Sequential aneurysms of the internal carotid artery with fibromuscular dysplasia

Abstract

A 50-year-old woman presented with a 6-month history of left-sided neck discomfort and headaches. She denied any history of lateralizing neurologic deficits and denied vascular risk factors including smoking and connective tissue disorders. Her physical examination demonstrated a tender pulsatile mass on the left side of the neck and an associated carotid bruit. Carotid duplex ultrasound revealed four left internal carotid artery (ICA) aneurysms consistent with aneurysmal degeneration secondary to fibromuscular dysplasia. Computed tomography angiography of the neck confirmed these findings and revealed a bovine aortic arch without significant occlusive disease. The largest aneurysm measured 2.0 cm in diameter with three smaller “string-of-beads” dilations extending to within 1 cm of the skull base (A/Cover). Treatment options included ongoing surveillance, open repair with an interposition graft, and endovascular repair using stent grafts to exclude the aneurysms. The patient rejected surveillance, given her symptoms and concern for thromboembolization. Open repair was deemed high risk because of the superior extent of the aneurysms. Therefore, we proceeded with an endovascular strategy using transfemoral access to select the left common carotid artery. Embolic protection was deferred because of the low atherosclerotic burden, and awake neuromonitoring was performed. Selective arteriography demonstrated the known left ICA aneurysms (B). A 0.018-inch wire was used to traverse the ICA aneurysms. A 6-mm × 5-cm Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) stent graft was placed distally and overlapped with an 8-mm × 5-cm Viabahn stent graft proximally to accommodate tapering of the native vessel. Completion arteriography revealed aneurysm exclusion and excellent flow to the intracranial ICA (C). The patient was maintained on clopidogrel postoperatively. At 1 month, she was free from complications, and follow-up computed tomography angiography demonstrated aneurysm exclusion and patent stent grafts (D). The patient's consent was obtained for publication. Extracranial carotid artery aneurysms (ECAAs) are rare and have primarily been treated with open surgery.1McCollum C.H. Wheeler W.G. Noon G.P. DeBakey M.E. Aneurysms of the extracranial carotid artery. Twenty-one years' experience.Am J Surg. 1979; 137: 196-200Abstract Full Text PDF PubMed Scopus (231) Google Scholar Common causes of ECAAs remain atherosclerosis and trauma; however, fibromuscular dysplasia is responsible for 8% to 11% of all ECAAs.2El-Sabrout R. Cooley D.A. Extracranial carotid artery aneurysms: Texas Heart Institute experience.J Vasc Surg. 2000; 31: 702-712Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 3Fankhauser G.T. Stone W.M. Fowl R.J. O'Donnell M.E. Bower T.C. Meyer F.B. et al.Surgical and medical management of extracranial carotid artery aneurysms.J Vasc Surg. 2015; 61: 389-393Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Endovascular repair of ECAAs is increasingly used to decrease morbidity and mortality associated with repair of ECAAs complicated by redo surgical fields or prior radiation exposure and for those that extend to the skull base.2El-Sabrout R. Cooley D.A. Extracranial carotid artery aneurysms: Texas Heart Institute experience.J Vasc Surg. 2000; 31: 702-712Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 3Fankhauser G.T. Stone W.M. Fowl R.J. O'Donnell M.E. Bower T.C. Meyer F.B. et al.Surgical and medical management of extracranial carotid artery aneurysms.J Vasc Surg. 2015; 61: 389-393Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 4Zhou W. Lin P.H. Bush R.L. Peden E. Guerrero M.A. Terramani T. et al.Carotid artery aneurysm: evolution of management over two decades.J Vasc Surg. 2006; 43 (discussion: 497): 493-496Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 5Li Z. Chang G. Yao C. Guo L. Liu Y. Wang M. et al.Endovascular stenting of extracranial carotid artery aneurysm: a systematic review.Eur J Vasc Endovasc Surg. 2011; 42: 419-426Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar