|Ahead of print
Common carotid artery pseudoaneurysm: A perilous powderkeg
Sakshi Kadian1, Rudrashish Haldar2, Nitin Trivedi2
1 Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand
2 Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||07-Aug-2021|
|Date of Decision||15-Oct-2021|
|Date of Acceptance||26-Dec-2021|
|Date of Web Publication||30-Jan-2023|
Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareilly Road, Lucknow, Uttar Pradesh 226014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
An 11-year-old boy presented with pseudoaneurysm of the common carotid artery, which posed an anaesthetic and surgical challenge. Just prior to the incision, the pseudoaneurysm ruptured necessitating manual compression and emergent endovascular coiling to arrest the bleeding. Appropriate resuscitative steps were undertaken simultaneously, and the coiling was successful thereby saving the patient. Definitive flap reconstruction was later performed. The case report highlights vulnerability of pseudoaneurysms to rupture without warning and causing torrential and life-threatening hemorrhage. The necessity of prior planning and preparation to manage such an emergency should it arise cannot be overemphasized.
Keywords: Aneurysm, carotid artery, computed tomography angiography, endovascular procedure
| Introduction|| |
Extracranial carotid artery aneurysms (ECCAs) are uncommon (1%), and isolated aneurysms of the extracranial carotid artery are even rarer.,, These aneurysms can be true aneurysms involving all layers of the carotid arterial wall or pseudoaneurysms representing blood collection held by a wall of connective tissue and not involving the vessel wall.,, They carry the risk of impending rupture heralding catastrophic hemorrhage. Open surgical repair remains the appropriate strategy for ECCA, although recently endovascular approach has gained popularity. We report (after prior written and informed consent from the patient’s parents) the sequence of management of a large left common carotid artery aneurysm in an 11-year-old boy and the successful outcome of the case, despite a tumultuous course.
| Case Report|| |
An 11-year-old male presented to the emergency department with complaint of large swelling on the left neck for past 10 days which had developed and was growing rapidly after sustaining a firecracker injury [Figure 1]A. He also had difficulty in mouth opening (interincisor gap of 1 cm) and hoarseness of voice. Magnetic resonance angiography (MRA) evaluation revealed large left common carotid artery pseudoaneurysm measuring 10 × 9×7 cm [Figure 2]B. Chest roentgenogram suggested tracheal deviation toward the opposite side. Rest of the preanesthetic examination was normal. The patient was planned for open surgical resection on the next day. Adequate blood products were requisitioned beforehand anticipating heavy bleeding and drills for transfusion and resuscitation, involving that all members of the anesthesia teams were undertaken in case of massive hemorrhage. On the day of surgery after confirming all the resuscitative measures to be in place, the patient was wheeled in the operation theater. Awake fiberoptic intubation was planned after topical anesthesia of the airway. Two wide bore intravenous accesses were obtained, and under dexmedetomidine sedation, airway was secured with a size 6.5 mm endotracheal tube. General anesthesia was then induced using propofol (50 mg,) injection vecuronium (5 mg) and maintained with oxygen, air, and sevofluorane at 1 MAC. Right subclavian vein cannulation was performed. However, during the cleaning and draping just prior to incision, the pseudoaneurysm ruptured and started bleeding profusely. Neurosurgical team tried to arrest the bleeding using manual compression but were unsuccessful. Considering the imminent catastrophe, the patient was immediately shifted for endovascular coiling where it commenced via femoral arterial access under radiological guidance. During the entire process of endovascular coiling, attending anesthesiologists kept resuscitating the patient with crystalloids, colloids, and blood products. Persistent bleeding despite resuscitation necessitated noradrenaline infusion to maintain hemodynamics. Endovascular coiling could be successfully performed within 30 minutes, and bleeding was arrested [Figure 2]A. Total blood loss was about 9000 mL which required transfusion of 12 U of packed red blood cells, 12 U of fresh frozen plasma, and 12 U of random donor platelets (RDPs). Serial arterial blood gases were also performed, and metabolic corrections were done accordingly with 10% calcium gluconate and sodium bicarbonate. A thromboelastogram was performed at the end of procedure and based on that another 4 U of RDPs were transfused. After 2 h of the endovascular procedure and continuous resuscitative efforts, blood gases started to normalize and the patient was sedated and put on overnight mechanical ventilation under dexmedetomidine sedation. Vasopressor support was tapered gradually and could be stopped completely by 10 h. Next morning, the patient’s respiratory efforts resumed and excision of the necrotic tissue [Figure 2]B and flap reconstruction were planned. The procedure was conducted uneventfully and the patient could be extubated the next morning after overnight ventilation. The patient was discharged with no neurological deficit after 7 days.
|Figure 1: (A) Picture of the pseudoaneurysm at presentation. (B) Digital subtraction angiography image showing anatomy of major vessels along with pseudoaneurysm|
Click here to view
|Figure 2: (A) Digital subtraction angiography image showing successful coiling of pseudoaneurysm of the right common carotid artery. (B) Flap reconstruction over the pseudoaneurysm|
Click here to view
| Discussion|| |
The common cause of pseudoaneurysm of CCA is a blunt or sharp trauma that results in the partial arterial wall thickness lesion. In the pre-antibiotic era, infections such as middle-ear infection, syphilis, or tuberculosis were the common etiologies., Other causes could be irradiation, cervical surgery, Takayasu arteritis, Marfan’s syndrome, etc. Aneurysms of the common carotid artery usually do not exceed size of 5 cm.,, However, the aneurysm of the indexed case measured around 10 × 9×7 cm.
Usually, patients present with pulsatile neck mass, airway distortion, vascular impairment of neck, and neurological impairments. Audible bruit, palpable thrill, or pulsatile laterocervical mass can be observed. Our patient presented with a pulsatile swelling in the left lower neck.
Increasing size of aneurysm compresses on the adjacent structures, causing pain, deviation of the trachea and esophagus, and neurological involvement., Our patient also had tracheal deviation and subsequently developed difficulty in opening mouth and hoarseness of voice.
In our case, difficult intubation was anticipated due to the huge mass, restricted mouth opening, and tracheal shift. Also, there existed the risk of inadvertent injury to the swelling during intubation.
Although conventional angiography remains the diagnostic standard, modalities such as duplex Doppler ultrasonography (USG), spiral computed tomography angiography (CTA), and MRA are useful tools for the non-invasive detection and diagnosis of pseudoaneurysms., Thrombosed areas associated with the pseudoaneurysm can be identified on contrast-enhanced CT scan.
In our patient, CT angiography demonstrated a partly thrombosed large left CCA pseudoaneurysm.
These pseudoaneurysms should be managed immediately as they have high incidence of rupture and thromboembolic events such as stroke and transient ischemic attacks.,
The mortality has been reported to be 70% in non-operated patients and 28% in operated patients. Both open surgical and endovascular approaches can be used. Surgical management plays an important role, especially in pseudoaneurysms with local mass effect, complications such as ischemia and neuropathy, infected pseudoaneurysms, and in patients with failure of minimally invasive therapeutic techniques. Usually, autologous venous graft is used; other options being prosthetic grafts, primary arterial closure, patch angioplasty, or end-to-end anastomosis. Endovascular coiling is preferred over surgical repair when the aneurysm is a part of the distal internal carotid artery, when managing post-traumatic pseudoaneurysms and in patients with “hostile neck” due to previous surgery or radiotherapy.
We tabulate few recently reported similar case reports to compare with our index case.
As described earlier, the size usually seen is approximately 6 × 6 cm, except larger pseudoaneurysm of 14 × 12 cm reported by Akhiwu et al. Earlier, only few centers had the facility of neurointervention by endovascular coiling of pseudoaneurysms, but nowadays as endovascular approach is available at larger number of centers, it is being favored.
Ni et al. in 2018 conducted a retrospective cohort study to compare the open surgical resection with endovascular approach for the treatment of extracranial carotid artery aneurysms who were managed at their center during the period 1997–2017. Out of the total 48 patients who were managed, 34 had true aneurysms and 14 had pseudoaneurysms. Among these 48 patients, 32 patients had surgical resection and 16 had endovascular treatment. The cranial nerve injuries were seen in eight of the surgical resection patients (25%) and none in endovascular patients (P-value = 0.029). The 30-day stroke rate was 6.3% in the open group (2/32) and 0 in the endovascular group (P-value = 0.307). The median length of stay was significantly longer in the open surgical resection group (20 days) vs. endovascular group (14 days) (P-value = 0.013). The authors suggested that endovascular treatment should be preferred if possible and anatomically favorable due to lower risk of cranial nerve injuries and shorter length of hospital stay.
In the indexed case, endovascular coiling was preferred owing to rupture of the aneurysm and distorted anatomy, where open surgery was not possible. Torrential bleeding was anticipated beforehand, and thus preparations were made to handle such an event and it was managed accordingly with positive outcomes.
| Conclusion|| |
Anticipation and thorough planning to tackle the difficulties associated with surgical management of pseudoaneurysm are crucial and influence the outcomes. Endovascular coiling is a feasible and safe option and should be considered for repairing of the common carotid artery pseudoaneurysm, especially in patients with altered neck anatomy or surgically unapproachable lesion. Adequate logistical, material, and manpower support should be ensured before handling such cases to manage any unforeseen intraoperative catastrophe.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pourier VEC, van Laarhoven CJHCM, Vergouwen MDI, Rinkel GJE, de Borst GJ. Prevalence of extracranial carotid artery aneurysms in patients with an intracranial aneurysm. PLoS One 2017;12:e0187479.
Argenta R, Braun SK. Surgical repair of an extra-cranial carotid aneurysm. J Vasc Bras. 2015; 14:84-87.
Garg K, Rockman CB, Lee V, Maldonado TS, Jacobowitz GR, Adelman MA, et al
. Presentation and management of carotid artery aneurysms and pseudoaneurysms. J Vasc Surg 2012;55:1618-22.
Zhou W, Lin PH, Bush RL, Peden E, Guerrero MA, Terramani T, et al
Carotid artery aneurysm: evolution of management over two decades. J Vasc Surg 2006;43:493-96.
Nordanstig J, Gelin J, Jensen N, Osterberg K, Strömberg S. National experience with extracranial carotid artery aneurysms: epidemiology, surgical treatment strategy, and treatment outcome. Ann Vasc Surg 2014;28:882-6.
Donato GD, Giubbolini M, Chisci E, Setacci F, Setacci C. Giant external carotid aneurysm: a rare cause of dyspnoea, Dysphagia and Horner’s syndrome. EJVES Extra 2006;11:19-22.
Soto JA, Múnera F, Morales C, Lopera JE, Holguín D, Guarín O, et al
. Focal arterial injuries of the proximal extremities: helical CT arteriography as the initial method of diagnosis. Radiology 2001;218:188-94.
Ahmed A, Samuels SL, Keeffe EB, Cheung RC. Delayed fatal hemorrhage from pseudoaneurysm of the hepatic artery after percutaneous liver biopsy. Am J Gastroenterol 2001;96:233-7.
Mokri B, Piepgras DG, Sundt TM Jr, Pearson BW. Extracranial internal carotid artery aneurysms. Mayo Clin Proc 1982;57:310-21.
Attigah N, Külkens S, Zausig N, Hansmann J, Ringleb P, Hakimi M, et al
. Surgical therapy of extracranial carotid artery aneurysms: long-term results over a 24-year period. Eur J Vasc Endovasc Surg 2009;37:127-33.
Morgan R, Belli AM. Current treatment methods for postcatheterization pseudoaneurysms. J Vasc Interv Radiol 2003;14:697-710.
Srivastava SD, Eagleton MJ, O’Hara P, Kashyap VS, Sarac T, Clair D. Surgical repair of carotid artery aneurysms: a 10-year, single-center experience. Ann Vasc Surg 2010;24:100-5.
Vizjak M, Strlek D, Cvetko D, Ljubotina M. A case of pseudoaneurysm of the common carotid artery presented with upper airway obstruction. Indian J Surg 2020;83:1564-6.
Akhiwu BI, Peter SD, Njem JM, Ojo EO, Omofuma IO, Adewale AG, et al
. Giant extracranial carotid artery pseudo-aneurysm causing acute airway obstruction. JAMMR 2018;28:1-7.
Sanap G, Naiknaware K, Taori K, Bhaya A. An unusual case of common carotid artery pseudoaneurysm caused by migration of swallowed sewing needle. Internet J Med Update 2014;9:45-9.
Pal N, Das SN, Kiran U, Bhan A. Anesthetic implications and management of carotid artery pseudoaneurysm in a child. Internet J Anesthesiol 2007;12:1-5.
Ni L, Weng H, Pu Z, Zheng Y, Liu B, Ye W, et al
. Open surgery versus endovascular approach in treatment of extracranial carotid artery aneurysms. J Vasc Surg 2018;67:1429-37.
[Figure 1], [Figure 2]