Extracranial Carotid Aneurysms Research Articles

Surgical and Endovascular Management of Extracranial Carotid Aneurysms, Outcomes from the American College of Surgeons, National Surgical Quality Improvement Program

Extracranial carotid artery aneurysms (ECAAs) are rare. Etiologies include dissection, atherosclerosis, trauma, mycotic infection, and iatrogenic. Patients are often asymptomatic at the time of diagnosis, but some present with a palpable mass or after an embolic cerebrovascular accident. Management of ECAAs includes thromboprophylaxis and surgical excision or exclusion of the aneurysmal segment. Intervention criterion for ECAAs has not been clearly delineated for either asymptomatic or symptomatic disease.

Emergency Endovascular Treatment of Recurrent Internal Carotid Artery False Aneurysm Complicated By Carotid-Cutaneous Fistula and Life-Threatening Bleeding

Background: Carotid pseudoaneurysms can generally be the result of arterial wall degeneration developed after carotid endarterectomy, previous spontaneous carotid dissection, post-traumatic neck injuries, non-vascular procedures and, rarely, infections. The ideal surgical management of extracranial carotid artery false aneurysms is still controversial and treatment should be tailored to the aneurysm’s aetiology, anatomy and presentation. Case presentation: We describe the case of an 81-year-old man presented with an enlarged pulsatile cervical mass coupled with a small cutaneous fistula, which had developed in roughly 1 year. He had undergone several carotid operations over the last 15 years (endarterectomy, venous-patch-angioplasty for restenosis and bovine-pericardial patch-angioplasty for a pseudoaneurysm). Methods: A CT-Scan revealed a recurrent pseudoaneurysm. Due to the previous multiple cervicotomies, the aneurysm wall was very closely adjacent to the skin plane; no gas bubbles or cervical fluid collections were evident. The patient rejected treatment at first, but six months later suffered major bleeding from the fistula. Results: The pseudoaneurysm was emergency excluded with a Viabhan-Stent-graft while the external carotid artery was occluded via vascular-plug. The fistula healed spontaneously in four months. There was no pseudo-aneurysm recurrence, endoleak or any sign of graft infection at 36-month follow-up. Conclusion: We present a singular case of emergency endovascular treatment of recurrent post-surgical internal carotid artery pseudoaneurysm complicated by a carotid-cutaneous and life-threatening bleeding. In these cases emergency endovascular treatment via covered-stent-graft represents the most effective, definitive or “bridge” management option. Carotid sheath protection via a myo-cutaneous flap could be considered in cases of previous multiple cerivcotomies.

A novel approach to high-grade carotid stenosis with concomitant extracranial carotid aneurysms using transcarotid artery revascularization

We present the novel application of transcarotid artery revascularization (TCAR) in two high-risk patients with high-grade internal artery stenosis and concomitant atherosclerotic extracranial carotid artery aneurysms (ECAAs). ECAAs account for <1% of arterial aneurysms and are usually clinically silent at presentation. Historically, the treatment of ECAAs has been via open reconstruction or stent grafting. TCAR is an effective alternative for carotid revascularization in high-risk patients with high-grade carotid stenosis, but has not been widely used for aneurysmal management. We report two cases to describe our management of concomitant carotid stenoses and ECCA with TCAR.

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

BackgroundHybrid 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. ObjectiveThis study evaluated the long-term effects of hybrid and endovascular procedures in treating juxta-skullbase ECAA. MethodsThe 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. ResultsFour 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. ConclusionsHybrid and endovascular procedures were found effective and durable alternatives to open operation for treatment of extracranial juxta-skullbase carotid aneurysm.

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

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. Fifty-seven consecutive patients who were diagnosed with ECCA and underwent intervention from January 2005 to July 2019at 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 1cm of peri-aneurysmal carotid artery≤90°; subgroup Ⅱ, severe ICA or CCA tortuosity proximal to the aneurysm, tortuosity of the aneurysm and 1cm of peri-aneurysmal carotid artery≤90°; subgroup Ⅲ, aneurysm tortuosity and 1cm peri-aneurysmal carotid artery>90°. 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±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. 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.

Co-prevalence of extracranial carotid aneurysms differs between European intracranial aneurysm cohorts.

Background and purposePreviously, we showed that co-prevalence of extracranial carotid artery aneurysms (ECAAs) in patients with intracranial aneurysms (IAs) was 2% in a Dutch cohort. In order to obtain more precise estimates and discover potential predictors of ECAA co-prevalence in the European population, we retrospectively compared differences and similarities of our Dutch cohort with a Finnish cohort using protocolled imaging of the cerebrovascular tree.MethodsIA patients within the prospective database of the Kuopio University Hospital were eligible for this study (n = 1,118). Image analysis and hospital chart review were conducted.ResultsIn total, 458 patients with complete carotid imaging conform protocol were analyzed. Twenty-four ECAAs in 21 patients were identified (4.6%, 95% CI 2.9–6.9), a higher co-prevalence than in the Dutch cohort (1.9%; 95% CI 1.0–3.3), prevalence odds ratio (POR) 2.45 (95% CI 1.19–5.03). In the Finnish cohort, 25% of all ECAAs were located around the carotid bifurcation, others in the internal carotid artery distally from the bifurcation. Independent predictors for ECAA co-prevalence were origin of country (POR 2.41, 95% CI 1.15–5.06) and male gender (POR 2.25, 95% CI 1.09–4.64).ConclusionThe co-prevalence of ECAA in IA patients was twice as high in the Finnish compared to the Dutch IA cohort, with origin of country and male gender as independent predictors. Twenty-five percent of ECAAs would be missed, if the carotid bifurcation was not imaged. Therefore, we propose to always include imaging of the carotid bifurcation as the gold standard technique to identify ECAA in IA patients.

Carotid artery aneurysm associated with Marfan Syndrome: A case report

Incidence of extracranial carotid aneurysms is low.Figure 4 The operative field during reconstruction after resection of the aneurysm.Usually the lesion develops from internal carotid artery, where...

Pseudoaneurisma carotídeo en niño de 2 años, complicación de la lesión esofágica por cuerpo extraño: reporte de caso y revisión de la literatura

The extracranial carotid aneurysm is a rare occurrence in clinical practice, as it involves all layers of the arterial wall. A pseudoaneurysm occurs when there are only one or two layers involved, and may be secondary to inflammatory, traumatic, or iatrogenic processes. A total of 30 cases in the paediatric population were reported in the literature between 1984 and 2016. Determining the diagnosis of this disease is difficult, and requires medical expertise to identify the findings that can guide the decision-making process in these cases.The case is reported of a 2 year-old male patient who showed symptoms characteristic of gastroenteritis. The patient was discharged, and then returned with respiratory symptoms characteristic of pneumonia that progressed to respiratory failure and required mechanical ventilation and vasoactive agents. The patient was diagnosed with a pseudoaneurysm, that was surgically treated, but no improvements were noticed. Different studies were performed that showed oesophageal perforation and mediastinitis secondary to a fishbone ingestion. The patient had massive bleeding and as a result, he died.

Single-center experience with extracranial carotid aneurysm open repair.

Our aim is to report our single center experience with extracranial carotid artery aneurysms (ECAA) open repair. A retrospective review was performed including the perioperative and postoperative data of all patients who underwent ECAA repair between 2008 and 2015. The operative technique was based on aneurysm size, anatomical features and operative risk. Fourteen patients (6 men and 8 women, mean age 60.5 years) were admitted for ECAA. Thirteen patients (92.8%) were submitted to ECCA open repair while in one patient (7.2%) conservative treatment was realized. Bilateral lesions and concomitant internal carotid artery (ICA) kinking was observed in 2 cases (14.2%). Seven patients (50%) were asymptomatic at diagnosis and ECCA localization involved ICA in 9 cases (64.2-69.2%). Aneurysmectomy with end-to-end anastomosis was performed in 3 cases (23.07-23.1%), patch arterioplasty in 2 cases (15.38-15.4%), prosthetic graft interposition in 4 cases (30.76-30.7%), autologous vein graft bypass in 3 cases (23.07-23.1%) and artery ligation with distal ICA anastomosis in one case (7.6-7.6%). No perioperative deaths, major neurological complications and surgical reinterventions were recorded. Overall survival at a mean follow-up of 19.6 months (range 0-52 months) was 100%. ECAA open repair represents a safe surgical option, with lower prevalence of complications and no need for reintervention in high volume centers.

Simultaneous Endovascular Treatment of Tandem Internal Carotid Lesions

The incidence of concomitant extracranial carotid artery stenosis and ipsilateral intracranial carotid aneurysm has been reported to vary between 2.8% and 5%. These complex lesions may present a challenge for treatment decision-making. This case report describes an asymptomatic male patient with severe carotid bifurcation stenosis, coupled with an unruptured supraclinoid internal carotid aneurysm. Both lesions were treated simultaneously. Patient underwent carotid stenting followed by aneurysm coiling in the same setting without any complication.

Stent Graft-in-Stent Graft as a Rescue Technique for Endovascular Treatment of Giant Extracranial Internal Carotid Aneurysm.

Endovascular treatment of a giant extracranial internal carotid aneurysm by a stent graft implantation was unsuccessful due to a high flow leak directly through the stent graft's coating. The problem was solved deploying a second stent graft inside the previously implanted one resulting in complete exclusion of the aneurysmal sac and patent carotid lumen preservation. The review of the literature did not provide a case using this endovascular strategy. Follow-up for more than 12 months, using CT angiography, showed confirmed aneurysmal exclusion and carotid patency and no clinical complications have been detected.

Surgical repair of an extracranial carotid aneurysm

Aneurysms of the supra-aortic trunks are rare conditions that can cause peripheral neurological conditions or embolization resulting in stroke. The upper airways can even be affected and rupture is potentially fatal. We present a case of a patient with an aneurysm of the carotid bifurcation who was treated conventionally with reconstruction of the carotid bifurcation using a venous patch. Surgical treatment enabled accurate histopathological diagnosis and anatomic correction of the carotid bifurcation.

Un anévrisme de l’artère carotide interne d’origine dysplasique

Extracranial carotid aneurysms are rare, but are of significant clinical interest due to the high risk of cerebral embolism. Despite considerable progress in endovascular techniques, surgical treatment of these aneurysms remains the golden standard. We report the case of a 50-year-old man who presented an aneurysm of the left internal carotid artery measuring 46 × 26 mm. Resection of the aneurysm with interposition of a prosthetic graft was performed. The postoperative course was uneventful. Pathology reported that the aneurysmal sac probably had a dysplastic origin.

A tailored approach to operative repair of extracranial carotid aneurysms based on anatomic types and kinks

BackgroundTo present outcomes following an operative approach of extracranial carotid artery aneurysm (ECAAs) based on anatomic types and associated kinks. MethodsThis study represents retrospective analysis of anatomic type based approach to operative repair of 84 patients with ECAA from 1994 to 2011, 28 (33.3%) with associated kinking. Patients were followed for neurological ischemic events, hematoma, cranial nerve injury, myocardial infarction, neurological, and overall mortality. The results are presented as early, within 30 days after the surgery, and long term during the follow-up. ResultsIn the early postoperative period, there were no strokes or mortalities, cranial nerve injury rate was 2.4% while 1 patient had myocardial infarction (1.2%). During the follow-up, 4 patients (4.8%) had stroke, out of which 2 patients died (2.3%), while overall mortality was 4.6%. The average 5-year survival rate was 96 ± 3%. ConclusionExcellent outcomes can be obtained with surgical repair of ECAA, which should be tailored to the anatomic types and presence of kinks.

A Case of Giant Extracranial Carotid Artery Aneurysm

A Case of Giant Extracranial Carotid Artery Aneurysm Extracranial carotid aneurysms are uncommon. Most patients remain asymptomatic. Local pain and a pulsating mass in the neck are the most frequently described symptoms. Most carotid artery aneurysms are caused by atherosclerosis, other common causes include trauma and infection. Surgical management of a 80-year-old female patient with a giant extracranial internal carotid artery aneurysm is presented in this report .

Management approach to an extracranial internal carotid artery aneurysm

This patient is an 84-year-old female who presented with left-sided facial swelling and complaints of tightness in her throat for the past few months. On examination, she was noted to have a pulsatile mass in her left pharyngeal space. The patient denied any history of trauma or surgery to her left neck. She denied any cerebrovascular symptoms or history of recent fevers. Computed tomography revealed an extracranial internal carotid aneurysm (B). We performed a carotid arteriogram confirming a large saccular aneurysm at the very distal segment of the extracranial left internal carotid artery (C). Rotational angiography with three-dimensional reconstruction was performed to better visualize the exact anatomy (A and D). Given the tortuosity of the proximal common carotid artery and the internal carotid just proximal to the aneurysm, we did not believe a covered stent could be safely advanced to the area of concern. After consideration of endoluminal options and open repair, we proceeded with open surgical clipping of the aneurysm with 11.420-mm standard cerebral aneurysm clips. Though mandibular disarticulation can augment exposure of this segment of the carotid artery, it was not necessary in this case as we were able to expose the base of the aneurysm adequately. The patient’s recovery was uneventful. Extracranial carotid aneurysms are rare and have a relative incidence of about 1.25% among all peripheral aneurysms. Etiology is usually infection, atherosclerotic disease, trauma, dissection, previous carotid surgery, or connective tissue and vasculitis disorders. Devastating complications include hemorrhage and stroke, but the most common presenting symptoms are pain, a pulsatile mass in the neck or pharynx, or cranial nerve palsies. Treatment options depend largely on the aneurysm location and anatomy. Operative options are clipping, resection with patch repair, or resection with bypass. Endoluminal treatment by coil embolization or covered stent placement has also been described and is being employed with greater frequency. Though these newer options have shown promise, associated complications have also been reported and long-term results of these treatment modalities are not available. Treatment should, therefore, be individualized to the patient’s anatomy and overall medical condition.

Caution: Carotid Artery Aneurysm May Disguise as Neck Tumor

Objective: 1) To present a case where a right common carotid aneurysm was clinically undistinguishable from tumor. 2) Stress the importance of contrast-enhanced imaging in the workup of a neck mass. 3) Review of literature. Method: A 64-year-old male smoker with hypertension presented with hoarseness, dysphagia, and an enlarging right neck mass. Physical examination revealed 6-cm neck mass, nonfluctuant, nonpulsatile. F/L: Right parapharyngeal mass impinging right hemilarynx, causing partial airway obstruction. Noncontrast computed tomography (CT) scan was suggestive of neoplasia versus abscess formation. Contrast-enhanced CT revealed an aneurysm of the right carotid bifurcation. PubMed literature was reviewed. Results: Extracranial carotid aneurysms are rare (1-4%), with atherosclerosis being the most common etiology. They arise in the internal carotid (67%), bifurcation (32%), and the external carotid artery (1%). Airway obstruction and dysphagia has been reported in very few cases. In our patient this led to the clinical diagnosis of tumor. Contrast-enhanced imaging is essential in the workup of a neck mass. Management options include interposition bypass grafting, resection with patch angioplasty, or carotid ligation, as well as endovascular interventions with stenting or occlusion. Conclusion: Large carotid artery aneurysms may resemble a tumor and they must be considered in the differential diagnosis of a neck mass. The importance of contrast-enhanced imaging before attempting invasive procedures cannot be overemphasized.

Technical options for the treatment of extracranial carotid aneurysms

Extracranial carotid artery aneurysm (ECAA) is an uncommon but serious condition. The morbidity and mortality of ECAA are assumed to be high when untreated. ECAA treatment presents a challenge because of accessibility of the carotid artery and lack of evidence-based guidelines. When exclusion of the aneurysm is considered, surgical resection of the aneurysm with reconstruction of blood flow is still considered the gold standard. Several alternative and endovascular approaches are discussed.

Traitement chirurgical des anévrismes carotidiens extracrâniens : à propos de dix cas

Aneurysm of the extracranial carotid artery is rare. The embolic risk mandates prompt intervention once diagnosed. The aim of this study was to determine therapeutic techniques, their indications and outcomes. We report a series of ten patients who underwent surgery for extracranial carotid artery aneurysm in the cardiovascular surgery department of La Rabta hospital. There were six men and four women, mean age 43 years. All patients were symptomatic (swelling and pulsatile cervical mass). Two patients had dysphonia and one patient underwent an emergency procedure because of aneurismal rupture. Aneurismal excision was performed in most patients. The arterial reconstruction was performed by end-to-end anastomosis in four cases, interposition of an autologous venous graft in four, interposition of a prosthetic graft in one and suture of a small rent in the artery in one. There was no postoperative mortality. Early postoperative morbidity included one recurrent laryngeal nerve injury, one hypoglossal nerve injury, one stroke and one infection with thrombosis of a prosthetic graft. The follow-up was uneventful. Surgical treatment of extracranial carotid aneurysms is required, in most cases with good results. Endovascular treatment may be an effective therapy in selected cases.

Diagnosis of non-atherosclerotic carotid disease

Summary Non-atherosclerotic carotid disease in an uncommon group of angiographic defects. It includes the entities: Takayasu's arteritis, giant cell arteritis, fibromuscular disease, moyamoya syndrome, arterial dissection and extracranial carotid aneurysms. Due to advance in imaging techniques, they are being increasingly identified. Growing awareness of diverse clinical picture along with advances in imaging technologies enables early diagnosis. Although catheter angiography is a gold standard in diagnosing most of these diseases, neurosonological tests serve as an excellent screening tool, and are suitable for monitoring. Brain MR and MRA are sometimes essential for confirmation of the diagnosis. Mortality rates are low and functional outcome is generally good if the disease is diagnosed early.