Case Report Carotid Artery Pseudoaneurysm as a Complication of Carotid Artery Stenting Mustafa Baldawi, Anas Renno, Jihad Abbas, and Munier Nazzal, Toledo, Ohio

Carotid artery stenting (CAS) has been adopted more in the treatment of carotid artery stenosis recently. The vast majority of studies about this procedure have concentrated mainly on the short- and long-term clinical complications, that is, stroke, myocardial infarction, and restenosis. However, mechanical complications including both stent fracture and carotid pseudoaneurysm are under-reported. In the present report, we present a patient with a common carotid artery psuedoaneurysm as a complication of CAS.

As carotid artery stenting (CAS) is becoming more widely used as an alternative to carotid endarterectomy (CEA) in the treatment of carotid artery stenosis, more complications associated with CAS are occurring, which include traumatic and myoctic pseudoaneurysm.1 Most carotid artery studies concentrated mainly on the short-term cardiac and neurologic complications of CAS. Less emphasis has been made on long-term complications such as restenosis, stent fracture, and carotid pseudoaneurysms. Long-term in-stent restenosis has been reported to range from 1.49% to 17.3%.2e5 Stent fracture has been reported to occur after carotid stenting.6 We reported a case of carotid stent fracture occurring in the early postoperative period.7 The frequency and significance of such complications are difficult to estimate because of lack of long-term studies and proper radiologic evaluations for such complications, which might be asymptomatic in most cases. The incidence of pseudoaneurysm formation secondary to CAS is extremely rare.

Division of Vascular and Endovascular Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH. Correspondence to: Munier Nazzal, MD, FRCS, FACS, Division of Vascular and Endovascular Surgery, Department of surgery, University of Toledo Medical Center, Mail Stop 1095, 3000 Arlington Avenue, Toledo, OH 43614, USA; E-mail: [email protected] Ann Vasc Surg 2015; -: 1–3 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: January 28, 2014; manuscript accepted: August 21, 2014; published online: ---.

Injury to the native artery by stent struts may lead to such a complication. The complications of a pseudoaneurysm of the CCA can be fatal, including hemorrhage due to rupture, distal embolization resulting in a transient ischemic attack, or stroke.8 The authors report a rare case of pseudoaneurysm formation, years after CAS.

CASE REPORT A 61-year-old woman is being seen in the vascular surgery clinic for evaluation of bilateral carotid stenosis. The patient has a history of severe arterial occlusive disease with previous bilateral carotid endarterectomies, and subsequently, ending up with stents for recurrent stenosis in 2005. He is a smoker and has a medical history of hypertension. The patient denies any weakness, numbness, vision disturbances, memory loss, confusion, speech difficulty, or any other neurologic complaint. On physical examination, his temperature was 97.9 F , pulse 84 beats/min, and blood pressure 174/104 mm Hg. Carotid arteries are palpable and equal bilaterally with bilateral carotid bruits. No remarkable positive signs were detected by the lung, cardiac, and abdominal examinations. Carotid duplex ultrasound showed a 50e60% stenosis of the right common carotid proximal to the stent and a 50% stenosis of the left carotid proximal to stent with a pseudoaneurysm. Diagnostic angiography was subsequently performed, which showed a patent right common carotid artery (CCA) stent with a 50e60% stenosis in the proximal portion. The left CCA showed 50% patent stenosis with a partially thrombosed pseudoaneurysm in the left bulb measuring (0.5  0.6 cm2) and the stent penetrating through the arterial wall (Fig. 1). The right and 1

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Fig. 1. Angiogram demonstrating a partially thrombosed pseudoaneurysm in the left carotid bulb.

Fig. 2. Patent left internal carotid artery distal to stent with good intracerebral flow.

left internal carotid arteries (ICAs) were patent distal to the stents bilaterally (Fig. 2). Surgical intervention was decided to replace the aneurysmal segment with a stent graft. Left side of neck and left groin were prepared. The patient then underwent systemic heparinization with 8,000 units of aqueous intravenous heparin. The wound was opened through the previous scar, extended proximally and distally, and deepened through scar tissue. Dissection was carried out with exposure of the internal jugular vein and CCA. The external and ICAs were then sequentially exposed, isolating the hypoglossal nerve. Internal, external, and CCAs were occluded with vessel loops. Longitudinal arteriotomy was performed on the CCA at the site proximal to the previous surgery and stent placement. The pseudoaneurysm including the stent was then excised. The takeoff of the ICA and external carotid artery was widely patent, so only the CCA was replaced with a polytetrafluorethylene (PTFE) graft, considering the size. The 3  4 Sundt shunt was passed through the PTFE graft and then inserted into the ICA and CCA. The graft was then beveled, and distal anastomosis was carried out first using 6-0 prolene running suture. At this point, the lower anastomosis was carried out after beveling the graft. The shunt was then removed and blood flow was established to the external first, then subsequently to the ICA. Doppler signals were strongly audible at the ICA and external carotid artery. The patient had an uneventful recovery and was discharged with no complications related to the procedure.

aneurysm in which all walls are intact but expanded, whereas a pseudoaneurysm is an aneurysm with loss of integrity of one or more layers of the arterial wall.9,10 Pseudoaneurysm formation in the CCA and/or ICA has been described to occur after an infection, especially, in the pediatric age group and after traumatic injuries to the neck. After thorough literature review, we could not find any report describing pseudoaneurysm formation as a complication of carotid stenting. In our case, the pseudoaneurysm formed at the distal end of the stent years after the stenting procedure. The carotid angiogram was done as a part of the plan to cover the pseudoaneurysm by a stent. However, it was noticed that the distal end of the stent was penetrating the wall of the artery causing a pseudoaneurysm at the very distal part of the CCA near its bifurcation. Because of the discrepancy in the size of the internal carotid and common artery, a decision was made to perform a surgical repair using a synthetic graft. Infection and stent fracture are reported causes of carotid pseudoaneurysm.11 It accounts for less than 0.5% of carotid surgeries. Generally, the most common cause of pseudoaneurysm formation is traumatic. This can occur by direct penetrating gunshot, stab trauma, or direct blow. Another common cause of pseudoaneurysm formation is CEA. It is estimated that pseudoaneurysms due to CEA account for 13e16% of all psuedoaneurysms.12 Other causes include iatrogenic injury, vasculitides, carotid dissection, local tumor

DISCUSSION Pseudoaneurysm formation as a complication of CAS is a rare complication. A true aneurysm is an




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invasion, previous surgery, and deep neck infection (in which the infection is extended from deep neck spaces, e.g., retropharyngeal or parapharyngeal spaces).10,13,14 Carotid pseudoaneurysms are mostly asymptomatic, however, it may present as a pulsatile neck mass, transient ischemic attack (TIA), Horner’s syndrome, lower cranial nerves palsies, or epistaxis.9,13,15 Diagnosis depends mostly on clinical suspicion, followed by ultrasound or computed tomography scan. Complications include rupture with associated hemorrhage, and distal embolization leading to cardiovascular accident (CVA) or TIA. The risk of rupture depends mostly on the cause, whereby the traumatic and infectious causes have the highest risk.15 Early diagnosis is of ultimate importance, not only to prevent a fatal hemorrhage but also to avoid risky interventions, such as aspiration or drainage of a misdiagnosed abscess.16 Treatment options for pseudoaneurysms include surgery, endovascular occlusion, stent-graft placement, and selective embolization.13 Surgical options include resection with saphenous graft or prosthetic interposition, resection and primary reanastomosis, aneurysmorrhaphy, and reconstruction using venous or prosthetic patch. Complications of surgery include CVA and death (reported to be 9% and 15%, respectively), cranial nerves injury (as high as 15%), microembolization, and vascular rupture.9,15 Stent-graft placement has been reported for carotid pseudoaneurysm treatment. However, stenting is not recommended if mycotic pseudoaneurysms are suspected because of the controversy whether a recently infected stent graft contributes to a chronic infection.17 The use of local anesthesia without the need of intubation, minimal damage to surrounding structures, and the shorter stay are advantages of endovascular approach.1,11,14 Percutaneous thrombin injection was reported to be successful because of the lack of foreign material and the unaltered flow of the affected artery.13,18 However, it runs the risk of thrombin escape into the carotid circulation causing neurologic complications. In conclusion, pseudoaneurysm formation is a potential complication of CAS. Although not commonly reported, we think that carotid artery injury at the distal part of the stent is plausible because of the sharp end of the stent. Poststenting follow-up studies should be aware of pseudoaneurysm formation, for its complications can be fatal.

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REFERENCES 1. Raso J, Darwich R, Ornellas C, Cariri G. Cervical carotid pseudoaneurysm: a carotid artery stenting complication. Surg Neurol Int 2011;2:86. 2. Mohammadian R, Sohrabi B, Mansourizadeh R, et al. Unprotected carotid artery stenting: complications in 6 months follow-up. Neuroradiology 2012;54:225e30. 3. Lago A, Parkhutik V, Tembl JI, et al. Long-term outcome in patients with carotid artery stenting and contralateral carotid occlusion: a single neurovascular center prospective analysis. Neuroradiology 2012;54:965e72. 4. de Donato G, Setacci C, Deloose K, et al. Long-term results of carotid artery stenting. J Vasc Surg 2008;48:1431e40. discussion 1440e1441. 5. Stankovic G, Liistro F, Moshiri S, et al. Carotid artery stenting in the first 100 consecutive patients: results and follow up. Heart 2002;88:381e6. 6. Usman AA, Resnick SA, Benzuly KH, et al. Late stent fractures after endoluminal treatment of ostial supraaortic trunk arterial occlusive lesions. J Vasc Interv Radiol 2010;21:1364e9. 7. Nazzal M, Abbas J, Afridi S, Ritter M. Fractured internal carotid artery stent. Vascular 2008;16:179e82. 8. El-Sabrout R, Cooley DA. Extracranial carotid artery aneurysms: Texas Heart Institute experience. J Vasc Surg 2000;31:702e12. 9. Kim HO, Ji YB, Lee SH, et al. Cases of common carotid artery pseudoaneurysm treated by stent graft. Case Rep Otolaryngol 2012;2012:674827. 10. Sankararaman S, Velayuthan S, Gonzalez-Toledo E. Internal carotid artery stenosis as the sequela of a pseudoaneurysm after methicillin-resistant Staphylococcus aureus infection. Pediatr Neurol 2012;47:312e4. 11. Bracale UM, Vitale G, Caruso M, Bajardi G. Late carotid artery stent erosion and pseudoaneurysm after accidental hyperextension of the neck. J Vasc Surg 2012;55:242. 12. Bridge KI, Bailey MA, Coughlin PA, et al. Images in vascular medicine. Delayed Horner’s syndrome as a presenting symptom of traumatic internal carotid artery dissection and pseudoaneurysm. Vasc Med 2011;16:159e60. 13. Garcia-Monaco RD, Kohan AA, Martinez-Corvalan MP, et al. Thrombin injection failure with subsequent successful stent-graft placement for the treatment of an extracranial internal carotid pseudoaneurysm in a 5-year-old child. Cardiovasc Intervent Radiol 2012;35:704e8. 14. Ko JK, Lee TH, Lee JI, Choi CH. Endovascular treatment using graft-stent for pseudoaneurysm of the cavernous internal carotid artery. J Korean Neurosurg Soc 2011;50:48e50. 15. Fokou M, Pagbe JJ, Teyang A, et al. Surgical repair of a giant pseudoaneurysm of the right common carotid artery following a gunshot. Ann Vasc Surg 2011;25:268.e3e6. 16. Pearson SE, Choi SS. Pseudoaneurysm of the internal carotid artery: a case report and review of the literature. Arch Otolaryngol Head Neck Surg 2005;131:454e6. 17. Gralla J, Brekenfeld C, Schmidli J, et al. Internal carotid artery aneurysm with life-threatening hemorrhages in a pediatric patient: endovascular treatment options. J Endovasc Ther 2004;11:734e8. 18. Moller SM, Logason K, Karason S, Thorisson HM. Percutaneous thrombin injection of common carotid artery pseudoaneurysm without cerebral protection. Tex Heart Inst J 2012;39:696e8.

Carotid artery pseudoaneurysm as a complication of carotid artery stenting.

Carotid artery stenting (CAS) has been adopted more in the treatment of carotid artery stenosis recently. The vast majority of studies about this proc...
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