Aneurysms
of Extracranial Carotid Arteries E. Leeon Rhodes, MD; James C. Stanley, MD; Jack L. Cronenwett, MD; William J. Fry, MD
Gary
L.
Hoffman, MD;
\s=b\ Twenty-three extracranial carotid artery aneurysms were encountered in 19 patients. Arteriosclerosis was evident in 16 aneurysms. Severe arterial hypertension affected all patients with arteriosclerotic lesions. Trauma, penetrating neck injury once, and blunt neck injury three times caused four aneurysms. Three aneurysms resulted from earlier carotid artery operations. All 19 patients were symptomatic. Neurologic symptoms affected 13 individuals. Local symptoms referable to the aneurysmal mass troubled 15 patients. Twenty-one aneurysms were treated operatively. There was no operative mortality. Aneurysmectomy with arterial reconstruction was performed 16 times. Aneurysmorrhaphy was undertaken on four occasions and carotid ligation once. Two strokes and multiple cranial nerve injury accounted for three operative complications. No neurologic complications occurred during follow-up totaling 360 manmonths. These lesions may be successfully treated by a carefully performed, properly selected operation.
(Arch Surg 111:339-343, 1976)
of the extracranial carotid arteries are rare vascular lesions. Operative indications and tech¬ for vascular reconstruction are ill-defined. Interpre¬ tation of data generated from numerous isolated case reports has not provided a firm basis for our under¬ standing of these lesions. Large clinical experiences at any one given institution are nonexistent. Aneurysms involving the extracranial carotid arteries were encountered in 19 patients at the University of Michigan Medical Center from 1959 to 1975. Etiologic factors, clinical manifestations, and operative manage¬ ment of these patients provide the basis of this report.
Aneurysms niques L
Accepted
for publication Dec 4, 1975. Department of Surgery, Section of General Surgery, University of Michigan Medical Center, Ann Arbor. Read before the 83rd annual meeting of the Western Surgical Association, Colorado Springs, Colo, Nov 20, 1975. Reprint requests to University Hospital, 1405 E Ann St, Ann Arbor, MI 48104 (Dr Rhodes). From the
SUBJECTS AND METHODS
patients harboring
23 extracranial carotid artery identified. Included were 14 men and five women, ranging from 18 to 78 years in age. Aneurysm size varied from 1.5 to 8.0 cm. The common carotid artery was the site of two aneurysms. The internal carotid artery was involved with eight aneurysms. The carotid bifurcation, with common, external, and internal carotid artery involvement, was the location of the remaining 13 aneurysms. A saccular configuration was noted in five internal carotid artery aneurysms. Fusiform shapes occurred in the remaining aneurysms. Nine patients had aneurysms of the left side, six had right-sided lesions, and four exhibited bilateral lesions. Arteriosclerosis was the most common pathologic process observed in this series. Histologie confirmation of arteriosclerosis was present in 12 individuals (four of whom had bilateral lesions), and accounted for 16 carotid artery aneurysms. Internal elastic lamina disruption and medial thinning was apparent in 14 specimens available for histologie examination. All these lesions exhibited advanced calcifié arteriosclerosis. Manifestations of generalized arteriosclerosis were evident in eight of the 12 patients. Severe aortoiliac occlusive disease affected four individ¬ uals, three of whom also had previous myocardial infarctions. Infrarenal abdominal aortic aneurysms were documented in four additional patients. Severe arterial hypertension affected all 12 patients with arteriosclerotic carotid artery aneurysms. The mean blood pressure of these patients was 180/117 mm Hg (range, 160/100 to 240/160 mm Hg). Trauma caused four aneurysms. A gunshot injury of the neck resulted in one pseudoaneurysm of the right common carotid artery. Forceful blows in the region of the mandibular angle, the result of a fall (twice) and a karate chop (once), resulted in three aneurysms of the internal carotid artery. Previous carotid artery endarterectomy led to the development of three pseudoaneurysms of the carotid bifurcation. Suture line infection caused two of these lesions, while an anastomotic leak accounted for the third. Nineteen
aneurysms
were
Clinical Manifestations All 19 patients complained of symptoms referable to aneurysmal disease. Neurologic symptoms were a prominent feature in the
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patients. Frank stroke was apparent in three patients. Complaints of intermittent hemiparesis were described in three individuals. Amaurosis fugax was the only neurologic deficit in three cases. Vague neurologic disturbances including dizziness and numbness troubled the four remaining patients. Immediate loss of consciousness and contralateral hemiparesis histories of 13
affected four individuals who had sustained trauma to the neck. Unconsciousness was momentary in the case of penetrating trauma and in one case of blunt trauma. Unconsciousness lasted approximately 24 hours in two remaining patients. Neurologic deficits were permanent in three of these four individuals. An uncomfortable pulsating sensation in the neck was noted in nine of 13 patients with neurologic symptoms. Difficulty in swallowing affected one of these nine individuals. All four patients with traumatic aneurysms were unaware of their lesions. Presence of an uncomfortable, pulsatile mass in the neck was the only complaint in four individuals. Dysphasia was the only symptom in two patients. Acute expansion or rupture was not encountered in this experience.
Methods of Management Restoration of Arterial Continuity Primary arterial anastomosis Common carotid artery to internal carotid artery Common carotid artery to conjoined internal and external carotid artery External to internal carotid artery Vein graft
Operation Aneurysmectomy
Interposition graft
Common carotid artery to internal carotid artery Patch graft Common carotid artery
Aneurysmorrhaphy
Primary
closure Bifurcation Patch graft Vein graft Common carotid artery Internal carotid artery
Synthetic graft
Management Twenty-one aneurysms were treated by operation (Table). Aneurysmectomy was performed on 16 occasions. Restoration of arterial continuity by either primary end-to-end arterial anasto¬ mosis, interposition vein graft, or vein patch graft was accomplished following aneurysmectomy. Aneurysmorrhaphy was performed for four aneurysms. Restoration of arterial continuity by primary closure or patch grafts of either autogenous saphenous or synthetic material was accomplished following aneurysmorrha¬ phy. Ligation of the common and internal carotid arteries was employed in one severely infected pseudoaneurysm. Shunting technique (internal, 11 times, and external, twice) was used to preserve cerebral blood flow during 13 operations. Shunts were not used in the remaining operations. Two patients with aneurysms have been followed up without operation. These aneurysms remained less than 2 cm in greatest dimension. The only symptoms in these cases relate to sensations of a pulsatile neck mass. Each patient had undergone previous aneurysmectomy for arteriosclerotic lesions of the contralateral carotid artery. RESULTS
Eighteen aneurysms were successfully operated on without incident. Three preventable operative complica¬ tions occurred. Failure to spatulate proximal and distal anastomoses of an interposition graft in one patient resulted in suture line stricture six months following aneurysmectomy. Repair of the stenosis resulted in a transient hemiparesis. A second stroke resulted from distal embolization of dislodged mural thrombus during posi¬ tioning of an internal shunt. Injury to the glossopharyngeal, vagus, and hypoglossal nerves occurred following complete excision of a large arteriosclerotic aneurysm. No operative deaths occurred in this experience. Thirteen patients treated operatively were available for follow-up totaling 360 man-months. No subsequent neurologic defi¬ cits occurred during this interval. Two patients treated nonoperatively have been followed up a total of 35 manmonths. Their aneurysms have not enlarged or become symptomatic. Four patients died from diseases unrelated to their carotid artery aneurysm.
No.
1
Bifurcation
Ligation
1 1
Common and internal carotid artery
COMMENT
Pathogenesis Arteriosclerosis and trauma account for the majority of extracranial carotid artery aneurysms.1 :l Luetic aneu¬ rysms, more common in the past,' are now distinctly unusual." Severe arterial hypertension was a constant finding in all the patients of this series who had arterio¬ sclerotic lesions. Arterial hypertension appears more than coincidentally related to development of arteriosclerotic extracranial carotid artery aneurysms. Aneurysms follow¬ ing penetrating trauma are unusual lesions.7 Military*' and civilian7" experiences have documented the importance of this etiologic mechanism. Blunt trauma to the neck usually results in thrombosis of injured vessels rather than aneu¬ rysm development."' Hyperextension and rotation of the neck causes compression of the internal carotid artery on the transverse process of the atlas." This may result in intimai fracture and subsequent thrombosis." Aneurysm formation secondary to blunt trauma is believed to result from a similar mechanism of injury. It is speculated that impingement of the internal carotid artery between the mandibular angle and the atlas following a forceful blow is the basis of this injury. Pseudoaneurysm formation follow¬ ing previous carotid artery endarterectomy is an infre¬ quent, but well-known event.''"17' Suture line disruption due to technical error or infection results in the usual cause of these lesions.1115 "'
Therapeutic Approach It has been stated that hemorrhage due to rupture is the most frequent cause of death.1"1" Although well docu¬ mented,17/1" this complication of carotid artery aneurysm was not encountered in the present series. Neurologic complications are also recognized1 "' and are substantiated by our experience. Prevention of severe neurologic compli¬ cations, rather than prevention of rupture, provides the
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Fig 1.—Conjoining internal and external carotid arteries with end-to-end anasto¬ mosis to common carotid artery.
Fig 2.—End-to-end anastomosis of exter¬ nal carotid and internal carotid arteries.
Fig 3.—Interposing internal shunt.
a
vein
graft
over
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greater impetus for aggressive surgical management of these lesions.
Arteriograms evaluating the status of both the extra¬ cranial carotid vessels and the intracranial cerebral circu¬ lation are mandatory for planning an optimal operative approach to these lesions. Presence of intraluminal thrombus may be discovered with these studies. Tortuous internal carotid arteries, amenable to mobilization and end-to-end anastomosis with common carotid arteries, may similarly be recognized preoperatively. General Technical Considerations
Shunting.-Preservation of cerebral blood flow utilizing shunting techniques is preferable to reliance on the adequacy of collateral circulation to prevent cerebral
ischemia.7'" -' An internal shunt from the common to the internal carotid artery is the simplest means of assuring sufficient cerebral perfusion. This technique is especially useful when using autogenous saphenous vein interposi¬ tion grafts. External shunting of large aneurysms has been advocated7'--'; this is technically difficult.71 Internal shunting of even the largest carotid artery aneurysm seems more advisable. Occasionally, small saccular aneu¬ rysms of the internal carotid artery, amenable to tangen¬ tial excision, may be expeditiously managed without shunting techniques. A back pressure of 40 mm Hg within the internal carotid artery is necessary for adequate cerebral protection.77' Under these circumstances, no artifi¬ cial shunt is necessary. Exposure.—Adequate exposure of carotid aneurysms and uninvolved proximal and distal vessels is essential for successful operative management of these lesions. Trans¬ verse incisions begun at the hyoid and gently curved toward the mastoid process provide adequate exposure in most instances. Vertical neck incisions paralleling the medial border of the sternocleidomastoid or transverse incisions positioned lower in the neck may provide better exposure of the common carotid artery. Many aneurysms contain laminated clot not detected angiographically. Inju¬ dicious handling of aneurysms prior to placement of an internal shunt may cause distal embolization. This disas¬ trous complication is best avoided by first dissecting normal proximal and distal arteries. Once these vessels are controlled, they are clamped and the aneurysm incised. Laminated clot and atheromatous debris can then be removed from the aneurysmal sac. Once this is accom¬ plished, an internal shunt can be safely positioned under direct vision. Alternative Operative Techniques.—Aneurysmectomy with restoration of arterial continuity by primary end-to-end anastomosis of the common and internal carotid arteries was first performed over 20 years ago.7"' Aneurysm resec¬ tion with arterial reconstruction is the treatment of choice.7,777 Primary end-to-end anastomosis of common carotid and internal carotid arteries is the perferred means of reestablishing arterial continuity. Anastomotic stric¬ tures may be avoided by spatulation of both proximal and distal vessels prior to their approximation. A patulous anastomosis results that is unlikely to become stenotic. Size
discrepancies of the internal and common carotid arteries can be overcome by more extensive spatulation of the
internal carotid vessel. This maneuver is not without hazard. Extensive spatulation of the internal carotid artery sacrifices length. Alternative techniques should be utilized if suture line tension exists. Anastomotic tension may be lessened by spatulation of both the internal and external carotid arteries, suturing these vessels together, and approximating this conjoined vessel to the common carotid artery-'" (Fig 1). When the internal carotid artery is of insufficient length to use this technique, primary end-toend arterial anastomosis may be achieved by oversewing the orifice of the internal carotid artery at the carotid bifurcation, ligating the external carotid artery and its branches distally, dividing the external carotid artery, and suturing it to the internal carotid artery7'" (Fig 2). Interposition grafts are utilized when inadequate lengths of carotid vessels preclude primary anastomoses using one of the aforementioned techniques. Autologous saphenous vein is most suitable for this graft. Prior to clamping and resecting the aneurysm, a suitable section of saphenous vein is threaded over an internal shunt. The shunt is positioned in both the internal and common carotid arteries after blood flow is momentarily arrested and the aneurysm incised. The distal anastomosis and one half of the proximal anastomosis is completed around the shunt. The shunt is then removed and the proximal anas¬ tomosis completed (Fig 3). Appropriate synthetic grafts can be substituted when suitable saphenous vein is unavail¬ able. Complete excision of large carotid aneurysms is not advised. Large aneurysms may have important neural structures adherent to their walls. To avoid injury to these structures, entering and exiting vessels are momentarily occluded, the aneurysm incised, and an internal shunt inserted. The aneurysmal sac is then partially excised, leaving behind that portion of the sac adherent to adjacent cranial nerves. Saccular aneurysms with narrow necks are effectively treated by aneurysmectomy and vein patch repair of the arterial defect in the parent vessel. Saccular lesions with large necks are better treated by some other method. Al¬ though utilized on four occasions early in our experience, aneurysmorrhaphy has been abandoned as more appro¬ priate reconstructive vascular techniques have been advanced. Rarely, internal carotid artery aneurysms may extend to the base of the skull.1"·7'-"' Under these circum¬ stances, the internal carotid artery is not accessible. This problem has been successfully managed by performing endoaneurysmorrhaphy over an internal shunt wedged into the carotid foramen.' Ligation of the common and internal and carotid arteries was once considered the most judicious method of dealing with carotid aneurysms.171'- This procedure is associated with excessive mortality1" and presently should be consid¬ ered only as a last resort.1" Aneurysms of the extracranial carotid arteries are rare lesions attended by a high incidence of neurologic compli¬ cations. These aneurysms frequently present unusual tech-
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'"
nical challenges. Careful preoperative planning and execu¬ tion of an appropriate operation is essential to the successful management of these lesions. References 1. Boddie HG: Transient ischaemic attacks and stroke due to extracranial aneurysm of internal carotid artery. Br Med J 3:802-803, 1972. 2. Hammon JW Jr, Silver D, Young WG Jr: Congenital aneurysm of the extracranial carotid arteries. Ann Surg 176:777-781, 1972. 3. Hershey FB: Operation for aneurysm of the internal carotid artery high in the neck: A new and an old technique. Angiology 25:24-30, 1974. 4. Kirby CK, Johnson J, Donald JG: Aneurysm of the common carotid artery. Ann Surg 130:913-920, 1949. 5. Kianouri M: Extracranial carotid aneurysms: Treatment by excision and end-to-end anastomosis. Ann Surg 165:152-156, 1967. 6. Margolis MT, Stein RL, Newton TH: Extracranial aneurysms of the internal carotid artery. Neuroradiology 4:78-89, 1972. 7. Robinson NA, Flotte CT: Traumatic aneurysms of the carotid arteries. Am Surg 40:121-124, 1974. 8. Shumacker HB, Carter KL: Arteriovenous fistulas and arterial aneurysm in military personnel. Surgery 20:9-25, 1946. 9. Deysine M, Adiga R, Wilder JR: Traumatic false aneurysm of the cervical internal carotid artery. Surgery 66:1004-1007, 1969. 10. Salmon JH, Blatt ES: Aneurysm of the internal carotid artery due to closed trauma. Thorac Cardiovasc Surg 56:28-32, 1968. 11. Boldrey E, Maass L, Miller E: The role of atlantoid compression in the etiology of internal carotid thrombosis. J Neurosurg 13:127-139, 1956. 12. New PFJ, Momose KJ: Traumatic dissection of the internal carotid artery at the atlantoaxial level, secondary to nonpenetrating injury. Radiology 93:41-49, 1969. 13. Blackford JM, McLaughlin JS: Pseudoaneurysms of the carotid artery. Am Surg 38:257-259, 1973. 14. Ehrenfeld WK, Hays RJ: False aneurysm after carotid endarterectomy. Arch Surg 104:288-291, 1972. 15. Smith RB III, Perdue GD Jr, Collier RH, et al: Post-operative false aneurysms of the carotid artery. Am Surg 32:335-341, 1970. 16. Beall AC Jr, Crawford ES, Cooley DA, et al: Extracranial aneurysms J
of the carotid artery: Report of seven cases. Postgrad Med 32:93-102, 1962. 17. Shipley AM, Winslow N, Walker WW: Aneurysm in the cervical portion of the internal carotid artery: An analytical study of the cases recorded in the literature between Aug 1,1925, and July 31,1936: Report of two new cases. Ann Surg 105:673-699, 1937. 18. Winslow N: Extracranial aneurysm of the internal carotid artery: History and analysis of the cases registered up to Aug 1, 1925. Arch Surg 13:689-729, 1926. 19. Rittenhouse EA, Radke HM, Sumner DS: Carotid artery aneurysm: Review of the literature and report of a case with rupture into the
oropharynx.
Arch Surg 105:786-789, 1972. 20. Hardin CA: Cervical aneurysms and tumors: Management of cases requiring resection and restoration of the carotid artery. Arch Surg 82:435\x=req-\ 439, 1961. 21. Razdan AN, Sharma BD, Kak VK: Traumatic aneurysm of the common carotid artery treated by excision and arterial homograft. J Int Coll Surg 42:126-133, 1964. 22. Barnes WT, Jacoby GE: Aneurysm of the common carotid artery due to cystic medial necrosis treated by excision and graft. Ann Surg 155:82-85, 1962. 23. Halasz NA, Kennady JC: Excision of arteriosclerotic aneurysms of the cervical internal carotid artery. J Neurosurg 21:352-357, 1964. 24. Eiseman B, Paton BC, Hogshead H: The use of an internal polyethylene shunt during the resection of a carotid aneurysm. Am J Surg 102:702\x=req-\ 705, 1961. 25. Wylie EJ, Ehrenfeld WK: Surgical techniques, in Extracranial Occlusive Cerebrovascular Disease, Diagnosis and Management. Philadelphia, WB Saunders Co, 1970. 26. Dintza A: Aneurysm of carotid arteries: Report of two cases. Angiology 7:218-227, 1956. 27. Webb RC Jr, Barker WF: Aneurysms of the extracranial internal carotid artery. Arch Surg 99:501-505, 1969. 28. Wagner M, Benjamin HB, Zeit W: Carotid artery insufficiency: Variable etiological factors with tailored surgical treatment. Arch Surg 82:679-682, 1961. 29. Wilson JR, Jordan PH: Excision of an internal carotid artery aneurysm: Restitution of continuity by substitution of external for internal carotid artery. Ann Surg 154:45-47, 1961. 30. Kaupp HA, Haid SP, Jurayj MN, et al: Aneurysms of the extracranial carotid artery. Surgery 72:946-952, 1972.
Discussion Falls Bacon Hershey, MD, St Louis: I rise to inquire mainly about the internal carotid aneurysms. When these are high, they are a difficult challenge; these are the hard ones. An anastomosis cannot always be done high up at the base of the skull. Wiley Barker, a few years ago, published a series of cases in which the only feasible procedure was ligation of the internal carotid artery and, as Dr Rhodes noted, this is frequently followed by stroke and death. For these aneurysms, I recommend one old and one new technique. For example, there is the occurrence of a high aneu¬ rysm of the internal carotid, with an internal shunt in place: the ordinary internal shunt cannot be held in place because a clamp or tape cannot be placed above the high aneurysm. I used a tapered catheter, which can be found in a dialysis unit. The catheter can be trimmed to the appropriate length and size. The small end is wedged up into the artery at the bony foramen. The proximal end is held in place in the common carotid artery with the usual Javid clamp or with the tape. This shunt maintains flow to the brain during the aneurysmorrhaphy and it also serves as a stent for the aneurysmorrhaphy. The repair devised by Dr Matas in 1903 for popliteal aneurysms maintains continuity of the artery and makes
a new
with
channel
multiple
by folding the inside of the sac around the catheter
of sutures. than in 1903. The excess sac can be trimmed and by using monofilament sutures, one can place continuous sutures that glide through the tissue to construct the channel, and then extract the shunt just before the last few sutures are tied. I would like to reinforce Dr Rhodes' statement about the need for operation, especially for internal carotid aneurysms. An article by Winslow from 1925 reported 105 cases of internal carotid aneurysms. Of the patients not operated on, 71% died of complications of the aneurysm; at that time, ligation, the only procedure available, had a mortality of 30%. I hope this reminder and this experience in one old Matas operation and the new shunt may occasionally be helpful. Dr Fry: We are indebted to Dr Hershey for emphasizing a very excellent method to bypass and correct the very large internal carotid artery aneurysm that extends to the base of the skull. We, fortunately, have not encountered this lesion in our series. His reemphasis of Dr Matas' original work, in addition to the use of the shunt, is a very fine way to solve this very difficult It is easier
rows
now
problem.
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of Extracranial Carotid Arteries E. Leeon Rhodes, MD; James C. Stanley, MD; Jack L. Cronenwett, MD; William J. Fry, MD
Gary
L.
Hoffman, MD;
\s=b\ Twenty-three extracranial carotid artery aneurysms were encountered in 19 patients. Arteriosclerosis was evident in 16 aneurysms. Severe arterial hypertension affected all patients with arteriosclerotic lesions. Trauma, penetrating neck injury once, and blunt neck injury three times caused four aneurysms. Three aneurysms resulted from earlier carotid artery operations. All 19 patients were symptomatic. Neurologic symptoms affected 13 individuals. Local symptoms referable to the aneurysmal mass troubled 15 patients. Twenty-one aneurysms were treated operatively. There was no operative mortality. Aneurysmectomy with arterial reconstruction was performed 16 times. Aneurysmorrhaphy was undertaken on four occasions and carotid ligation once. Two strokes and multiple cranial nerve injury accounted for three operative complications. No neurologic complications occurred during follow-up totaling 360 manmonths. These lesions may be successfully treated by a carefully performed, properly selected operation.
(Arch Surg 111:339-343, 1976)
of the extracranial carotid arteries are rare vascular lesions. Operative indications and tech¬ for vascular reconstruction are ill-defined. Interpre¬ tation of data generated from numerous isolated case reports has not provided a firm basis for our under¬ standing of these lesions. Large clinical experiences at any one given institution are nonexistent. Aneurysms involving the extracranial carotid arteries were encountered in 19 patients at the University of Michigan Medical Center from 1959 to 1975. Etiologic factors, clinical manifestations, and operative manage¬ ment of these patients provide the basis of this report.
Aneurysms niques L
Accepted
for publication Dec 4, 1975. Department of Surgery, Section of General Surgery, University of Michigan Medical Center, Ann Arbor. Read before the 83rd annual meeting of the Western Surgical Association, Colorado Springs, Colo, Nov 20, 1975. Reprint requests to University Hospital, 1405 E Ann St, Ann Arbor, MI 48104 (Dr Rhodes). From the
SUBJECTS AND METHODS
patients harboring
23 extracranial carotid artery identified. Included were 14 men and five women, ranging from 18 to 78 years in age. Aneurysm size varied from 1.5 to 8.0 cm. The common carotid artery was the site of two aneurysms. The internal carotid artery was involved with eight aneurysms. The carotid bifurcation, with common, external, and internal carotid artery involvement, was the location of the remaining 13 aneurysms. A saccular configuration was noted in five internal carotid artery aneurysms. Fusiform shapes occurred in the remaining aneurysms. Nine patients had aneurysms of the left side, six had right-sided lesions, and four exhibited bilateral lesions. Arteriosclerosis was the most common pathologic process observed in this series. Histologie confirmation of arteriosclerosis was present in 12 individuals (four of whom had bilateral lesions), and accounted for 16 carotid artery aneurysms. Internal elastic lamina disruption and medial thinning was apparent in 14 specimens available for histologie examination. All these lesions exhibited advanced calcifié arteriosclerosis. Manifestations of generalized arteriosclerosis were evident in eight of the 12 patients. Severe aortoiliac occlusive disease affected four individ¬ uals, three of whom also had previous myocardial infarctions. Infrarenal abdominal aortic aneurysms were documented in four additional patients. Severe arterial hypertension affected all 12 patients with arteriosclerotic carotid artery aneurysms. The mean blood pressure of these patients was 180/117 mm Hg (range, 160/100 to 240/160 mm Hg). Trauma caused four aneurysms. A gunshot injury of the neck resulted in one pseudoaneurysm of the right common carotid artery. Forceful blows in the region of the mandibular angle, the result of a fall (twice) and a karate chop (once), resulted in three aneurysms of the internal carotid artery. Previous carotid artery endarterectomy led to the development of three pseudoaneurysms of the carotid bifurcation. Suture line infection caused two of these lesions, while an anastomotic leak accounted for the third. Nineteen
aneurysms
were
Clinical Manifestations All 19 patients complained of symptoms referable to aneurysmal disease. Neurologic symptoms were a prominent feature in the
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patients. Frank stroke was apparent in three patients. Complaints of intermittent hemiparesis were described in three individuals. Amaurosis fugax was the only neurologic deficit in three cases. Vague neurologic disturbances including dizziness and numbness troubled the four remaining patients. Immediate loss of consciousness and contralateral hemiparesis histories of 13
affected four individuals who had sustained trauma to the neck. Unconsciousness was momentary in the case of penetrating trauma and in one case of blunt trauma. Unconsciousness lasted approximately 24 hours in two remaining patients. Neurologic deficits were permanent in three of these four individuals. An uncomfortable pulsating sensation in the neck was noted in nine of 13 patients with neurologic symptoms. Difficulty in swallowing affected one of these nine individuals. All four patients with traumatic aneurysms were unaware of their lesions. Presence of an uncomfortable, pulsatile mass in the neck was the only complaint in four individuals. Dysphasia was the only symptom in two patients. Acute expansion or rupture was not encountered in this experience.
Methods of Management Restoration of Arterial Continuity Primary arterial anastomosis Common carotid artery to internal carotid artery Common carotid artery to conjoined internal and external carotid artery External to internal carotid artery Vein graft
Operation Aneurysmectomy
Interposition graft
Common carotid artery to internal carotid artery Patch graft Common carotid artery
Aneurysmorrhaphy
Primary
closure Bifurcation Patch graft Vein graft Common carotid artery Internal carotid artery
Synthetic graft
Management Twenty-one aneurysms were treated by operation (Table). Aneurysmectomy was performed on 16 occasions. Restoration of arterial continuity by either primary end-to-end arterial anasto¬ mosis, interposition vein graft, or vein patch graft was accomplished following aneurysmectomy. Aneurysmorrhaphy was performed for four aneurysms. Restoration of arterial continuity by primary closure or patch grafts of either autogenous saphenous or synthetic material was accomplished following aneurysmorrha¬ phy. Ligation of the common and internal carotid arteries was employed in one severely infected pseudoaneurysm. Shunting technique (internal, 11 times, and external, twice) was used to preserve cerebral blood flow during 13 operations. Shunts were not used in the remaining operations. Two patients with aneurysms have been followed up without operation. These aneurysms remained less than 2 cm in greatest dimension. The only symptoms in these cases relate to sensations of a pulsatile neck mass. Each patient had undergone previous aneurysmectomy for arteriosclerotic lesions of the contralateral carotid artery. RESULTS
Eighteen aneurysms were successfully operated on without incident. Three preventable operative complica¬ tions occurred. Failure to spatulate proximal and distal anastomoses of an interposition graft in one patient resulted in suture line stricture six months following aneurysmectomy. Repair of the stenosis resulted in a transient hemiparesis. A second stroke resulted from distal embolization of dislodged mural thrombus during posi¬ tioning of an internal shunt. Injury to the glossopharyngeal, vagus, and hypoglossal nerves occurred following complete excision of a large arteriosclerotic aneurysm. No operative deaths occurred in this experience. Thirteen patients treated operatively were available for follow-up totaling 360 man-months. No subsequent neurologic defi¬ cits occurred during this interval. Two patients treated nonoperatively have been followed up a total of 35 manmonths. Their aneurysms have not enlarged or become symptomatic. Four patients died from diseases unrelated to their carotid artery aneurysm.
No.
1
Bifurcation
Ligation
1 1
Common and internal carotid artery
COMMENT
Pathogenesis Arteriosclerosis and trauma account for the majority of extracranial carotid artery aneurysms.1 :l Luetic aneu¬ rysms, more common in the past,' are now distinctly unusual." Severe arterial hypertension was a constant finding in all the patients of this series who had arterio¬ sclerotic lesions. Arterial hypertension appears more than coincidentally related to development of arteriosclerotic extracranial carotid artery aneurysms. Aneurysms follow¬ ing penetrating trauma are unusual lesions.7 Military*' and civilian7" experiences have documented the importance of this etiologic mechanism. Blunt trauma to the neck usually results in thrombosis of injured vessels rather than aneu¬ rysm development."' Hyperextension and rotation of the neck causes compression of the internal carotid artery on the transverse process of the atlas." This may result in intimai fracture and subsequent thrombosis." Aneurysm formation secondary to blunt trauma is believed to result from a similar mechanism of injury. It is speculated that impingement of the internal carotid artery between the mandibular angle and the atlas following a forceful blow is the basis of this injury. Pseudoaneurysm formation follow¬ ing previous carotid artery endarterectomy is an infre¬ quent, but well-known event.''"17' Suture line disruption due to technical error or infection results in the usual cause of these lesions.1115 "'
Therapeutic Approach It has been stated that hemorrhage due to rupture is the most frequent cause of death.1"1" Although well docu¬ mented,17/1" this complication of carotid artery aneurysm was not encountered in the present series. Neurologic complications are also recognized1 "' and are substantiated by our experience. Prevention of severe neurologic compli¬ cations, rather than prevention of rupture, provides the
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Fig 1.—Conjoining internal and external carotid arteries with end-to-end anasto¬ mosis to common carotid artery.
Fig 2.—End-to-end anastomosis of exter¬ nal carotid and internal carotid arteries.
Fig 3.—Interposing internal shunt.
a
vein
graft
over
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greater impetus for aggressive surgical management of these lesions.
Arteriograms evaluating the status of both the extra¬ cranial carotid vessels and the intracranial cerebral circu¬ lation are mandatory for planning an optimal operative approach to these lesions. Presence of intraluminal thrombus may be discovered with these studies. Tortuous internal carotid arteries, amenable to mobilization and end-to-end anastomosis with common carotid arteries, may similarly be recognized preoperatively. General Technical Considerations
Shunting.-Preservation of cerebral blood flow utilizing shunting techniques is preferable to reliance on the adequacy of collateral circulation to prevent cerebral
ischemia.7'" -' An internal shunt from the common to the internal carotid artery is the simplest means of assuring sufficient cerebral perfusion. This technique is especially useful when using autogenous saphenous vein interposi¬ tion grafts. External shunting of large aneurysms has been advocated7'--'; this is technically difficult.71 Internal shunting of even the largest carotid artery aneurysm seems more advisable. Occasionally, small saccular aneu¬ rysms of the internal carotid artery, amenable to tangen¬ tial excision, may be expeditiously managed without shunting techniques. A back pressure of 40 mm Hg within the internal carotid artery is necessary for adequate cerebral protection.77' Under these circumstances, no artifi¬ cial shunt is necessary. Exposure.—Adequate exposure of carotid aneurysms and uninvolved proximal and distal vessels is essential for successful operative management of these lesions. Trans¬ verse incisions begun at the hyoid and gently curved toward the mastoid process provide adequate exposure in most instances. Vertical neck incisions paralleling the medial border of the sternocleidomastoid or transverse incisions positioned lower in the neck may provide better exposure of the common carotid artery. Many aneurysms contain laminated clot not detected angiographically. Inju¬ dicious handling of aneurysms prior to placement of an internal shunt may cause distal embolization. This disas¬ trous complication is best avoided by first dissecting normal proximal and distal arteries. Once these vessels are controlled, they are clamped and the aneurysm incised. Laminated clot and atheromatous debris can then be removed from the aneurysmal sac. Once this is accom¬ plished, an internal shunt can be safely positioned under direct vision. Alternative Operative Techniques.—Aneurysmectomy with restoration of arterial continuity by primary end-to-end anastomosis of the common and internal carotid arteries was first performed over 20 years ago.7"' Aneurysm resec¬ tion with arterial reconstruction is the treatment of choice.7,777 Primary end-to-end anastomosis of common carotid and internal carotid arteries is the perferred means of reestablishing arterial continuity. Anastomotic stric¬ tures may be avoided by spatulation of both proximal and distal vessels prior to their approximation. A patulous anastomosis results that is unlikely to become stenotic. Size
discrepancies of the internal and common carotid arteries can be overcome by more extensive spatulation of the
internal carotid vessel. This maneuver is not without hazard. Extensive spatulation of the internal carotid artery sacrifices length. Alternative techniques should be utilized if suture line tension exists. Anastomotic tension may be lessened by spatulation of both the internal and external carotid arteries, suturing these vessels together, and approximating this conjoined vessel to the common carotid artery-'" (Fig 1). When the internal carotid artery is of insufficient length to use this technique, primary end-toend arterial anastomosis may be achieved by oversewing the orifice of the internal carotid artery at the carotid bifurcation, ligating the external carotid artery and its branches distally, dividing the external carotid artery, and suturing it to the internal carotid artery7'" (Fig 2). Interposition grafts are utilized when inadequate lengths of carotid vessels preclude primary anastomoses using one of the aforementioned techniques. Autologous saphenous vein is most suitable for this graft. Prior to clamping and resecting the aneurysm, a suitable section of saphenous vein is threaded over an internal shunt. The shunt is positioned in both the internal and common carotid arteries after blood flow is momentarily arrested and the aneurysm incised. The distal anastomosis and one half of the proximal anastomosis is completed around the shunt. The shunt is then removed and the proximal anas¬ tomosis completed (Fig 3). Appropriate synthetic grafts can be substituted when suitable saphenous vein is unavail¬ able. Complete excision of large carotid aneurysms is not advised. Large aneurysms may have important neural structures adherent to their walls. To avoid injury to these structures, entering and exiting vessels are momentarily occluded, the aneurysm incised, and an internal shunt inserted. The aneurysmal sac is then partially excised, leaving behind that portion of the sac adherent to adjacent cranial nerves. Saccular aneurysms with narrow necks are effectively treated by aneurysmectomy and vein patch repair of the arterial defect in the parent vessel. Saccular lesions with large necks are better treated by some other method. Al¬ though utilized on four occasions early in our experience, aneurysmorrhaphy has been abandoned as more appro¬ priate reconstructive vascular techniques have been advanced. Rarely, internal carotid artery aneurysms may extend to the base of the skull.1"·7'-"' Under these circum¬ stances, the internal carotid artery is not accessible. This problem has been successfully managed by performing endoaneurysmorrhaphy over an internal shunt wedged into the carotid foramen.' Ligation of the common and internal and carotid arteries was once considered the most judicious method of dealing with carotid aneurysms.171'- This procedure is associated with excessive mortality1" and presently should be consid¬ ered only as a last resort.1" Aneurysms of the extracranial carotid arteries are rare lesions attended by a high incidence of neurologic compli¬ cations. These aneurysms frequently present unusual tech-
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nical challenges. Careful preoperative planning and execu¬ tion of an appropriate operation is essential to the successful management of these lesions. References 1. Boddie HG: Transient ischaemic attacks and stroke due to extracranial aneurysm of internal carotid artery. Br Med J 3:802-803, 1972. 2. Hammon JW Jr, Silver D, Young WG Jr: Congenital aneurysm of the extracranial carotid arteries. Ann Surg 176:777-781, 1972. 3. Hershey FB: Operation for aneurysm of the internal carotid artery high in the neck: A new and an old technique. Angiology 25:24-30, 1974. 4. Kirby CK, Johnson J, Donald JG: Aneurysm of the common carotid artery. Ann Surg 130:913-920, 1949. 5. Kianouri M: Extracranial carotid aneurysms: Treatment by excision and end-to-end anastomosis. Ann Surg 165:152-156, 1967. 6. Margolis MT, Stein RL, Newton TH: Extracranial aneurysms of the internal carotid artery. Neuroradiology 4:78-89, 1972. 7. Robinson NA, Flotte CT: Traumatic aneurysms of the carotid arteries. Am Surg 40:121-124, 1974. 8. Shumacker HB, Carter KL: Arteriovenous fistulas and arterial aneurysm in military personnel. Surgery 20:9-25, 1946. 9. Deysine M, Adiga R, Wilder JR: Traumatic false aneurysm of the cervical internal carotid artery. Surgery 66:1004-1007, 1969. 10. Salmon JH, Blatt ES: Aneurysm of the internal carotid artery due to closed trauma. Thorac Cardiovasc Surg 56:28-32, 1968. 11. Boldrey E, Maass L, Miller E: The role of atlantoid compression in the etiology of internal carotid thrombosis. J Neurosurg 13:127-139, 1956. 12. New PFJ, Momose KJ: Traumatic dissection of the internal carotid artery at the atlantoaxial level, secondary to nonpenetrating injury. Radiology 93:41-49, 1969. 13. Blackford JM, McLaughlin JS: Pseudoaneurysms of the carotid artery. Am Surg 38:257-259, 1973. 14. Ehrenfeld WK, Hays RJ: False aneurysm after carotid endarterectomy. Arch Surg 104:288-291, 1972. 15. Smith RB III, Perdue GD Jr, Collier RH, et al: Post-operative false aneurysms of the carotid artery. Am Surg 32:335-341, 1970. 16. Beall AC Jr, Crawford ES, Cooley DA, et al: Extracranial aneurysms J
of the carotid artery: Report of seven cases. Postgrad Med 32:93-102, 1962. 17. Shipley AM, Winslow N, Walker WW: Aneurysm in the cervical portion of the internal carotid artery: An analytical study of the cases recorded in the literature between Aug 1,1925, and July 31,1936: Report of two new cases. Ann Surg 105:673-699, 1937. 18. Winslow N: Extracranial aneurysm of the internal carotid artery: History and analysis of the cases registered up to Aug 1, 1925. Arch Surg 13:689-729, 1926. 19. Rittenhouse EA, Radke HM, Sumner DS: Carotid artery aneurysm: Review of the literature and report of a case with rupture into the
oropharynx.
Arch Surg 105:786-789, 1972. 20. Hardin CA: Cervical aneurysms and tumors: Management of cases requiring resection and restoration of the carotid artery. Arch Surg 82:435\x=req-\ 439, 1961. 21. Razdan AN, Sharma BD, Kak VK: Traumatic aneurysm of the common carotid artery treated by excision and arterial homograft. J Int Coll Surg 42:126-133, 1964. 22. Barnes WT, Jacoby GE: Aneurysm of the common carotid artery due to cystic medial necrosis treated by excision and graft. Ann Surg 155:82-85, 1962. 23. Halasz NA, Kennady JC: Excision of arteriosclerotic aneurysms of the cervical internal carotid artery. J Neurosurg 21:352-357, 1964. 24. Eiseman B, Paton BC, Hogshead H: The use of an internal polyethylene shunt during the resection of a carotid aneurysm. Am J Surg 102:702\x=req-\ 705, 1961. 25. Wylie EJ, Ehrenfeld WK: Surgical techniques, in Extracranial Occlusive Cerebrovascular Disease, Diagnosis and Management. Philadelphia, WB Saunders Co, 1970. 26. Dintza A: Aneurysm of carotid arteries: Report of two cases. Angiology 7:218-227, 1956. 27. Webb RC Jr, Barker WF: Aneurysms of the extracranial internal carotid artery. Arch Surg 99:501-505, 1969. 28. Wagner M, Benjamin HB, Zeit W: Carotid artery insufficiency: Variable etiological factors with tailored surgical treatment. Arch Surg 82:679-682, 1961. 29. Wilson JR, Jordan PH: Excision of an internal carotid artery aneurysm: Restitution of continuity by substitution of external for internal carotid artery. Ann Surg 154:45-47, 1961. 30. Kaupp HA, Haid SP, Jurayj MN, et al: Aneurysms of the extracranial carotid artery. Surgery 72:946-952, 1972.
Discussion Falls Bacon Hershey, MD, St Louis: I rise to inquire mainly about the internal carotid aneurysms. When these are high, they are a difficult challenge; these are the hard ones. An anastomosis cannot always be done high up at the base of the skull. Wiley Barker, a few years ago, published a series of cases in which the only feasible procedure was ligation of the internal carotid artery and, as Dr Rhodes noted, this is frequently followed by stroke and death. For these aneurysms, I recommend one old and one new technique. For example, there is the occurrence of a high aneu¬ rysm of the internal carotid, with an internal shunt in place: the ordinary internal shunt cannot be held in place because a clamp or tape cannot be placed above the high aneurysm. I used a tapered catheter, which can be found in a dialysis unit. The catheter can be trimmed to the appropriate length and size. The small end is wedged up into the artery at the bony foramen. The proximal end is held in place in the common carotid artery with the usual Javid clamp or with the tape. This shunt maintains flow to the brain during the aneurysmorrhaphy and it also serves as a stent for the aneurysmorrhaphy. The repair devised by Dr Matas in 1903 for popliteal aneurysms maintains continuity of the artery and makes
a new
with
channel
multiple
by folding the inside of the sac around the catheter
of sutures. than in 1903. The excess sac can be trimmed and by using monofilament sutures, one can place continuous sutures that glide through the tissue to construct the channel, and then extract the shunt just before the last few sutures are tied. I would like to reinforce Dr Rhodes' statement about the need for operation, especially for internal carotid aneurysms. An article by Winslow from 1925 reported 105 cases of internal carotid aneurysms. Of the patients not operated on, 71% died of complications of the aneurysm; at that time, ligation, the only procedure available, had a mortality of 30%. I hope this reminder and this experience in one old Matas operation and the new shunt may occasionally be helpful. Dr Fry: We are indebted to Dr Hershey for emphasizing a very excellent method to bypass and correct the very large internal carotid artery aneurysm that extends to the base of the skull. We, fortunately, have not encountered this lesion in our series. His reemphasis of Dr Matas' original work, in addition to the use of the shunt, is a very fine way to solve this very difficult It is easier
rows
now
problem.
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