to rupture and neurologic symptoms from embolisation, with potentially fatal outcomes. Investigating the biomechanical behaviour of EECA with blood flow dynamics is crucial for identifying regions more susceptible to rupture. A coupled three-dimensional (3D) Windkessel-framework and hyperelastic fluid-structure interaction (FSI) analysis of ECCAs with patient-specific geometries, was developed in this paper with a particular focus on hemodynamic parameters and the arterial wall's biomechanical response. The blood flow has been modelled as non-Newtonian, pulsatile, and turbulent. The biomechanical characteristics of the aneurysm and artery are characterised employing a 5-parameter Mooney-Rivlin hyperelasticity model. The Windkessel effect is also considered to efficiently simulate pressure profile of the outlets and to capture the dynamic changes over the cardiac cycle. The study found the aneurysm carotid artery exhibited the high levels of pressure, wall shear stress (WSS), oscillatory shear index (OSI), and relative residence time (RRT) compared to the healthy one. The deformation of the arterial wall and the corresponding von Mises (VM) stress were found significantly increased in aneurysm cases, in comparison to that of no aneurysm cases, which strongly correlated with the hemodynamic characteristics of the blood flow and the geometric features of the aneurysms. This escalation would intensify the risk of aneurysm wall rupture. These findings have critical implications for enhancing treatment strategies for patients with extracranial aneurysms.

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.

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."

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.

Endovascular coiling of recurrent trapped pseudoaneurysm of petrous ICA across the distal barrier: When the other way round is the only way around!

BACKGROUND

The pseudoaneurysms of the internal carotid artery (ICA) at the skull base form a unique subset of craniofacial pseudoaneurysms with varied diagnostic and therapeutic challenges. Recurrence in a surgically treated pseudoaneurysm may become a nightmare due to very limited number of open and endovascular options.

REPORT

We report a rare case of recurrent pseudoaneurysm of petrous ICA, which presented with massive epistaxis following an initial successful occlusion by surgical trapping of the parent arterial segment with surgical clip. Cerebral angiography revealed filling of the pseudoaneurysm by small arterial channels from the external carotid, contralateral internal carotid and basilar arterial branches and emptying through the "slipped" distal clip. After a meticulous analysis of the cerebral angiogram, the recurrent pseudoaneurysm was eventually embolized retrogradely through the "slipped" clip after crossing the anterior communicating artery taking a contralateral internal carotid access.

CONCLUSION

Scrupulous planning and execution of ICA pseudoaneurysms is necessary to prevent recurrence. Naturally occuring collateral routes through the Circle of Willis aid in treatment of "unreachable" vascular lesions.

Management strategy for extracranial carotid artery aneurysms: A single-center experience

ABSTRACT

This single-center, retrospective study aimed to describe the anatomic and clinical characteristics of extracranial carotid artery aneurysms (ECAAs) and to compare various ECAA management strategies in terms of outcomes.A total of 41 consecutive patients, who underwent treatment for ECAAs between November 1996 and May 2020, were included in this study. The ECAAs were anatomically categorized using the Attigah and Peking Union Medical College Hospital (PUMCH) classifications. The possible study outcomes were restenosis or occlusion of the ipsilateral carotid artery after treatment and treatment-associated morbidity or mortality.The 41 patients were stratified into three groups according to the management strategies employed: surgical (n = 25, 61.0%), endovascular (n = 10, 24.4%), and conservative treatment (n = 6, 14.6%). A palpable, pulsatile mass was the most common clinical manifestation (n = 16, 39.0%), and degenerative aneurysms (n = 29, 65.9%) represented the most common pathogenetic or etiological mechanism. According to the Attigah classification, type I ECAAs (n = 24, 58.5%) were the most common. Using the PUMCH classification, type I ECAAs (n = 26, 63.4%) were the most common. There was a higher prevalence of Attigah type I ECAAs among patients who underwent surgical treatment compared with those who underwent endovascular treatment (64.0% vs 40.0%, P = .09), whereas patients with PUMCH type IIa aneurysms were more likely to receive endovascular treatment (12.0% vs 30.0%). False aneurysms were more likely to be treated using endovascular techniques (20% vs 70%, P = 0.02). Except for two early internal carotid artery occlusions (one each among patients who underwent surgical and endovascular treatments, respectively), there were no early or late restenoses or occlusions during follow-up. Cranial nerve injuries were noted in three patients after surgical treatment, and late ipsilateral strokes occurred in two patients (one each among patients who underwent endovascular and conservative treatment, respectively). There were no other treatment-associated complications or deaths during the study period.

CONCLUSIONS

Both surgical and endovascular treatments could be performed safely for ECAAs with good long-term results according to anatomic location and morphology.

Surgical Management of a Type II Extracranial Internal Carotid Aneurysm near to the Skull Base

True aneurysmal disease in the carotid arteries is very uncommon, but individuals with this pathology face the grave risk of thromboembolism, which may consequently lead to cerebrovascular accidents. Clinical knowledge remains relatively limited owing to its rarity. We present the case of a 41-year-old obese female with a type II right extracranial internal carotid artery aneurysm incidentally found during imaging work-up. She underwent open surgical reconstruction with an autologous interposition graft from the common carotid artery to the internal carotid artery at the base level of the skull. Her postoperative period was uneventful, and the patient was discharged on postoperative day five with aspirin. At 12 months of follow-up, the patient remained symptom-free without complications.

Open versus endovascular repair for extracranial carotid aneurysms

BACKGROUND

Extracranial carotid artery aneurysms (ECCAs) are rare; however, they are associated with a high risk of stroke and mortality if untreated. In the present review, we compared the major outcomes between open and endovascular repair of ECCAs.

METHODS

We systematically searched PubMed, Embase, Scopus, and the Cochrane Library for clinical studies reported online up to September 2020 that had evaluated major outcomes after both open and endovascular repair of ECCAs. Eligible studies were required to have evaluated at least the 30-day mortality or stroke and/or transient ischemic attack rates. The quality of the studies was also evaluated.

RESULTS

Overall, seven studies (three high quality, two medium quality, and two low quality) with 374 patients and 383 ECCAs were eligible. All the studies had been reported from 2004 to 2020. In total, 220 open repairs were compared with 81 endovascular repairs. The open and endovascular treatments showed similar 30-day mortality rates (4% vs 0%; pooled odds ratio [OR], 2.67; 95% confidence interval [CI], 0.291-24.451) and stroke and transient ischemic attack rates (5.5% vs 1.2%; pooled OR, 1.42; 95% CI, 0.412-4.886). Open repair was associated in six studies with a greater incidence of cranial nerve injury compared with endovascular repair (14.5% vs 0%; OR, 3.98; 95% CI, 1.178-13.471). The hematoma or bleeding rate was also similar between the two methods in six studies (5.2% vs 0%; OR, 1.92; 95% CI, 0.518-7.094).

CONCLUSIONS

Open and endovascular repair of ECCAs is associated with similarly low early mortality and cerebrovascular event rates, although open repair showed a greater risk of cranial nerve injuries. An endovascular approach could be more appropriate when the aneurysm is located distally or requires extensive dissection. More studies are needed with standardized follow-up durations to evaluate late outcomes.

Acute Nonruptured Expansion of Extracranial Carotid Artery Aneurysm. An Infrequent Clinical Presentation

The extracranial carotid artery aneurysms are a rare disease, representing a low percentage of peripheral aneurysms (0.4-4%). Their main symptoms are derived from cerebral events and local compression, with rupture being rare. We report the case of a 79-year-old woman who presented with a right Common Carotid Artery aneurysm with pain and local symptoms. The expansion of the aneurysm is documented with images and the surgical treatment consisting of bypass from Common Carotid artery to Internal Carotid artery with Dacron prosthesis and reimplantation of External Carotid artery is described and discussed. To the best of our knowledge, this is the first case of expansion directly documented in the literature.

Endovascular and Hybrid Interventions for Extracranial Juxta-Skullbase Carotid Artery Aneurysms: Experience and Long-Term Results

BACKGROUND

Hybrid and endovascular procedures maybe effective and less invasive alternatives to open surgery for treatment of extracranial carotid artery aneurysm (ECAA), but the optimal management of juxta-skullbase ECAA is controversial.

OBJECTIVE

This study evaluated the long-term effects of hybrid and endovascular procedures in treating juxta-skullbase ECAA.

METHODS

The records of 9 consecutive patients who underwent hybrid or endovascular interventions for juxta-skullbase ECAA in a single center from April 2014 to May 2020 were retrospectively reviewed.

RESULTS

Four patients presented with a pulsating mass, 1 with dysphagia, 1 with pain in the left temporal region, 1 with dizziness and headache, 1 with cerebral infarction, and 1 with dizziness and cerebral infarction. Seven true aneurysms, 1 false aneurysm, and 1 dissecting aneurysm were diagnosed with CTA in the 9 patients (mean age, 50.8±20.3 years; 1 male). The aneurysms were divided into two subgroups: 4 type I, and 5 type IIb according to a recent classification. Per schedule, 7 patients (4 type I and 3 type IIb) were treated with endovascular intervention, and 2 (type IIb) were treated with hybrid procedures. The technique success rate was 88.9%. One patient (type IIb) who was scheduled to be treated with an endovascular procedure was transferred to a hybrid procedure because of failure of the endovascular procedure. Eleven covered stents were implanted to exclude the aneurysms. During follow-up (mean duration 31.2±23.2 months), all aneurysms were proven excluded, no significant complication occurred, and preoperative symptoms resolved. One patient (type I) in the endovascular group had occlusion of the internal carotid artery but no symptoms; the internal carotid artery was patent in the other 8 patients.

CONCLUSIONS

Hybrid and endovascular procedures were found effective and durable alternatives to open operation for treatment of extracranial juxta-skullbase carotid aneurysm.

Endovascular treatment of blunt injury of the extracranial internal carotid artery: the prospect and dilemma

The extracranial internal carotid artery (ICA) refers to the anatomic location that reaches from the common carotid artery proximally to the skull base distally. The extracranial ICA belongs to the C1 segment of the Bouthillier classification and is at considerable risk for injury. Currently, the understanding of endovascular treatment (EVT) for blunt injury of the extracranial ICA is limited, and a comprehensive review is therefore important. In this review, we found that extracranial ICA blunt injury should be identified in patients presenting after blunt trauma, including classical dissection, pseudoaneurysm, and stenosis/occlusion. Computed tomography angiography (CTA) is the first-line method for screening for extracranial ICA blunt injury, although digital subtraction angiography (DSA) remains the "gold standard" in imaging. Antithrombotic treatment is effective for stroke prevention. However, routine EVT in the form of stenting should be reserved for patients with prolonged neurological symptoms from arterial stenosis or considerably enlarged pseudoaneurysm. Endovascular repair is now emerging as a favored therapeutic option given its demonstrated safety and positive clinical and radiographic outcomes.

Endovascular techniques in the treatment of extracranial carotid artery aneurysms

OBJECTIVE

Carotid artery aneurysms and pseudoaneurysms (extracranial carotid artery aneurysm [ECCAs]) are relatively rare. The gold standard treatment has historically been open repair; however, there is increasing evidence of successful treatment of ECCAs with endovascular techniques. Our study examines the evolving experience with endovascular management of ECCAs at a tertiary care center.

METHODS

We performed a retrospective analysis of patients with ECCAs who underwent endovascular interventions at a single institution from 2010 to 2020. With increasing experience, the techniques evolved from covered stents to stent-assisted coil embolization and finally to braided stents and overlapping closed cell stents.

RESULTS

There were 18 ECCAs in 17 patients treated with endovascular modalities. The average age was 65.9 years. There were 11 males (64.7%). Seven aneurysms (38.9%) were symptomatic: three patients had painless pulsatile masses, three patients had painful pulsatile masses, and one had transient ischemia attacks. Two (11.1%) were treated with covered stents, 2 (11.1%) were treated with stent-assisted embolization, 2 (11.1%) were treated with flow-diverting braided stents, 10 (55.6%) were treated with overlapping bare metal stents, and 2 (11.1%) were treated with embolization or ligation alone. Technical success was achieved in all patients. The mean duration of follow up was 338 days (range, 8-3039 days). No perioperative or postoperative complications were encountered, including no neurologic deficits and no embolic events. All patients were discharged on postoperative day 1 or 2. All 16 stents (100%) retained vessel patency on follow-up imaging and exclusion of ECCAs was confirmed on postprocedure surveillance imaging.

CONCLUSIONS

Endovascular modalities for the management of ECCAs have evolved with experience. Our study suggests that endovascular management is technically feasible as well as clinically effective and suggests an algorithm for navigating the various treatment modalities.