Carotid Artery Pseudoaneurysm

Abstract

Introduction

The development of a carotid artery pseudoaneurysm (PA) after carotid endarterectomy is a rare complication with a reported incidence of 0.25% to 0.74%. It results from suture line failure or disruption, degeneration of the arterial wall, or patch material and/or infection. Patients present with neck swelling and pain that can be complicated by thrombosis, rupture, or infection.

Case Report

We describe a 72-year-old man who underwent bilateral carotid endarterectomies in 1987. He presented with bilateral upper-extremity swelling after a kidney transplant. An upper-extremity venous duplex performed with a Philips iU22 (Bothell, WA) with an 8-4 MHZ linear transducer revealed normal phasic pulsed Doppler waveforms. Compression images of the patient's left side of the neck revealed acute thrombus within the internal jugular vein. An incidental finding of bilateral common carotid PAs at their proximal patch surgical sites was noted. The right carotid PA measured 1.8 × 2.6 cm, whereas the left measured 2 × 1.3 cm.

Discussion

Carotid artery PA has been reported within 2 days or as late as 22 years after surgery. A true carotid aneurysm is usually caused by atherosclerosis or arteritis, whereas a carotid artery PA develops after endarterectomy as the result of infection, suture line disruption, or degeneration of the arterial wall or at the patch angioplasty site. A potential for rupture, embolization, thrombosis, or compression of the cranial nerves requires urgent attention. The conventional treatment approach is excision and repair via a vein graft. However, the risk of complications, especially cranial nerve injury, is high. A reasonable alternative to open surgery is covered carotid artery stenting if infection is excluded as the etiology of the pseudoaneurysm.

Conclusion

Although the diagnosis of carotid artery PA is usually suspected clinically, an imaging procedure is necessary for confirmation. Duplex scanning is the gold standard that can be augmented by arteriography or magnetic resonance imaging.