Aneurysms of the Extracranial Carotid Artery Twenty-One Years’ Experience
Charles H. McCollum, MD, Houston, Texas Wllllam G. Wheeler, MD, Houston, Texas George P. Noon, MD, Houston, Texas Michael E. DeBakey, MD, Houston, Texas
Aneurysms of the extracranial carotid artery are uncommon vascular lesions. A previous report from this institution revealed only seven aneurysms of the extracranial carotid artery during an eleven year period when approximately 2,300 operations were performed for aneurysms in other areas of the arterial tree [I]. Until recently the most common complication was expansion, rupture, and hemorrhage [2]. Recently, many of these patients have presented with symptoms of transient ischemic cerebral attacks from emboli [3]. Although aneurysms of the extracranial carotid artery have been reported for many years in the medical literature, it has been only within the past twenty-five years that modern vascular technics were available for surgical corrections. Material and Methods The present report deals with the twenty-one year experience with aneurysms of the extracranial carotid artery at the Methodist Hospital, Houston, Texas. During the period from 1956 to 1977, thirty-seven aneurysms of the extracranial carotid artery were seen in thirty-four patients. During this same period approximately 8,500 aneurysms of the arterial tree were treated surgically. All patients presented with a swelling or mass in the neck. The diagnosis was confirmed by arteriography in all cases. The average age at diagnosis was fifty-nine years (range, 29 to 92 years). Men outnumbered women 2:1(23 males, 11 females). Sixteen (44 per cent) were atheroscle-
rotic aneurysms. (Table I.) Twenty-one patients (56 per cent) had false aneurysms of the carotid artery; nineteen of these aneurysms followed previous carotid artery surgery, and two developed after remote gunshot wounds of the neck. Of the nineteen false aneurysms following previous carotid artery surgery, sixteen occurred after carotid endarterectomy with patch angioplasty. The other three false aneurysms developed after carotid-subclavian bypass, aortocarotid bypass, and previous resection of an atherosclerotic aneurysm of the carotid artery with Dacron”graft replacement. Patients with six of the nineteen false aneurysms had the primary carotid artery procedure done elsewhere. Associated diseases are shown in Table II. Only five patients (15 per cent) had cerebrovascular symptoms associated with the extracranial carotid artery aneurysm. Hypertension and coronary artery disease were each seen in fourteen patients (41 per cent). Aortic or other peripheral aneurysms were seen in eight patients (24 per cent). Associated occlusive vascular disease of the lower extremities was seen in six patients (18 per cent). Both associated aneurysmal and occlusive diseases were more commonly seen in patients with previous carotid artery occlusive disease surgery than with atherosclerotic carotid artery aneurysms. Diabetes mellitus was present in only two patients.
TABLE I
Classification of Extracranial Carotid Artery Aneurysms In Thirty-Four Patients
Classification From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas. Reprint requests should be addressed to Charles Ii. MoCollum. MD, Cora and Webb Mading Department of Surgery. Baylor College of Medicine, 1200 Moursund Avenue, Houston, Texas 77030. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
196
Atherosclerotic False Preyious carotid artery surgery PosttraumaGc Total
No. of Aneurysms 16 (44%) 21 (56%) 19 2 37 (100%)
The American Journal 01 Surgery
Extracranial
TABLE II
Cerebrovascular Symptoms
Atherosclerotic False
2 (15%) 3 (14%)
Total
5 (15%)
Hypertension 6 (46%) 6 (38%) 14(41%)
Our technic for carotid artery surgery included general anesthesia and normothermia [4]. Blood pressure was maintained at normotensive levels with the use of vasodilator or vasopressor agents or volume replacement. Standard oxygen and carbon dioxide tensions were maintained. A temporary intraluminal carotid artery shunt was usually used to minimize cerebral ischemia. Results
Twenty-eight aneurysms were treated operatively (Table III) and nine nonoperatively. The usual reason for a nonoperative approach was an asymptomatic patient with a small aneurysm which was known to be stable in size or the presence of other severe, high risk medical disease. Eighteen aneurysms were resected, and patch angioplasty was performed. Six aneurysms were completely resected and replaced with a Dacron tube graft. Four aneurysms were resected with proximal and distal ligation of the internal carotid artery. Nine atherosclerotic aneurysms were treated surgically. The aneurysm was resected and the internal carotid artery ligated proximally and distally in three patients early in the series; these aneurysms were inaccessibly high in location. (Figure 1.) Three aneurysms were treated with resection of the aneurysmal portion and patch angioplasty (Figure 2), and three required resection and tube graft replacement (Figure 3). Two patients with atherosclerotic aneurysms had neurological symptoms preoperatively; one had
Coronary Artery Disease
Other Aneurysms
Peripheral Occlusive Disease
Diabetes
4(31%) 10 (48%)
2 (15%) 6 (29%)
: (29%)
0 2 (10%)
14(41%)
8 (24%)
6 (18%)
2 (6%)
transient ischemic attacks and one had hemiparesis. (Table IV.) The one with transient ischemic attacks had no neurological symptoms postoperatively, and the patient with the hemiparesis was improved postoperatively. One patient with no preoperative neurological symptoms underwent resection of an atherosclerotic aneurysm and patch angioplasty, and mild hemiparesis developed postoperatively. One other patient who preoperatively was intact neurologically underwent resection of the aneurysm and ligation in 1961. Postoperatively, massive cerebral infarction developed, and he died. Postmortem examination revealed a congenitally incomplete circle of Willis. The other operative death was due to a myocardial infarction after resection of an atherosclerotic extracranial aneurysm. False aneurysms developing after previous carotid artery surgery occurred between one month and fifteen years later, with an average of 6.2 years later. The majority of false aneurysms were handled by resection of the aneurysmal portion and replacement with a Dacron patch. (Figure 4.) This allowed a quicker repair with minimal cerebral ischemic time. Only one false aneurysm required resection and graft replacement. One false aneurysm was resected with
Treatment of Extracranial Carotid Artery Aneurysms in 34 Patients
Aneurysms Atherosclerotic False Previous carotid artery surgery Posttraumatic Total
Aneurysms
Diseases Associated with Extracranial Carotid Artery Aneurysms
Aneurysms
TABLE III
Carotid
Resection and Patch Tube AngioReplaceplasty ment
None
Ligation
7
3
3
3
16
2
1
15
1
19
0
0
0
2
2
9(24%)
Volume 137, February 1979
4(11%)
18(49%)
6(16%)
Total
37
Figure 1. Large atherosclerotic aneurysms high in lett internal carotid artery treated by resection with proximal and distal ligation.
197
McCollumet al
Figure 2. Large saccular atherosclerotic aneurysm of left internal carotid artery treated by resection and patch angioplasty.
proximal and distal ligation in a patient with an occluded internal carotid artery. Three patients with false aneurysm of the carotid artery had cerebrovascular symptoms preoperatively. Two had fixed neurological deficits; one of these was admitted with acute hemiplegia and the other had had multiple ischemic attacks and developed hemiplegia prior to the previous carotid endarterectomy. The third patient had only transient ischemic attacks. All of these patients were improved or stable neurologically after operation. One patient with no preoperative neurological symptoms underwent resection of a false aneurysm and patch angioplasty and developed hemiplegia postoperatively. Both of the posttraumatic false aneurysms were treated by resection of the aneurysm of the common carotid artery and tube graft replacement. (Figure 5.) None of the patients with posttraumatic aneurysms had any pre- or postoperative neurological symptoms. There were no deaths in the false aneurysm group. The patients have been followed from one to fifteen years. Only one patient was lost to follow-up.
TABLE IV
Results Atter Surgery for Extracranial Carotid Artery Aneurysms in 28 Patients
Aneurysms
Neurologically Stable or Improved
Hemiparesis
Deaths
Atherosclerotic False Previous carotid artery surgery Posttraumatic
6
1
2
16
1
0
2
0
0
Total
24
2
2 (7%)
198
Figure 3. Patient presented w/th transknt &chemk cerebral attacks and pukatife mass in leff neck. Carotid arterk&ram demonstrated atherosclerotic aneurysm of left internal carotid artery which was treated by resection and replacement with tube graft.
Eight of the twenty-six patients who survived surgery for correction of the extracranial carotid artery aneurysm died one to fourteen years after surgery. One patient died of cerebral thrombosis seven years after surgery. Three of the late deaths were due to myocardial infarction, two to malignancy, and one to intestinal obstruction. The cause of one death was unknown. Three of the nonoperated patients died two weeks to two years after the diagnosis of extracranial carotid artery aneurysms; two died of myocardial infarction and one of a ruptured thoracic aneurysm. Comments
The first successful surgical treatment for an aneurysm of the extracranial carotid artery was by Sir Athley Cooper [5] in 1808. Carotid artery ligation generally has been abandoned as the treatment of choice because of the high risk of cerebral ischemia (30 per cent) [6]. Wrapping of the aneurysm with fascia or cellophane is no longer considered adequate [7]. Resection of the aneurysm with restoration of arterial continuity is the preferable treatment. Many authors prefer resection with primary end-to-end anastomosis [8,9]. Many causes of aneurysms of the extracranial carotid artery have been reported. Many are atherosclerotic in origin [8-IO]. Other causes include mycotic aneurysms [11,12], posttraumatic aneurysms [13], dissecting aneurysms of the carotid artery [14],
The American Journal 01 Surgery
Extracranial
Carotid Aneurysms
Figure 4. Patient with transient ischemic attacks secondary to atherosclerotic occlusive disease of right carotid artery bifurcation treated wtth carotid endarterectomy patch and angk@asty in 7963. Patient presented in 1967 with mass in neck. Arteriograms demonstrated fatse aneurysm at site of endarterectomy which resected was with patch angioplasty. Follow-up arteriogram three years later ( 1979) showed satisfactory postoperative results.
aneurysms after irradiation of cervical malignancy [15], aneurysms after carotid arteriograms [16], congenital aneurysms, and aneurysms associated with cystic medial necrosis. Other reports demonstrate a rising incidence of false aneurysms after carotid endarterectomy [17,18]. Most previously published reports show a higher incidence of atherosclerotic aneurysms of the extracranial carotid artery than the present series. Only 44 per cent of our series were atherosclerotic aneurysms (16 aneurysms in 13 patients). Three of these were fusiform and located at the carotid bifurcation. (Figure 6.) Thirteen were saccular and located in the extracranial internal carotid artery, including bilateral aneurysms in three patients. Fifty-six per cent of aneurysms in the present series were considered false aneurysms (21 aneurysms in 21 patients). Nineteen of these aneurysms followed previous carotid artery surgery, and sixteen of these followed carotid endarterectomy. Only ten known false aneurysms developed in patients undergoing the original carotid endarterectomy at the Methodist Hospital from 1956 to 1977. During this same period, approximately 4,000 carotid endarterectomies were performed, most employing patch angioplasty. Thus, the incidence of false aneurysm development after carotid endarterectomy with patch angioplasty is low. It was difficult to determine a common factor in the formation of these false aneurysms. Of the thirteen false aneurysms of the extracranial carotid artery that developed after the initial carotid surgery here, silk suture was used in nine patch angioplasties, polyethylene in three, and Tycron@ in one. Localized wound infection was present in one patient. Differential diagnoses of the extracranial carotid aneurysm include carotid body tumors [19], peritonsillar abscess [20], cervical malignancy or lymphadenopathy, or elongation and tortuosity of the cervical carotid or subclavian arteries [21].
Volume 137, February 1979
The present series demonstrates that extracranial carotid aneurysms are rare but interesting problems in vascular surgery. Although the number of atherosclerotic aneurysms has been higher, the incidence of false aneurysms is increasing. The previous forms of surgery, including ligation or wrapping, have been replaced by resection and restoration of arterial continuity. The potential complications of cerebral emboli or rupture from extracranial carotid artery aneurysms justify an aggressive surgical approach. We have been pleased with the gratifying results in the surgical management of twenty-eight aneurysms of the extracranial carotid artery,
Figure 5. Patient who sustained gunshot wound to neck sixteen years prior to admission. He noted a mass in his neck two years rater, which gradually enlarged. The arteriogram confirmed the presence of posttraumatic false aneurysm of the left common carotid artery. This was resected with tube graft replacement with good resutts.
199
McCollum et al
References 1. BeallAC Jr, Crawford ES, Cooley DA, DeBakey ME: Extracranial 13
I 2.
(three bilateral)
v
3
i
3.
fall unilateral) 4.
5.
;:
Figure 6. Location and morphoiogy of atherosclerotic aneurysm.
6.
7. 8.
Summary
Aneurysms of the extracranial carotid artery are an uncommon but potentially serious problem, usually due to rupture or thromboembolic events. Thirty-seven aneurysms of the extracranial carotid artery were seen in thirty-four patients from 1956 to 1977. The ages ranged from twenty-nine to ninetytwo years, with an average of fifty-nine years. There were twenty-three males and eleven females. Nineteen (51 per cent) were false aneurysms, sixteen (44 per cent) atherosclerotic aneurysms, and two (5 per cent) posttraumatic aneurysms. All patients presented with evidence of a mass in the neck, and only five (15 per cent) had neurological symptoms related to the aneurysm. Surgery was performed on twenty-eight carotid aneurysms. Resection and patch angioplasty was employed for eighteen aneurysms, resection with graft replacement for six, and resection and ligation of the internal carotid artery for four. Postoperative neurologic deficits developed in three patients (11 per cent), and one of these died. There was one other operative death due to acute myocardial infarction (operative mortality, 7 per cent). Nonoperative treatment was employed when the patient had other associated high risk disease or a small asymptomatic aneurysm.
200
9.
10. 11.
12.
13. 14. 15.
16.
17. 18. 19.
20.
21.
aneurysms of the carotid artery: report of seven cases. Postgrad Med32: 93, 1962. Winslow N: Extracranial aneurysm of the internal carotid artery: history and analysis of the cases registered up to August 1, 1925. Arch Surg 13: 689, 1926. Spencer FC: Aneurysm of the common carotid artery treated by excision and primary anastomosis. Ann Surg 145: 254, 1957. Crawford ES, DeBakey ME, Garrett HC, Howell J: Surgical treatment of occlusive cerebrovascular disease. Surg C/in North Am 46: 873, 1966. Cooper A: Account of the first successful operation performed on the common carotid artery for aneurysm in the year of 1808 with postmortem examination in the year 1821. Guys Hasp Rep 1: 53, 1836. Leech PJ, Miller JD, Fitch W, Barker J: Cerebral blood flow, internal carotid artery pressure, and the EEG as a guide to the safety of carotid ligation. J Neural Neurosurg Psychiatry 37: 854, 1974. Thompson JE, Austin DJ: Surgical management of cervical carotid aneurysms. Arch Surg 74: 80, 1957. Kaupp HA, Haid SP, Jurayj MN, Bergan JJ, Trippel OH: Aneurysms of the extracranial carotid artery. Surgery 72: 946. 1972. Rhodes EL, Stanley JC, Hoffman GL, Cronenwett JL, Fry WJ: Aneurysms of the extracranial carotid arteries. Arch Surg 11: 339, 1976. Martinez NS: Extracranial carotid aneurysms-a complication of carotid endarterectomy. 111 MedJ 150: 583, 1976. Gilchrist AG: Aneurysms of internal carotid artery. J Laryngol Otol87: 501, 1973. Shea PC, Glass LF, Reid WA: Anastomosis of common and internal carotid arteries following excision of mycotic aneurysm. Surgery 37: 829, 1955. Robinson NA, Floote T: Traumatic aneurysms of the carotid arteries. Am Surg 40: 121, 1974. Lloyd J, Bahnson HT: Bilateral dissecting aneurysms of the internal carotid arteries. Am J Surg 122: 549,.1971. Bole PV, Hintz G. Chander P. Chan YS. Clauss RH: Bilateral carotid aneurysms secondary to radiation therapy. Ann Surg 181: 888, 1975. Braunstein H: Dissecting aneurysm of the carotid artery and aorta after carotid angiography. Am Heart J 67: 545, 1964. Buscaglia LC, Moore WS, Hall A: False aneurysm after carotid endarterectomy. JAMA 209: 1529, 1969. Ehrenfeld WK, Hays RJ: False aneurysms after carotid endarterectomy. Arch Surg 104: 288, 1972. Kianouri M: Extracranial carotid aneurysms: treatment by excision and end-to-end anastomosis. Ann Surg 165: 152, 1967. Van Rensberg LCJ: Aneurysms of the internal carotid artery presenting as a peritonsillar abscess. S AfrMedJ38: 567, 1964. Wychulis AR, Bealiss OH, Bumatz PE: Aneurysm of the internal carotid artery treated by excision and anastomosis to external carotid artery. Arch Surg 88: 803, 1964.
The American Journal 01 Surgery
Charles H. McCollum, MD, Houston, Texas Wllllam G. Wheeler, MD, Houston, Texas George P. Noon, MD, Houston, Texas Michael E. DeBakey, MD, Houston, Texas
Aneurysms of the extracranial carotid artery are uncommon vascular lesions. A previous report from this institution revealed only seven aneurysms of the extracranial carotid artery during an eleven year period when approximately 2,300 operations were performed for aneurysms in other areas of the arterial tree [I]. Until recently the most common complication was expansion, rupture, and hemorrhage [2]. Recently, many of these patients have presented with symptoms of transient ischemic cerebral attacks from emboli [3]. Although aneurysms of the extracranial carotid artery have been reported for many years in the medical literature, it has been only within the past twenty-five years that modern vascular technics were available for surgical corrections. Material and Methods The present report deals with the twenty-one year experience with aneurysms of the extracranial carotid artery at the Methodist Hospital, Houston, Texas. During the period from 1956 to 1977, thirty-seven aneurysms of the extracranial carotid artery were seen in thirty-four patients. During this same period approximately 8,500 aneurysms of the arterial tree were treated surgically. All patients presented with a swelling or mass in the neck. The diagnosis was confirmed by arteriography in all cases. The average age at diagnosis was fifty-nine years (range, 29 to 92 years). Men outnumbered women 2:1(23 males, 11 females). Sixteen (44 per cent) were atheroscle-
rotic aneurysms. (Table I.) Twenty-one patients (56 per cent) had false aneurysms of the carotid artery; nineteen of these aneurysms followed previous carotid artery surgery, and two developed after remote gunshot wounds of the neck. Of the nineteen false aneurysms following previous carotid artery surgery, sixteen occurred after carotid endarterectomy with patch angioplasty. The other three false aneurysms developed after carotid-subclavian bypass, aortocarotid bypass, and previous resection of an atherosclerotic aneurysm of the carotid artery with Dacron”graft replacement. Patients with six of the nineteen false aneurysms had the primary carotid artery procedure done elsewhere. Associated diseases are shown in Table II. Only five patients (15 per cent) had cerebrovascular symptoms associated with the extracranial carotid artery aneurysm. Hypertension and coronary artery disease were each seen in fourteen patients (41 per cent). Aortic or other peripheral aneurysms were seen in eight patients (24 per cent). Associated occlusive vascular disease of the lower extremities was seen in six patients (18 per cent). Both associated aneurysmal and occlusive diseases were more commonly seen in patients with previous carotid artery occlusive disease surgery than with atherosclerotic carotid artery aneurysms. Diabetes mellitus was present in only two patients.
TABLE I
Classification of Extracranial Carotid Artery Aneurysms In Thirty-Four Patients
Classification From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas. Reprint requests should be addressed to Charles Ii. MoCollum. MD, Cora and Webb Mading Department of Surgery. Baylor College of Medicine, 1200 Moursund Avenue, Houston, Texas 77030. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
196
Atherosclerotic False Preyious carotid artery surgery PosttraumaGc Total
No. of Aneurysms 16 (44%) 21 (56%) 19 2 37 (100%)
The American Journal 01 Surgery
Extracranial
TABLE II
Cerebrovascular Symptoms
Atherosclerotic False
2 (15%) 3 (14%)
Total
5 (15%)
Hypertension 6 (46%) 6 (38%) 14(41%)
Our technic for carotid artery surgery included general anesthesia and normothermia [4]. Blood pressure was maintained at normotensive levels with the use of vasodilator or vasopressor agents or volume replacement. Standard oxygen and carbon dioxide tensions were maintained. A temporary intraluminal carotid artery shunt was usually used to minimize cerebral ischemia. Results
Twenty-eight aneurysms were treated operatively (Table III) and nine nonoperatively. The usual reason for a nonoperative approach was an asymptomatic patient with a small aneurysm which was known to be stable in size or the presence of other severe, high risk medical disease. Eighteen aneurysms were resected, and patch angioplasty was performed. Six aneurysms were completely resected and replaced with a Dacron tube graft. Four aneurysms were resected with proximal and distal ligation of the internal carotid artery. Nine atherosclerotic aneurysms were treated surgically. The aneurysm was resected and the internal carotid artery ligated proximally and distally in three patients early in the series; these aneurysms were inaccessibly high in location. (Figure 1.) Three aneurysms were treated with resection of the aneurysmal portion and patch angioplasty (Figure 2), and three required resection and tube graft replacement (Figure 3). Two patients with atherosclerotic aneurysms had neurological symptoms preoperatively; one had
Coronary Artery Disease
Other Aneurysms
Peripheral Occlusive Disease
Diabetes
4(31%) 10 (48%)
2 (15%) 6 (29%)
: (29%)
0 2 (10%)
14(41%)
8 (24%)
6 (18%)
2 (6%)
transient ischemic attacks and one had hemiparesis. (Table IV.) The one with transient ischemic attacks had no neurological symptoms postoperatively, and the patient with the hemiparesis was improved postoperatively. One patient with no preoperative neurological symptoms underwent resection of an atherosclerotic aneurysm and patch angioplasty, and mild hemiparesis developed postoperatively. One other patient who preoperatively was intact neurologically underwent resection of the aneurysm and ligation in 1961. Postoperatively, massive cerebral infarction developed, and he died. Postmortem examination revealed a congenitally incomplete circle of Willis. The other operative death was due to a myocardial infarction after resection of an atherosclerotic extracranial aneurysm. False aneurysms developing after previous carotid artery surgery occurred between one month and fifteen years later, with an average of 6.2 years later. The majority of false aneurysms were handled by resection of the aneurysmal portion and replacement with a Dacron patch. (Figure 4.) This allowed a quicker repair with minimal cerebral ischemic time. Only one false aneurysm required resection and graft replacement. One false aneurysm was resected with
Treatment of Extracranial Carotid Artery Aneurysms in 34 Patients
Aneurysms Atherosclerotic False Previous carotid artery surgery Posttraumatic Total
Aneurysms
Diseases Associated with Extracranial Carotid Artery Aneurysms
Aneurysms
TABLE III
Carotid
Resection and Patch Tube AngioReplaceplasty ment
None
Ligation
7
3
3
3
16
2
1
15
1
19
0
0
0
2
2
9(24%)
Volume 137, February 1979
4(11%)
18(49%)
6(16%)
Total
37
Figure 1. Large atherosclerotic aneurysms high in lett internal carotid artery treated by resection with proximal and distal ligation.
197
McCollumet al
Figure 2. Large saccular atherosclerotic aneurysm of left internal carotid artery treated by resection and patch angioplasty.
proximal and distal ligation in a patient with an occluded internal carotid artery. Three patients with false aneurysm of the carotid artery had cerebrovascular symptoms preoperatively. Two had fixed neurological deficits; one of these was admitted with acute hemiplegia and the other had had multiple ischemic attacks and developed hemiplegia prior to the previous carotid endarterectomy. The third patient had only transient ischemic attacks. All of these patients were improved or stable neurologically after operation. One patient with no preoperative neurological symptoms underwent resection of a false aneurysm and patch angioplasty and developed hemiplegia postoperatively. Both of the posttraumatic false aneurysms were treated by resection of the aneurysm of the common carotid artery and tube graft replacement. (Figure 5.) None of the patients with posttraumatic aneurysms had any pre- or postoperative neurological symptoms. There were no deaths in the false aneurysm group. The patients have been followed from one to fifteen years. Only one patient was lost to follow-up.
TABLE IV
Results Atter Surgery for Extracranial Carotid Artery Aneurysms in 28 Patients
Aneurysms
Neurologically Stable or Improved
Hemiparesis
Deaths
Atherosclerotic False Previous carotid artery surgery Posttraumatic
6
1
2
16
1
0
2
0
0
Total
24
2
2 (7%)
198
Figure 3. Patient presented w/th transknt &chemk cerebral attacks and pukatife mass in leff neck. Carotid arterk&ram demonstrated atherosclerotic aneurysm of left internal carotid artery which was treated by resection and replacement with tube graft.
Eight of the twenty-six patients who survived surgery for correction of the extracranial carotid artery aneurysm died one to fourteen years after surgery. One patient died of cerebral thrombosis seven years after surgery. Three of the late deaths were due to myocardial infarction, two to malignancy, and one to intestinal obstruction. The cause of one death was unknown. Three of the nonoperated patients died two weeks to two years after the diagnosis of extracranial carotid artery aneurysms; two died of myocardial infarction and one of a ruptured thoracic aneurysm. Comments
The first successful surgical treatment for an aneurysm of the extracranial carotid artery was by Sir Athley Cooper [5] in 1808. Carotid artery ligation generally has been abandoned as the treatment of choice because of the high risk of cerebral ischemia (30 per cent) [6]. Wrapping of the aneurysm with fascia or cellophane is no longer considered adequate [7]. Resection of the aneurysm with restoration of arterial continuity is the preferable treatment. Many authors prefer resection with primary end-to-end anastomosis [8,9]. Many causes of aneurysms of the extracranial carotid artery have been reported. Many are atherosclerotic in origin [8-IO]. Other causes include mycotic aneurysms [11,12], posttraumatic aneurysms [13], dissecting aneurysms of the carotid artery [14],
The American Journal 01 Surgery
Extracranial
Carotid Aneurysms
Figure 4. Patient with transient ischemic attacks secondary to atherosclerotic occlusive disease of right carotid artery bifurcation treated wtth carotid endarterectomy patch and angk@asty in 7963. Patient presented in 1967 with mass in neck. Arteriograms demonstrated fatse aneurysm at site of endarterectomy which resected was with patch angioplasty. Follow-up arteriogram three years later ( 1979) showed satisfactory postoperative results.
aneurysms after irradiation of cervical malignancy [15], aneurysms after carotid arteriograms [16], congenital aneurysms, and aneurysms associated with cystic medial necrosis. Other reports demonstrate a rising incidence of false aneurysms after carotid endarterectomy [17,18]. Most previously published reports show a higher incidence of atherosclerotic aneurysms of the extracranial carotid artery than the present series. Only 44 per cent of our series were atherosclerotic aneurysms (16 aneurysms in 13 patients). Three of these were fusiform and located at the carotid bifurcation. (Figure 6.) Thirteen were saccular and located in the extracranial internal carotid artery, including bilateral aneurysms in three patients. Fifty-six per cent of aneurysms in the present series were considered false aneurysms (21 aneurysms in 21 patients). Nineteen of these aneurysms followed previous carotid artery surgery, and sixteen of these followed carotid endarterectomy. Only ten known false aneurysms developed in patients undergoing the original carotid endarterectomy at the Methodist Hospital from 1956 to 1977. During this same period, approximately 4,000 carotid endarterectomies were performed, most employing patch angioplasty. Thus, the incidence of false aneurysm development after carotid endarterectomy with patch angioplasty is low. It was difficult to determine a common factor in the formation of these false aneurysms. Of the thirteen false aneurysms of the extracranial carotid artery that developed after the initial carotid surgery here, silk suture was used in nine patch angioplasties, polyethylene in three, and Tycron@ in one. Localized wound infection was present in one patient. Differential diagnoses of the extracranial carotid aneurysm include carotid body tumors [19], peritonsillar abscess [20], cervical malignancy or lymphadenopathy, or elongation and tortuosity of the cervical carotid or subclavian arteries [21].
Volume 137, February 1979
The present series demonstrates that extracranial carotid aneurysms are rare but interesting problems in vascular surgery. Although the number of atherosclerotic aneurysms has been higher, the incidence of false aneurysms is increasing. The previous forms of surgery, including ligation or wrapping, have been replaced by resection and restoration of arterial continuity. The potential complications of cerebral emboli or rupture from extracranial carotid artery aneurysms justify an aggressive surgical approach. We have been pleased with the gratifying results in the surgical management of twenty-eight aneurysms of the extracranial carotid artery,
Figure 5. Patient who sustained gunshot wound to neck sixteen years prior to admission. He noted a mass in his neck two years rater, which gradually enlarged. The arteriogram confirmed the presence of posttraumatic false aneurysm of the left common carotid artery. This was resected with tube graft replacement with good resutts.
199
McCollum et al
References 1. BeallAC Jr, Crawford ES, Cooley DA, DeBakey ME: Extracranial 13
I 2.
(three bilateral)
v
3
i
3.
fall unilateral) 4.
5.
;:
Figure 6. Location and morphoiogy of atherosclerotic aneurysm.
6.
7. 8.
Summary
Aneurysms of the extracranial carotid artery are an uncommon but potentially serious problem, usually due to rupture or thromboembolic events. Thirty-seven aneurysms of the extracranial carotid artery were seen in thirty-four patients from 1956 to 1977. The ages ranged from twenty-nine to ninetytwo years, with an average of fifty-nine years. There were twenty-three males and eleven females. Nineteen (51 per cent) were false aneurysms, sixteen (44 per cent) atherosclerotic aneurysms, and two (5 per cent) posttraumatic aneurysms. All patients presented with evidence of a mass in the neck, and only five (15 per cent) had neurological symptoms related to the aneurysm. Surgery was performed on twenty-eight carotid aneurysms. Resection and patch angioplasty was employed for eighteen aneurysms, resection with graft replacement for six, and resection and ligation of the internal carotid artery for four. Postoperative neurologic deficits developed in three patients (11 per cent), and one of these died. There was one other operative death due to acute myocardial infarction (operative mortality, 7 per cent). Nonoperative treatment was employed when the patient had other associated high risk disease or a small asymptomatic aneurysm.
200
9.
10. 11.
12.
13. 14. 15.
16.
17. 18. 19.
20.
21.
aneurysms of the carotid artery: report of seven cases. Postgrad Med32: 93, 1962. Winslow N: Extracranial aneurysm of the internal carotid artery: history and analysis of the cases registered up to August 1, 1925. Arch Surg 13: 689, 1926. Spencer FC: Aneurysm of the common carotid artery treated by excision and primary anastomosis. Ann Surg 145: 254, 1957. Crawford ES, DeBakey ME, Garrett HC, Howell J: Surgical treatment of occlusive cerebrovascular disease. Surg C/in North Am 46: 873, 1966. Cooper A: Account of the first successful operation performed on the common carotid artery for aneurysm in the year of 1808 with postmortem examination in the year 1821. Guys Hasp Rep 1: 53, 1836. Leech PJ, Miller JD, Fitch W, Barker J: Cerebral blood flow, internal carotid artery pressure, and the EEG as a guide to the safety of carotid ligation. J Neural Neurosurg Psychiatry 37: 854, 1974. Thompson JE, Austin DJ: Surgical management of cervical carotid aneurysms. Arch Surg 74: 80, 1957. Kaupp HA, Haid SP, Jurayj MN, Bergan JJ, Trippel OH: Aneurysms of the extracranial carotid artery. Surgery 72: 946. 1972. Rhodes EL, Stanley JC, Hoffman GL, Cronenwett JL, Fry WJ: Aneurysms of the extracranial carotid arteries. Arch Surg 11: 339, 1976. Martinez NS: Extracranial carotid aneurysms-a complication of carotid endarterectomy. 111 MedJ 150: 583, 1976. Gilchrist AG: Aneurysms of internal carotid artery. J Laryngol Otol87: 501, 1973. Shea PC, Glass LF, Reid WA: Anastomosis of common and internal carotid arteries following excision of mycotic aneurysm. Surgery 37: 829, 1955. Robinson NA, Floote T: Traumatic aneurysms of the carotid arteries. Am Surg 40: 121, 1974. Lloyd J, Bahnson HT: Bilateral dissecting aneurysms of the internal carotid arteries. Am J Surg 122: 549,.1971. Bole PV, Hintz G. Chander P. Chan YS. Clauss RH: Bilateral carotid aneurysms secondary to radiation therapy. Ann Surg 181: 888, 1975. Braunstein H: Dissecting aneurysm of the carotid artery and aorta after carotid angiography. Am Heart J 67: 545, 1964. Buscaglia LC, Moore WS, Hall A: False aneurysm after carotid endarterectomy. JAMA 209: 1529, 1969. Ehrenfeld WK, Hays RJ: False aneurysms after carotid endarterectomy. Arch Surg 104: 288, 1972. Kianouri M: Extracranial carotid aneurysms: treatment by excision and end-to-end anastomosis. Ann Surg 165: 152, 1967. Van Rensberg LCJ: Aneurysms of the internal carotid artery presenting as a peritonsillar abscess. S AfrMedJ38: 567, 1964. Wychulis AR, Bealiss OH, Bumatz PE: Aneurysm of the internal carotid artery treated by excision and anastomosis to external carotid artery. Arch Surg 88: 803, 1964.
The American Journal 01 Surgery
