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Table of Contents    
LETTER TO EDITOR
Year : 2018  |  Volume : 66  |  Issue : 2  |  Page : 512-513

Distal cervical carotid artery pseudoaneurysm after carotid endarterectomy:Inflated?


Department of Neurosurgery, Shunan Memorial Hospital, Yamaguchi, Japan

Date of Web Publication15-Mar-2018

Correspondence Address:
Dr. Masaru Honda
Department of Neurosurgery, Shunan Memorial Hospital, 1-10-1 Ikunoyaminami, Kudamatsu City, Yamaguchi 744-0033
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.227312

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How to cite this article:
Honda M, Maeda H. Distal cervical carotid artery pseudoaneurysm after carotid endarterectomy:Inflated?. Neurol India 2018;66:512-3

How to cite this URL:
Honda M, Maeda H. Distal cervical carotid artery pseudoaneurysm after carotid endarterectomy:Inflated?. Neurol India [serial online] 2018 [cited 2019 Aug 21];66:512-3. Available from: http://www.neurologyindia.com/text.asp?2018/66/2/512/227312




Sir,

The development of a pseudoaneurysm (PA) after a carotid endarterectomy (CEA) is a rare complication, and an intraoperative shunt insertion and/or its retrieval is the most commonly reported cause.[1],[2] PAs are treated by endovascular stent placement or are observed conservatively along with administration of antiplatelet treatment.[1],[2] Here, we report a distal cervical PA that developed after a CEA, which was treated by carotid stenting and coil embolization.

A 78-year old woman was admitted to our hospital for undergoing a CEA procedure for left carotid artery stenosis. The CEA was performed with an internal double-balloon shunt (Inter Medical Co., Ltd., Nagoya, Japan). The planned computed tomography angiography one day after surgery incidentally showed an approximately 20-mm sized pseudoaneurysm [Figure 1]. Digital subtraction angiography revealed that the inflated balloon-like PA. The investigation also revealed that the vessel at the distal end of the PA was partially kinked and narrowed [Figure 2]. Two Carotid WALLSTENT (Boston Scientific, Natick, MA, USA) were inserted to cover the aneurysmal lumen, and a 13 Target XL ® coil (Stryker Neurovascular, Fremont, CA, USA) embolization of the aneurysm followed [Figure 3]. The patient showed no new neurological deficits and was discharged 1 week after surgery.
Figure 1: Computed tomography angiography disclosed the pseudoaneurysm located at the level of the first to third cervical vertebrae

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Figure 2: An angiography revealed that the vessel at the distal end of the pseudoaneurysm was partially kinked and narrowed by pseudoaneurysmal compression of the parent vessel. The carotid endarterectomy had been completed

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Figure 3: An angiography showed that additional coil embolization further decreased the blood flow and the kinking of the distal part of the aneurysm had resolved

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We speculate that the distally inserted shunt tube itself or the inflation of its balloon resulted in the PA formation.[1],[2] Furthermore, the anatomy of the cervical internal carotid artery has often also been one of the influencing factors.[3] A 0.3 ml inflation of the balloon is enough to shut down the flow of the internal carotid artery, and the maximum balloon size of the balloon that we used was 7 mm wide, according to the company's brochure. We demonstrated that a 3–5 ml balloon inflation yielded a 1.8 cm length, and a width similar to that of the PA. These dimensions are similar to that of the PA developed in our patient [Figure 4]. Though the normal balloon inflation did not seem to cause a huge ballooning of the vessel, the presence of pre-existing intimal damage caused by the catheter manipulation, the vessel shunt insertion, the plaque removal, and the intrinsic vulnerability of the vessel undergoing the endarterectomy procedure due to the presence of atherosclerosis within its walls might have resulted in the development of a new dissection plane and in PA formation.[1],[2],[4]
Figure 4: The shape of intentionally overinflated (3 ml saline injected) shunt balloon resembles that of the pseudoaneurysm

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Usually, cervical PAs are treated by surgical resection/repair or endovascular treatment.[1] In a small terminal PA that does not demonstrate any more progression, conservative management with antiplatelet agents may be the treatment of choice.[1],[2],[4] However, there is still the underlying danger of embolic stroke and massive epistaxis developing.[1],[2],[4] Furthermore, often the location of the PA is too high to perform a direct surgical repair. Hence, endovascular stenting with coiling is a technically feasible alternative and is also a reasonable treatment.[1],[2],[4],[5],[6],[7],[8] It can also decrease the PA-induced kinking of the distal carotid artery, as was observed in our case. Surgeons should carefully pay attention to the insertion of internal shunt and avoid performing an overinflation of the intraluminal balloon during the procedure of CEA. A stent with coil embolization procedure successfully obliterated this large PA.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dahya V, Chalasani P. Successful obliteration of a pseudoaneurysm from post-CEA repair secondary to a Pruitt-Inahara Shunt using a stent graft. Case Rep Vasc Med 2013;2013:382485.  Back to cited text no. 1
    
2.
Troisi N, Dorigo W, Pulli R, Pratesi C. A case of traumatic internal carotid artery aneurysm secondary to carotid shunting. J Vasc Surg 2010;51:225-7.  Back to cited text no. 2
    
3.
Janzen J, Lanzer P, Rothenberger-Janzen K, Vuong PN. Variable extension of the transitional zone in the medial structure of carotid artery tripod. Vasa 2001;30:101-6.  Back to cited text no. 3
    
4.
Nazari P, Tan LA, Wewel JT, Moftakhar R, Kasliwal MK. Massive epistaxis resulting from radiation-induced internal carotid artery pseudoaneurysm. Neurol India 2017;65:380-2.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Bhaisora KS, Behari S, Godbole C, Phadke RV. Traumatic aneurysms of the intracranial and cervical vessels: A review. Neurol India 2016;64, Suppl S1:14-23.  Back to cited text no. 5
    
6.
Cai MJ, Xu GZ, Yang M, Ma LT, Yang XJ, Shi BC. Treatment strategies for traumatic cervico-cranial pseudoaneurysms: Single institution experience. Neurol India 2018;66:105-14.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Ergun O, Celtikci P, Canyigit M, Birgi E, Hidiroglu M, Hekimoglu B. Covered stent-graft treatment of a postoperative common carotid artery pseudoaneurysm Pol J Radiol 2014;79:333-6.   Back to cited text no. 7
    
8.
Yi AC, Palmer E, Luh GY, Jacobson JP, Smith DC. Endovascular treatment of carotid and vertebral pseudoaneurysms with covered stents. Am J Neuroradiol 2008;29:983-87.  Back to cited text no. 8
    


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