Contemporary Outcomes of Open and Endovascular Intervention for Extracranial Carotid Artery Aneurysms: A Single Centre Experience

Abstract

WHAT THIS PAPER ADDS This study retrospectively reviewed 57 cases of extracranial carotid aneurysm treated by open and endovascular surgery with mid term follow up. Outcomes of the two therapy groups were analysed. Endovascular surgery may be a safe and durable method for selected aneurysms, while for severe tortuous aneurysms, endovascular surgery alone may be difficult to apply.Objective: The objective of this study was to evaluate the outcomes of open surgery (OS) and endovascular surgery (ES) for extracranial carotid aneurysm (ECCA) in the authors' centre. Methods: Fifty-seven consecutive patients who were diagnosed with ECCA and underwent intervention from January 2005 to July 2019 at Zhongshan Hospital, Fudan University, were reviewed retrospectively. Patient characteristics and surgical outcomes for OS and ES were analysed. ECCAs were divided into three morphological subgroups: subgroup I, no severe tortuosity of the internal carotid artery (ICA) or common carotid artery (CCA) proximal to the aneurysm, tortuosity of the aneurysm and 1 cm of peri-aneurysmal carotid artery 90 ; subgroup II, severe ICA or CCA tortuosity proximal to the aneurysm, tortuosity of the aneurysm and 1 cm of peri-aneurysmal carotid artery 90 ; subgroup III, aneurysm tortuosity and 1 cm perianeurysmal carotid artery > 90 . Results: 35 patients underwent OS, 20 patients underwent ES and 2 patients underwent OS after the failure of ES. Thirty-six cases were classified in subgroup I, 11 cases in subgroup II, and 10 cases in subgroup III. ES was achieved successfully in all 18 cases of subgroup I, but failed in three of four cases in subgroups II and III. With a mean duration of 62.9 AE 44.5 months of follow up, five deaths were recorded in the OS group, two of which were caused by ipsilateral stroke and three were not neurologically related. There was no stroke or death in the ES group during follow up. One case of stroke and two cases of death occurred in symptomatic patients, while one case of stroke and three cases of death occurred in asymptomatic patients. Conclusion:This series demonstrates that ES may be a safe and durable option for ECCA in subgroup I, while in subgroups II and III, ES alone may be difficult to apply. A 30 day stroke rate around 5% existed in ECCAs with interventions, which should be considered before the intervention.

High-flow bypass surgery using a radial artery graft for an extracranial internal carotid artery aneurysm: Case reports and literature review

“…[ 2 , 11 ] The risk for iatrogenic cranial nerve injury is 2.2–44% and particularly high when the aneurysm is located at a high cervical level. [ 2 , 7 , 11 - 13 ] Therefore, the addition of reconstruction to the basic strategy is recommended when the aneurysm can be approached easily, and repair should not be attempted when there is strong adhesion to surrounding tissues or when the aneurysm is at a high cervical level. [ 6 ] The aneurysms of our patients were on a high cervical level; this rendered exposure of the distal neck difficult and we considered incomplete direct aneurysmal repair dangerous.…”

“…Some extracranial carotid artery aneurysms can be addressed endovascularly. [ 1 , 5 , 9 , 13 ] As exposure of the aneurysmal neck, even of aneurysms at a high cervical level, is not necessary, cranial nerve injury is avoidable. [ 4 , 7 , 9 , 11 , 13 ] However, endovascular procedures are not risk-free.…”

“…[ 1 , 5 , 9 , 13 ] As exposure of the aneurysmal neck, even of aneurysms at a high cervical level, is not necessary, cranial nerve injury is avoidable. [ 4 , 7 , 9 , 11 , 13 ] However, endovascular procedures are not risk-free. Stroke, aneurysmal rupture, and blood vessel damage have been reported[ 1 , 9 ] after endovascular stenting of ECA aneurysms; 4.1% of patients died, 1.8% suffered a stroke, 6.3% a late stroke, and in 1% the carotid artery ruptured.…”

“…[ 9 ] The treatment of highly tortuous or kinked carotid artery aneurysms is difficult. [ 1 , 5 , 7 , 13 ] Because our patients presented with severe aneurysmal tortuosity, we ruled out endovascular treatment. Advances in technology and instrumentation and the accumulation of information are needed to increase the number of patients whose aneurysms can be treated endovascularly.…”

“…While the rupture rate is low, the morbidity and mortality rates are high and aggressive treatment is recommended. [ 2 , 8 , 9 , 11 - 13 ] Even with various surgical methods, their treatment is difficult especially when the aneurysms are tortuous and located at a high cervical level. [ 2 , 7 , 8 , 11 - 13 ] We report two patients whose tortuous extracranial internal carotid artery (ICA) aneurysms at a high cervical level were successfully treated with a high-flow bypass using a radial artery (RA) graft between the external carotid artery (ECA) and the middle cerebral artery (MCA) (ECA-RA-M2 portion).…”