Common carotid pseudoaneurysm after carotid endarterectomy: a case presentation

Abstract

A patient with a previous history of neck cancer and carotid endarterectomy presents with a pulsatile cervical mass. Further evaluation reveals the presence of a pseudoaneurysm of the common carotid artery. The endovascular treatment options and techniques employed to exclude the pseudoaneurysm are presented and discussed.Key words: carotid pseudoaneurysm; carotid stent; stent graft Case presentationA 64-year-old white male presented with a 4-cm, pulsatile mass in his left mid neck. The tissue covering this mass was extremely thin. He stated he had no fever, chills, drainage or redness at the site. The mass had first been noticed approximately 1 year previously, but over the past month had become alarmingly bigger. He presented as an emergency to our institution with pain in the pulsatile mass.Fourteen years ago, he was treated for neck cancer (squamous cell) with radical neck dissection and radiation. Twenty-four months ago, he underwent a left carotid endarterectomy which was complicated by laryngeal nerve injury and dysphagia. Twenty months ago, he underwent a right carotid endarterectomy which was complicated by stroke. His stroke recovery had been nearly complete.His past medical history was significant for hypertension, hypothyroidism, and COPD secondary to cigarette smoking. His medical regimen included: fluvastatin (Lescol; Novartis, Inc.) 20 mg qd; levothyroxine (Levoxyl; Jones Pharma, Inc.) 200 mg qd; aspirin 325 mg qd; omeprazole (Prilosec; Astra Zeneca) 20 mg qd; atenolol 100 mg qd; albuterol=ipratropium (Combivent; Boehringer Ingelheim, Inc.) inhaler prn. At the time of his physical exam, his blood pressure was 170=98 mmHg on the left and 190=102 mmHg on the right. The 4-cm neck mass was protruding from firm, sclerotic skin and was purplish in color. There were no bruits in the neck or subclavian areas. Superficial temporal signals, and carotid and radial pulses were normal. Neurologic findings were normal except for a harsh and raspy voice. Diagnostic work-upExtensive work-up at an outside facility, prior to our evaluation, included an MRA (2 months prior), a carotid arteriogram (1½ months prior), and a CTA (1 month prior); however, no treatment was rendered. Our evaluation started with a duplex ultrasound, which revealed an ectatic left common carotid artery. Emergent arteriography was then performed. The arteriogram confirmed the presence of a large pseudoaneurysm of the left common carotid artery. Figure 1 displays the angiographic findings with the diameters obtained from the duplex scan. Duplex also demonstrated a laminar thrombus throughout the left common carotid and proximal internal carotid arteries.Arteriography also demonstrated an aortic arch with the innominate and the left common carotid sharing a common origin. The left external carotid artery was patent. The entire ectatic segment of the carotid artery measured approximately 90 mm in length, coinciding with the previous endarterectomy site which extended from the base of the skull into the arch (Figure 1).

Diagnosing Pseudoaneurysm of the Extracranial Carotid Arteries Using Doppler Ultrasonography: A Case Report

“…10 Although there are cases of patients presenting with neurological deficits and stroke secondary to a PA, the most common presentation appears to be a new neck swelling, which may or may not be painful, with no systemic symptoms. 4,5,16 Doppler US is considered the first-line diagnostic investigation of the extracranial carotid arteries 13 and is essential in determining the level of disease, stenosis, and any arterial abnormalities. 13,17 In this case, the combined use of B-mode, color and spectral Doppler US imaging were essential in providing information to grade the initial stenosis and subsequently identify the PA.…”

“…10 Although there are cases of patients presenting with neurological deficits and stroke secondary to a PA, the most common presentation appears to be a new neck swelling, which may or may not be painful, with no systemic symptoms. 4,5,16…”

Endovascular repair of a post-traumatic right common carotid artery pseudoaneurysm

“…1,4 In contrast, endovascular repair is a minimally invasive, safe, and effective alternative to surgical repair. 2,3 Endovascular repair can be performed by a PTFE-covered self-expanding stent-graft deployment, 1–3,5 as done in this case. There is a risk of stent thrombosis and restenosis with stent-graft placement; 2,3,5 however, thus far, our patient has had a favorable clinical outcome and continues to be followed.…”

Postendarterectomy Common Carotid Artery Pseudoaneurysm

“…Pseudoaneurysm (PSA) formation is an uncommon but well-recognized complication after carotid endarterectomy (CEA), 1 most frequently described after patch angioplasty following longitudinal arteriotomy of the common carotid artery (CCA) and the internal carotid artery (ICA) for the treatment of atherosclerotic disease. [2][3][4] Infection is most frequently identified as a cause of PSA formation, either through suture-line failure or after bacterial colonization of the patch material. 2 When diagnosed, PSA of the carotid artery requires surgical or endovascular treatment to prevent PSA thrombosis, 3,4 potentially fatal embolization from the thrombotic material often present within the PSA, hemorrhage after rupture, or compression on the adjacent structures.…”

“…[2][3][4] Infection is most frequently identified as a cause of PSA formation, either through suture-line failure or after bacterial colonization of the patch material. 2 When diagnosed, PSA of the carotid artery requires surgical or endovascular treatment to prevent PSA thrombosis, 3,4 potentially fatal embolization from the thrombotic material often present within the PSA, hemorrhage after rupture, or compression on the adjacent structures. We present a case of a symptomatic common carotid PSA that occurred 14 months after eversion CEA.…”