Surgical Management of Extracranial Carotid Artery Aneurysms P. Petrovic, MD, S. Avramov, MD, J. Pfau, MD, M. Fabri, MD, J. Obradovic, MD, V. Vukobratov, MD, Novi Sad, Yugoslavia
Between 1982 and 1991 we performed eight operations on seven patients with carotid artery aneurysms. Their mean age was 52.8 years (range: 20-67 years). Five aneurysms were atherosclerotic, one was associated with Marfan's syndrome, and two were pseudoaneurysms, one occurring after Dacron patch angioplasty and the other due to tuberculosis. Seven aneurysms were treated electively; one patient underwent an emergency surgical procedure. In one case, the internal carotid artery was ligated. Seven operations were reconstructive. No intraluminal shunt was used. No perioperative deaths occurred. Regressive hemiparesis and ipsUateral Horner's syndrome developed in One patient. The follow-up period ranged from six months to nine and a half years. One patient died of myocardial infarction three months after surgery. (Ann Vasc Surg 1991;5:506-509). KEY WORDS: Carotid artery; aneurysms; atherosclerosis; Marfan's syndrome; angioplasty; postoperative aneurysm.
Aneurysms of the cervical segment of the carotid artery are relatively rare. In a review of the literature during the last 290 years, Schechter [1] found 853 cases of carotid aneurysms. Larger series have been reported by McCollum [2] and others [3,4]. In the last few years, reports on the surgical treatment of aneurysms of the extracranial segment of the carotid artery have become more frequent, probably because of the increasing number of operations being performed on the carotid arteries and a greater incidence of blunt neck traumas. Three basic forms of aneurysms have been described [5]: spontaneous, infective, and traumatic. A fourth group is comprised of postoperative aneurysms. Spontaneous aneurysms are usually true aneurysms; their growth is moderately progressive and their tendency to rupture is small [6,7]. These aneurysms are atherosclerotic in origin and can be From the Department of Vascular Surgery, Institute for Surgery, Faculty of Medicine, Novi Sad, Yugoslavia. Reprint requests: P. Petrovic, MD, Institut za Hirurgigu Post fah 98, 21000 Novi Sad, Yugoslavia.
bilateral in about 10% of cases [8]. Mycotic aneurysms are true aneurysms in only about 20% [9] of cases, and appear as a consequence of hematogenous or contact infection [5,10]. The traumatic, accidental, or iatrogenic aneurysms are, according to certain authors [5], the most frequent today. Most surgeons think that arterial wall disruption and the formation of a postoperative pseudoaneurysm occurs mostly after Dacron patch angioplasty and less frequently after a direct suture or venous patch angioplasty [11-14].
PATIENTS AND METHODS Of a consecutive series of 422 carotid operations performed during the last nine and a half years (January 1, 1982-January 6, 1991), we treated seven patients with carotid artery aneurysms (1.9%). Mean age of patients with aneurysms was 52.8 years (range: 20-67 years). There were six men and one woman. Of five spontaneous atherosclerotic aneurysms three were located on the carotid bifurcation and
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Fig. 2. Arteriogram of right carotid bifurcation pseudoaneurysm after Dacron patch angioplasty.
Fig. 1. Arteriogram of right internal carotid artery aneurysm in patient with Marfan's syndrome.
Marfan's aneurysm. Seven days prior to vascular surgery, a cervicotomy had been performed with the suspicion of a neck tumor. A pulsatile mass was the only symptom in four patients. In two patients, typical hemispherical transient symptoms appeared. The patient with mycotic pseudoaneurysm
two on the internal carotid artery (bilateral in the same patient). A spontaneous Marfan's aneurysm was discovered in a 20-year-old patient (Fig. 1). This aneurysm was located on the internal carotid artery ( I C A ) j u s t below the skull. A pseudoaneurysm of the ICA appeared in one patient three years after endarterectomy and Dacron patch angioplasty (Fig. 2). In the seventh case, a large pseudoaneurysm originating from the c o m m o n carotid artery (CCA), infected by contact with a tuberculous cervical adenitis, ruptured into the lateral neck compartment (Fig. 3). This was the only patient who underwent an emergency surgical procedure. Distal stenotic changes were found in a patient with an atherosclerotic aneurysm of the carotid bifurcation as well as in the patient with a ruptured tuberculous pseudoaneurysm. In six cases, the lesions were located on the right side, and in the seventh case, lesions were bilateral. All patients underwent arteriography. Intraoperative bacteriological analysis was negative, while histological findings confirmed the preoperative diagnosis. An incorrect diagnosis was made in the case of
Fig. 3. Digital subtraction arteriography of ruptured tuberculous pseudoaneurysm of right common carotid artery. Severe internal carotid artery stenosis is also present.
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SURGICAL M A N A G E M E N T OF ECA A N E U R YSMS
rupture, except for central neurological symptoms, had signs of compression, pain, torticollis, and norner's syndrome.
RESULTS Six patients underwent seven reconstructive surgical procedures (one bilateral). In three cases of atherosclerotic aneurysm we performed excision and Dacron patch angioplasty. In the patient with bilateral aneurysm, both located on the ICA, the first operation was an external carotid artery (ECA)-ICA anastomosis, while in the second operation an autologous vein interposition bypass was performed. The patient with Marfan's syndrome had already undergone an operation; his aneurysm was located very close to the skull. For these reasons, aneurysmectomy and ICA ligation were performed. A presternomastoid cervicotomy was the standard approach. A partial sternotomy was necessary to obtain proximal control in the patient with ruptured CCA mycotic aneurysm. No intraluminal shunt was used. Aneurysmectomy and ICA ligation in the young patient with Marfan's syndrome did not lead to neurological complications. Regressive hemiparesis and Horner's syndrome appeared in a 67-year-old patient with a ruptured mycotic aneurysm and severe ICA stenosis. Three months after surgery, he died of myocardial infarction, without signs of infection in the operative site. This patient had been treated by povidone-iodine irrigation of the operative site and conventional antibiotic therapy, as well as anti-tuberculosis drugs. The postoperative 1CA pseudoaneurysm was treated by aneurysmectomy and polytetrafluoroethylene (PTFE) prosthesis interposition associated with reimplantation of the ECA. There were no perioperative deaths in this series. In the follow-up period ranging from six months to nine and a half years, one patient died of myocardial infarction three months after surgery.
DISCUSSION Compared to other sites of aneurysm, carotid artery aneurysms are not influenced by the gender of the patient, nor do they present any special features. Aneurysms occur five to six times more frequently in men. The cervical location is predominant. Hypertension and infection are favoring factors [13]. Of the etiologies of spontaneous aneurysms, atherosclerosis is the most frequent [2,5,8], while Marfan's syndrome and medial necrosis are sporadic causes [15,16]. Blunt neck trauma is the most frequent cause of pseudoaneurysm formation
ANNALS OF VASCULAR SURGERY
[5]. Hematogenous spread originating from or due to contact with an infective focus is a possible cause of false anenrysmal formation in 80% of patients [9]. Tuberculous arteritis is a rarity [5]. Arterial tuberculous involvement has been described in the subclavian artery in contact with apical lung tuberculosis [10]. Postoperative pseudoaneurysms appear mainly after endarterectomy and Dacron patch angioplasty. According to several authors [11,14], they can develop even after a direct suture and autologous vein patch angioplasty. Infection plays a major role in postoperative pseudoaneurysms [13,17]. Neurological symptoms are the consequence of thrombosis or embolism [15], and expansive aneurysm growth leads to the compression of the autonomic or peripheral nervous systems, the upper respiratory airways, or the esophagus. Rupture and secondary bleeding are exceptional [6,7], especially in spontaneous atherosclerotic aneurysms. For this reason, urgent procedures are rarely performed. Diagnostic errors are possible, usually in the case of neck tumors caused by chemodectoma or arterial anomalies. Ultrasound and computed tomographic (CT) scan aid in diagnosing carotid artery aneurysms. Arteriographic investigations are mandatory. Because of high morbidity (28%) and mortality (17%) following aneurysmectomy and carotid ligation [9], reconstruction is the only acceptable surgical procedure. Atherosclerotic aneurysms of the carotid bifurcation are easily excised and closed by a patch angioplasty. Postoperative and post-traumatic aneurysms are best treated by venous or prosthetic graft interposition bypass. The most formidable problem is that of mycotic aneurysms, regardless of their morphology. Since the bifurcation and the ICA are most often affected, the possibilities of an extraanatomical reconstruction are extremely limited. Because of the severity of complications in the event of postoperative occlusion, our opinion is that reconstruction is justified in these cases with an autologous vein graft or, if this is not available, an external iliac or hypogastric arterial autograft. In case of infection, thorough local treatment with povidone-iodine [18], broad-spectrum antibiotic therapy, and organism-specific therapy whenever indicated, can prevent severe complications. In the case of aneurysmal location on the ICA, the ECA-ICA anastomosis is a very simple and reliable alternative. If the aneurysm is bilateral, bilateral end-to-end ECA-ICA anastomosis is contraindicated because of possible mesenteric claudication. In this case, the solution is a unilateral autologous vein interposition graft. Rare attempts at brain protection during transient surgical ischemia by cardiopulmonary bypass [19] have not been encouraging.
VOLUME 5 No 6 - 1991
SURGICAL M A N A G E M E N T OF ECA A N E U R YSMS
CONCLUSION Carotid artery aneurysms are relatively rare. The most common clinical signs in a patient are a pulsatile mass, hemispheric deficits, and compression symptoms. Rupture occurs very rarely. Ligation of the carotid vessels can lead to severe complications and is associated with high mortality. An elective reconstructive surgical procedure should be performed before ligation. Saccular bifurcation aneurysms are easily treated by excision and patch angioplasty In all other cases, a graft interposition or reconstruction with the external artery is necessary.
REFERENCES 1. SCHECHTER DC. Cervical carotid aneurysms, part I and II. N Y State J M e d 1979;79:892-901, 1042-1048. 2. McCOLLUM CH, WHEELER WG, NOON G, et al. Aneurysms of the extracranial carotid artery: twenty-one years experience. A m J Surg 1979;137:196-200. 3. WELLING RE, TAHA A, GOEL T, et al. Extracranial artery aneurysms. Surgery 1983;93:319-323. 4. KRUPSKI WC, EFFENEY DJ, EHRENFELD WK, et al. Aneurysms of the carotid arteries. Aust N Z J Surg 1983;53: 521-525. 5. JAVID H, DE LARIA GA. Carotid and subclavian aneurysm. In: KERSTEIN MD, MOULDER PV, WEBB WR (eds). Aneurysms. Baltimore: 1983, 27-62.
mmm
509
6. JOHNSON JN, HELSBY CR, STELL PM. Aneurysm of the external carotid artery. J Cardiovasc Surg 1980;21:105-107. 7. RITTENHOUSE EA. Carotid artery aneurysm. Arch Surg 1972;105:786--789. 8. NESBIT RR, NEISTADT A, MAY AG. Bilateral internal carotid artery aneurysm. Arch Surg 1979;114:293-295. 9. ANDERSON CB, BUTCHER HR, BALLINGER VF. Mycotic aneurysm. Arch Surg 1974;109:712-717. 10. HARA M, BRANSFORD RM. Aneurysm of the subclavian artery associated with contiguous pulmonary tuberculosis. J Thorac Cardiovasc Surg 1963;46:256-264. 11. GRAVER ML, MULCARE RJ. Pseudoaneurysm after carotid endarterectomy. J Cardiovasc Surg 1986;27:294-297. 12. MOTTE S, WAUTRECHT JC, BELLENS B, et al. Infected false aneurysm following carotid endarterectomy with vein patch angioplasty. J Cardiovasc Surg 1987;28:734-736. 13. COMBE J, BALMAT P, DUSTUYNDER O, et al. Faux an6vrysme apr~s endart6riectomie carotidienne. Lyon Chir 1986;82:174-176. 14. MONSON RC, ALEXANDER RH. Vein reconstruction of a mycotic internal carotid aneurysm. Ann Surg 1980;191:47-50. 15. LOBE T, COOPERMAN M, EVANS V. Bilateral carotid aneurysms associated with an aneurysm of the abdominal aorta. Vasc Surg 1978;12:210-214. 16. HARDIN CA. Successful resection of carotid and abdominal aneurysm in two related patients with Marfan's syndrome. N Engl J Med 1962;267:141-142. 17. BONTE MJ, BLACKFORD JM. Ruptured carotid mycotic pseudoaneurysm after simple carotid endarterectomy. Vasc Surg 1988;22:129-133. 18. ZAMORA JL. Povidone-iodine and wound infection. Surgery 1984;95:121-122. 19. AGRIFOGLIO M, RONA P, SPIRITO R, et al. External carotid artery aneurysms. J Cardiovasc Surg 1989;30:942-944.
Between 1982 and 1991 we performed eight operations on seven patients with carotid artery aneurysms. Their mean age was 52.8 years (range: 20-67 years). Five aneurysms were atherosclerotic, one was associated with Marfan's syndrome, and two were pseudoaneurysms, one occurring after Dacron patch angioplasty and the other due to tuberculosis. Seven aneurysms were treated electively; one patient underwent an emergency surgical procedure. In one case, the internal carotid artery was ligated. Seven operations were reconstructive. No intraluminal shunt was used. No perioperative deaths occurred. Regressive hemiparesis and ipsUateral Horner's syndrome developed in One patient. The follow-up period ranged from six months to nine and a half years. One patient died of myocardial infarction three months after surgery. (Ann Vasc Surg 1991;5:506-509). KEY WORDS: Carotid artery; aneurysms; atherosclerosis; Marfan's syndrome; angioplasty; postoperative aneurysm.
Aneurysms of the cervical segment of the carotid artery are relatively rare. In a review of the literature during the last 290 years, Schechter [1] found 853 cases of carotid aneurysms. Larger series have been reported by McCollum [2] and others [3,4]. In the last few years, reports on the surgical treatment of aneurysms of the extracranial segment of the carotid artery have become more frequent, probably because of the increasing number of operations being performed on the carotid arteries and a greater incidence of blunt neck traumas. Three basic forms of aneurysms have been described [5]: spontaneous, infective, and traumatic. A fourth group is comprised of postoperative aneurysms. Spontaneous aneurysms are usually true aneurysms; their growth is moderately progressive and their tendency to rupture is small [6,7]. These aneurysms are atherosclerotic in origin and can be From the Department of Vascular Surgery, Institute for Surgery, Faculty of Medicine, Novi Sad, Yugoslavia. Reprint requests: P. Petrovic, MD, Institut za Hirurgigu Post fah 98, 21000 Novi Sad, Yugoslavia.
bilateral in about 10% of cases [8]. Mycotic aneurysms are true aneurysms in only about 20% [9] of cases, and appear as a consequence of hematogenous or contact infection [5,10]. The traumatic, accidental, or iatrogenic aneurysms are, according to certain authors [5], the most frequent today. Most surgeons think that arterial wall disruption and the formation of a postoperative pseudoaneurysm occurs mostly after Dacron patch angioplasty and less frequently after a direct suture or venous patch angioplasty [11-14].
PATIENTS AND METHODS Of a consecutive series of 422 carotid operations performed during the last nine and a half years (January 1, 1982-January 6, 1991), we treated seven patients with carotid artery aneurysms (1.9%). Mean age of patients with aneurysms was 52.8 years (range: 20-67 years). There were six men and one woman. Of five spontaneous atherosclerotic aneurysms three were located on the carotid bifurcation and
506
VOLUME 5
No 6 - 1991
SURGICAL M A N A G E M E N T OF ECA A N E U R YSMS
507
Fig. 2. Arteriogram of right carotid bifurcation pseudoaneurysm after Dacron patch angioplasty.
Fig. 1. Arteriogram of right internal carotid artery aneurysm in patient with Marfan's syndrome.
Marfan's aneurysm. Seven days prior to vascular surgery, a cervicotomy had been performed with the suspicion of a neck tumor. A pulsatile mass was the only symptom in four patients. In two patients, typical hemispherical transient symptoms appeared. The patient with mycotic pseudoaneurysm
two on the internal carotid artery (bilateral in the same patient). A spontaneous Marfan's aneurysm was discovered in a 20-year-old patient (Fig. 1). This aneurysm was located on the internal carotid artery ( I C A ) j u s t below the skull. A pseudoaneurysm of the ICA appeared in one patient three years after endarterectomy and Dacron patch angioplasty (Fig. 2). In the seventh case, a large pseudoaneurysm originating from the c o m m o n carotid artery (CCA), infected by contact with a tuberculous cervical adenitis, ruptured into the lateral neck compartment (Fig. 3). This was the only patient who underwent an emergency surgical procedure. Distal stenotic changes were found in a patient with an atherosclerotic aneurysm of the carotid bifurcation as well as in the patient with a ruptured tuberculous pseudoaneurysm. In six cases, the lesions were located on the right side, and in the seventh case, lesions were bilateral. All patients underwent arteriography. Intraoperative bacteriological analysis was negative, while histological findings confirmed the preoperative diagnosis. An incorrect diagnosis was made in the case of
Fig. 3. Digital subtraction arteriography of ruptured tuberculous pseudoaneurysm of right common carotid artery. Severe internal carotid artery stenosis is also present.
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SURGICAL M A N A G E M E N T OF ECA A N E U R YSMS
rupture, except for central neurological symptoms, had signs of compression, pain, torticollis, and norner's syndrome.
RESULTS Six patients underwent seven reconstructive surgical procedures (one bilateral). In three cases of atherosclerotic aneurysm we performed excision and Dacron patch angioplasty. In the patient with bilateral aneurysm, both located on the ICA, the first operation was an external carotid artery (ECA)-ICA anastomosis, while in the second operation an autologous vein interposition bypass was performed. The patient with Marfan's syndrome had already undergone an operation; his aneurysm was located very close to the skull. For these reasons, aneurysmectomy and ICA ligation were performed. A presternomastoid cervicotomy was the standard approach. A partial sternotomy was necessary to obtain proximal control in the patient with ruptured CCA mycotic aneurysm. No intraluminal shunt was used. Aneurysmectomy and ICA ligation in the young patient with Marfan's syndrome did not lead to neurological complications. Regressive hemiparesis and Horner's syndrome appeared in a 67-year-old patient with a ruptured mycotic aneurysm and severe ICA stenosis. Three months after surgery, he died of myocardial infarction, without signs of infection in the operative site. This patient had been treated by povidone-iodine irrigation of the operative site and conventional antibiotic therapy, as well as anti-tuberculosis drugs. The postoperative 1CA pseudoaneurysm was treated by aneurysmectomy and polytetrafluoroethylene (PTFE) prosthesis interposition associated with reimplantation of the ECA. There were no perioperative deaths in this series. In the follow-up period ranging from six months to nine and a half years, one patient died of myocardial infarction three months after surgery.
DISCUSSION Compared to other sites of aneurysm, carotid artery aneurysms are not influenced by the gender of the patient, nor do they present any special features. Aneurysms occur five to six times more frequently in men. The cervical location is predominant. Hypertension and infection are favoring factors [13]. Of the etiologies of spontaneous aneurysms, atherosclerosis is the most frequent [2,5,8], while Marfan's syndrome and medial necrosis are sporadic causes [15,16]. Blunt neck trauma is the most frequent cause of pseudoaneurysm formation
ANNALS OF VASCULAR SURGERY
[5]. Hematogenous spread originating from or due to contact with an infective focus is a possible cause of false anenrysmal formation in 80% of patients [9]. Tuberculous arteritis is a rarity [5]. Arterial tuberculous involvement has been described in the subclavian artery in contact with apical lung tuberculosis [10]. Postoperative pseudoaneurysms appear mainly after endarterectomy and Dacron patch angioplasty. According to several authors [11,14], they can develop even after a direct suture and autologous vein patch angioplasty. Infection plays a major role in postoperative pseudoaneurysms [13,17]. Neurological symptoms are the consequence of thrombosis or embolism [15], and expansive aneurysm growth leads to the compression of the autonomic or peripheral nervous systems, the upper respiratory airways, or the esophagus. Rupture and secondary bleeding are exceptional [6,7], especially in spontaneous atherosclerotic aneurysms. For this reason, urgent procedures are rarely performed. Diagnostic errors are possible, usually in the case of neck tumors caused by chemodectoma or arterial anomalies. Ultrasound and computed tomographic (CT) scan aid in diagnosing carotid artery aneurysms. Arteriographic investigations are mandatory. Because of high morbidity (28%) and mortality (17%) following aneurysmectomy and carotid ligation [9], reconstruction is the only acceptable surgical procedure. Atherosclerotic aneurysms of the carotid bifurcation are easily excised and closed by a patch angioplasty. Postoperative and post-traumatic aneurysms are best treated by venous or prosthetic graft interposition bypass. The most formidable problem is that of mycotic aneurysms, regardless of their morphology. Since the bifurcation and the ICA are most often affected, the possibilities of an extraanatomical reconstruction are extremely limited. Because of the severity of complications in the event of postoperative occlusion, our opinion is that reconstruction is justified in these cases with an autologous vein graft or, if this is not available, an external iliac or hypogastric arterial autograft. In case of infection, thorough local treatment with povidone-iodine [18], broad-spectrum antibiotic therapy, and organism-specific therapy whenever indicated, can prevent severe complications. In the case of aneurysmal location on the ICA, the ECA-ICA anastomosis is a very simple and reliable alternative. If the aneurysm is bilateral, bilateral end-to-end ECA-ICA anastomosis is contraindicated because of possible mesenteric claudication. In this case, the solution is a unilateral autologous vein interposition graft. Rare attempts at brain protection during transient surgical ischemia by cardiopulmonary bypass [19] have not been encouraging.
VOLUME 5 No 6 - 1991
SURGICAL M A N A G E M E N T OF ECA A N E U R YSMS
CONCLUSION Carotid artery aneurysms are relatively rare. The most common clinical signs in a patient are a pulsatile mass, hemispheric deficits, and compression symptoms. Rupture occurs very rarely. Ligation of the carotid vessels can lead to severe complications and is associated with high mortality. An elective reconstructive surgical procedure should be performed before ligation. Saccular bifurcation aneurysms are easily treated by excision and patch angioplasty In all other cases, a graft interposition or reconstruction with the external artery is necessary.
REFERENCES 1. SCHECHTER DC. Cervical carotid aneurysms, part I and II. N Y State J M e d 1979;79:892-901, 1042-1048. 2. McCOLLUM CH, WHEELER WG, NOON G, et al. Aneurysms of the extracranial carotid artery: twenty-one years experience. A m J Surg 1979;137:196-200. 3. WELLING RE, TAHA A, GOEL T, et al. Extracranial artery aneurysms. Surgery 1983;93:319-323. 4. KRUPSKI WC, EFFENEY DJ, EHRENFELD WK, et al. Aneurysms of the carotid arteries. Aust N Z J Surg 1983;53: 521-525. 5. JAVID H, DE LARIA GA. Carotid and subclavian aneurysm. In: KERSTEIN MD, MOULDER PV, WEBB WR (eds). Aneurysms. Baltimore: 1983, 27-62.
mmm
509
6. JOHNSON JN, HELSBY CR, STELL PM. Aneurysm of the external carotid artery. J Cardiovasc Surg 1980;21:105-107. 7. RITTENHOUSE EA. Carotid artery aneurysm. Arch Surg 1972;105:786--789. 8. NESBIT RR, NEISTADT A, MAY AG. Bilateral internal carotid artery aneurysm. Arch Surg 1979;114:293-295. 9. ANDERSON CB, BUTCHER HR, BALLINGER VF. Mycotic aneurysm. Arch Surg 1974;109:712-717. 10. HARA M, BRANSFORD RM. Aneurysm of the subclavian artery associated with contiguous pulmonary tuberculosis. J Thorac Cardiovasc Surg 1963;46:256-264. 11. GRAVER ML, MULCARE RJ. Pseudoaneurysm after carotid endarterectomy. J Cardiovasc Surg 1986;27:294-297. 12. MOTTE S, WAUTRECHT JC, BELLENS B, et al. Infected false aneurysm following carotid endarterectomy with vein patch angioplasty. J Cardiovasc Surg 1987;28:734-736. 13. COMBE J, BALMAT P, DUSTUYNDER O, et al. Faux an6vrysme apr~s endart6riectomie carotidienne. Lyon Chir 1986;82:174-176. 14. MONSON RC, ALEXANDER RH. Vein reconstruction of a mycotic internal carotid aneurysm. Ann Surg 1980;191:47-50. 15. LOBE T, COOPERMAN M, EVANS V. Bilateral carotid aneurysms associated with an aneurysm of the abdominal aorta. Vasc Surg 1978;12:210-214. 16. HARDIN CA. Successful resection of carotid and abdominal aneurysm in two related patients with Marfan's syndrome. N Engl J Med 1962;267:141-142. 17. BONTE MJ, BLACKFORD JM. Ruptured carotid mycotic pseudoaneurysm after simple carotid endarterectomy. Vasc Surg 1988;22:129-133. 18. ZAMORA JL. Povidone-iodine and wound infection. Surgery 1984;95:121-122. 19. AGRIFOGLIO M, RONA P, SPIRITO R, et al. External carotid artery aneurysms. J Cardiovasc Surg 1989;30:942-944.
