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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 4  |  Issue : 3  |  Page : 202-204

Iatrogenic common carotid artery pseudoaneurysm


1 Department of CTVS/Trauma, All Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India
3 Department of Anesthesiology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India

Date of Web Publication9-Dec-2015

Correspondence Address:
Rajnish Kumar Arora
Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0521.171433

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  Abstract 

Extracranial pseudoaneurysms of the carotid artery are extremely uncommon lesions. Trauma, which is nowadays mostly iatrogenic, is responsible for the majority of these cases. Inflammation is uncommon etiology. Clinically, these aneurysms may present as neck swelling with expansion into adjacent structure and pressure symptoms, cerebral embolization, stroke, and rarely rupture. The treatment is usually by endovascular or open surgical techniques. Therapy must be individualized with major and prime objective being the prevention of neurological complications. We present a case of iatrogenic pseudoaneurysm of the common carotid artery resulting due to iatrogenic injury during cervical exploration at a Rural Health Center.

Keywords: Common carotid artery, iatrogenic, pseudoaneurysm


How to cite this article:
Darbari A, Arora RK, Arora P. Iatrogenic common carotid artery pseudoaneurysm. Saudi J Health Sci 2015;4:202-4

How to cite this URL:
Darbari A, Arora RK, Arora P. Iatrogenic common carotid artery pseudoaneurysm. Saudi J Health Sci [serial online] 2015 [cited 2019 May 19];4:202-4. Available from: http://www.saudijhealthsci.org/text.asp?2015/4/3/202/171433


  Introduction Top


Extracranial pseudoaneurysm of the carotid artery is a very rare entity.[1] Most common cause of carotid artery pseudoaneurysm is trauma.[2] The increasing number of interventions such as central venous cannulations for various purposes are causing increased incidence of this disease entity. Mostly, they are identified by symptoms, but the clinical presentation varies according to location and size. The most serious risk associated with carotid pseudoaneurysm is transient ischemic attacks, stroke, and fatal bleed. Therapy must be individualized with major and prime objective being the prevention of neurological complications. We present a case of iatrogenic pseudoaneurysm of the carotid artery resulting due to mishandling of neck swelling at a Rural Health Center.


  Case Report Top


A thin built, 25-year-old female had complaints suggestive of tubercular pathology with a small cervical swelling on the right side. Fine needle aspiration cytology was inconclusive. Considering the possibility of tubercular lymphadenitis and for confirmation, excisional biopsy was performed at a rural hospital by a general physician. During this surgical procedure, sudden bright red arterial hemorrhage started. By pressure application and blind suturing, hemostasis was achieved, procedure abandoned, and skin closed. Then, she started developing progressively increasing swelling just underneath the operative wound. Skin stitches were removed after 8 days, but swelling was progressively increasing, and she had also developed right eye dropping. She was quickly referred to our institute with presumptive diagnosis of cervical region hematoma [Figure 1]. On clinical examination, a firm nonpulsatile swelling with well-defined margins, size approximately 6 cm × 4 cm with an overlying operative scar at the lateral aspect of right mid region of the neck with right-sided Horner syndrome was present. All routine blood investigations were within normal limits except a total leukocyte count of 14,000/mm 3. Contrast enhanced computed tomography (CT) scan of neck and thorax done that showed it to be a right common carotid artery aneurysm of approximately 45 mm × 47 mm with pressure effects on adjacent structures [Figure 2]. Color Doppler study of this mass also confirmed this as pseudoaneurysm of the right common carotid artery. Considering the possibility of an infective focus, due to a history of recent complicated surgical procedure and raised counts, open surgical procedure was deemed meritorious over an attempt of endovascular stenting procedure. Under general anesthesia, she was operated. It was found to be an aneurysm of the right common carotid artery just below bifurcation, containing a big thrombus covered by an inflammatory tissue wall. Segment of approximately 3 cm of anterior arterial wall destroyed [Figure 3]. After taking proximal and distal control of artery, sloughy necrotic material and damaged arterial wall were resected and on-lay patch of saphenous vein graft was placed. No intravascular shunt was used. We preferred an autologous tissue rather than a prosthetic graft material. The cultures of necrosed inflammatory tissue were sterile. No intraoperative or postopertive complication and neurological deficit occurred [Figure 4]. Recovery was uneventful, and later the patient was discharged in satisfactory condition after 10 days. Oral anticoagulants were given for 3 months. A Doppler exam of neck after 3 months follow-up showed no recurrence of aneurysm.
Figure 1: Patient at presentation having right-sided neck swelling with overlying scar of surgery and right-sided ptosis

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Figure 2: Axial section computed tomography scan of neck. (a) plain. (b) contrast

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Figure 3: Intraoperative photograph showing destruction of arterial wall

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Figure 4: Postoperative patient, the Horner syndrome was also improved

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Extracranial pseudoaneurysms of the carotid artery are extremely uncommon lesions. The etiology may be due to trauma or inflammation and may also be iatrogenic.[3] The most frequent site of these aneurysms are the common carotid artery bifurcation. Usually, they are saccular in morphology. The clinical presentation of true or pseudoaneurysms of carotid artery varies according to their location and size. Pseudoaneurysms become symptomatic usually between the 2nd and 8th weeks of injury. However, the presentation may be at any time after injury, it may be delayed by many years in some.[4] Usually, these aneurysms present as a pulsatile or nonpulsatile mass in the neck region. Occasionally, true aneurysms may present as a pulsatile mass in the tonsillar fossa or oropharynx without external manifestation. Distal internal carotid artery aneurysms may be completely hidden. These may produce neck pain (carotidynia), recurrent facial pain, fifth or sixth cranial nerve palsy, and deafness, and sometimes interfere with the function of cranial nerves XII, X, or IX due to compression at the base of the skull. The Horner syndrome can result from vascular injury along the course of the postganglionic oculosympathetic nerve fibers. Raeder's paratrigeminal syndrome (the combination of internal facial pain and oculosympathetic paresis) has been caused by aneurysm situated at the base of the skull.[5] The most common serious risks associated with carotid artery pseudoaneurysms are transient ischemic attacks, stroke, and bleeding. In our case, inadvertent iatrogenic complication of carotid artery trauma due to the wrong surgical handling of cervical swelling and later resultant pseudoaneurysm occurred. During planned surgery, arterial wall tear occurred but by pressure application and suturing, the bleeding stopped. Superimposed infection and friability of wall caused rapid expansion and acute pressure symptoms on neighboring structures.

Although angiography remains the gold standard diagnostic investigation, other methods such as Doppler ultrasonography (USG), CT angiography, or magnetic resonance angiography are useful tools for the noninvasive detection and diagnosis of pseudoaneurysms.[6] USG has been reported to have a sensitivity of 94% and specificity of 97% in the detection of pseudoaneurysm.[7] On USG, pseudoaneurysms may demonstrate blood flow within a cystic structure characterized by a typical swirling motion referred to as the "Yin-yang sign."[8] The demonstration of a communicating channel between the sac and the feeding artery with a "to-and-fro" waveform at Doppler USG confirms the diagnosis. USG can also be used to follow-up patients following the treatment.

There are various methods of treating a pseudoaneurysm. Ultrasound-guided compression is useful for superficially located extremity pseudo aneurysms, particularly for femoral pseudoaneurysms.[7] Percutaneous thrombin can be injected in selected cases as well. However, this modality is not considered useful in carotid pseudoaneurysms. Despite the growing popularity of image-guided compression and endoluminal catheter-related management of pseudoaneurysms, surgical management still plays an important role. This is true, especially in pseudoaneurysms with local mass effect, complications such as ischemia and neuropathy, infected pseudoaneurysms, and in patients in whom minimally invasive therapeutic techniques have failed. Surgical techniques vary widely and may include resection and repair with bypass grafts (autologous vein or synthetic graft prostheses) and arterial ligation.[9] Though endovascular technique is a less invasive approach,[10] we preferred an open surgical approach with an autologous tissue over the latter because there was a theoretical possibility of harboring an infective focus and leaving a synthetic stent would have been devastating in such a scenario.

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.
El-Sabrout R, Cooley DA. Extracranial carotid artery aneurysms: Texas heart institute experience. J Vasc Surg 2000;31:702-12.  Back to cited text no. 1
    
2.
McCann RL. Basic data related to peripheral artery aneurysms. Ann Vasc Surg 1990;4:411-4.  Back to cited text no. 2
    
3.
Schwartz LB, Clark ET, Gewertz BL. Anastomotic and other pseudoaneurysms. In: Rutherford RB, editor. Vascular Surgery. 5th ed. Philadelphia: W B Saunders Company; 2000. p. 752-63.  Back to cited text no. 3
    
4.
Beena NV, Kishore MS, Mahale A, Poornima V. Pseudoaneurysm of internal carotid artery. Indian J Pediatr 2007;74:307-9.  Back to cited text no. 4
    
5.
Richard HD. Aneurysm of the carotid artery; disorders of the arterial system. In: Sabiston DC, editor. Text Book of Surgery – The Biological Basis of Surgical Practice. 15th ed. Philadelphia: W B Saunders Company; 1997. p. 1658-60.  Back to cited text no. 5
    
6.
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.  Back to cited text no. 6
    
7.
Morgan R, Belli AM. Current treatment methods for post catheterization pseudoaneurysms. J Vasc Interv Radiol 2003;14:697-710.  Back to cited text no. 7
    
8.
Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 2005;25 Suppl 1:S173-89.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
    
10.
Lubicz B, Gauvrit JY, Leclerc X, Lejeune JP, Pruvo JP. Giant aneurysms of the internal carotid artery: Endovascular treatment and long-term follow-up. Neuroradiology 2003;45:650-5.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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