Endovascular Management of an Extracranial Car Artery Aneurysm Using Stent Graft

Purpose: The extracranial carotid artery aneurysm is rare vascular disease in neck with variable presentation. The aneurysm is associated with significant mortality and morbidity and associated with fatal complication secondary to spontaneous rupture or tracheal compression or laryngeal edema and distal embolization. A 43-year-old male patient of large aneurysm arising from proximal CCA causing tracheal obstruction leading to life threatening respiratory symptoms. The endovascular interventional management is an emerging alternative for surgical options and providing promising results with almost similar safety and efficacy. Endovascular management of an extracranial carotid artery aneurysm using stent graft is minimally invasive and effective.

Materials and Methods: A 43-year-old male patient, presented in emergency department with respiratory obstruction. On examination there was large swelling in neck in anterior triangle on left side compressing the trachea leading to severe respiratory obstruction and stridor. Tracheostomy was performed and patient was resuscitated. After stabilizing patient, USG and Doppler study was performed which reveals large aneurysm arising from left proximal carotid artery displacing the carotid vessel posteriorly and the defect was not well visualized. As there was no significant atherosclerotic changes and no clinical history of trauma, diagnosis of spontaneous aneurysm of extracranial carotid artery was made. To evaluate the extent and neck of the aneurysm, 3 D CT angiography was performed which reveals large aneurysm arising from the proximal CCA located anterior to CCA with neck of the aneurysm is located anteromedially. The aneurysm is extending across the midline compressing the trachea toward right side. The carotid vessel is compressed posterolaterally by the aneurysm. The aneurysm is measuring approximately 4.4 × 2.3 × 3.8 cm in size and the defect is measuring approximately 8 mm. In view of difficult location, large size of aneurysm, posterior location of defect, the patient was refereed to interventional radiology department, for endovascular treatment option. Using right femoral access with 6 F sheath under all aseptic precaution, initial left Carotid angiography was performed which reveals large aneurysm arising from the left CCA with anteromedially pointing neck which measures approximately 6 to 7 mm in width. Using 0.035 hydrophilic wire, the wire is negotiated across the defect and access to external carotid artery was achieved distal to aneurysm over which Amplatz stiff wire was exchanged. Over the stiff wire, 9 F long sheath (70 cm Cook) was introduced beyond the neck of the aneurysm with the help of roadmap. Stent graft of 10 mm × 40 mm (fluency -Bard) was implanted across the neck in left proximal carotid artery under fluoroscopic and roadmap guidance and after conforming the position on preimplantation digital subtraction angiogram. Post-stenting balloon angioplasty was performed using 8 × 40 mm balloon. Post stenting angiogram reveals good flow in extracranial and intracranial carotid artery and in the intracranial circulation. There was no flow in aneurysm post-stenting without any endoleak. Patient was given bolus dose of ticagrelor (180 mg) bolus dose on table before stenting and 5000IU heparin during procedure to maintain ACT between 200–250. After stenting sheath was removed and compression was done manually. Patient was given injectable antibiotic for 3 days followed by oral antibiotic for total 7 days. Postprocedure immediate Doppler shows thrombus formation in aneurysm with fluid-fluid level A 48 hour follow-up shows significant regression in size of the swelling and regression in compression over trachea. Tracheostomy tube was removed after 5 days and patient was discharged with good outcome.

Results: An extracranial carotid artery aneurysm is uncommon with most of the patient presents as asymptomatic pulsatile neck mass. Respiratory obstructive symptoms leading is rare presentation of extracranial carotid artery aneurysm. The other presentation of the aneurysm is neurological or visual deficit and pain over the course of carotid artery. The aneurysm is associated with significant mortality and morbidity and associated with fatal complication secondary to rupture or tracheal compression or laryngeal edema and neurological morbidity secondary to distal embolization. The aneurysm is classified according to etiology into atherosclerotic, mycotic dissecting and posttraumatic aneurysm. The other classification of aneurysm in neck depends on shape as dissecting, fusiform, saccular, and pseudoaneurysm. Ultrasonography and Doppler are usually the initial screening and diagnostic modalities to confirm the diagnosis with limitation in demonstrating the defect, extension and relation of aneurysm with carotid vessel. The 3 D CT angiography and MR angiography plays important role to evaluate the relation of aneurysm with carotid vessel, evaluation of the defect, thereby helping in planning the treatment of the aneurysm. The treatment options for aneurysm of extracranial carotid artery are surgical procedures or endovascular interventional management like resection with end-to-end anastomosis or grafting, internal carotid artery ligation or extracranial to intracranial bypass open surgery. The other emerging alternative for surgical option is endovascular interventional management, which is providing promising results with almost similar safety and efficacy. The endovascular stenting is minimally invasive procedure thereby avoiding general anesthesia and is technically feasible with high procedure success and relatively lower complication rate (cranial nerve deficit associated with operative procedure). The Endovascular procedures are also not limited by location of aneurysm.

Conclusion: We report a case of an extracranial carotid artery aneurysm presented with severe tracheal compression and we demonstrate that the use of stent graft is minimally invasive and effective.

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Artikel online veröffentlicht:
02. April 2024