- Department of Neurosurgery, Instituto Mineiro de Neurocirurgia, Biocor Instituto, Belo Horizonte, MG, Brazil
- Department of Cardiologyy, Instituto Mineiro de Neurocirurgia, Biocor Instituto, Belo Horizonte, MG, Brazil
Department of Neurosurgery, Instituto Mineiro de Neurocirurgia, Biocor Instituto, Belo Horizonte, MG, Brazil
DOI:10.4103/2152-7806.82328Copyright: © 2011 Raso J This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
How to cite this article: Raso J, Darwich R, Ornellas C, Cariri G. Cervical carotid pseudoaneurysm: A carotid artery stenting complication. Surg Neurol Int 30-Jun-2011;2:86
How to cite this URL: Raso J, Darwich R, Ornellas C, Cariri G. Cervical carotid pseudoaneurysm: A carotid artery stenting complication. Surg Neurol Int 30-Jun-2011;2:86. Available from: http://sni.wpengine.com/surgicalint_articles/cervical-carotid-pseudoaneurysm-a-carotid-artery-stenting-complication/
Background:As carotid artery stenting becomes increasingly used, more complications are likely to occur. We present a case of Staphylococcus septicemia and pseudoaneurysm arising in the neck portion of the carotid artery after stenting.
Case Description:A 51-year-old man was admitted with mild left hemiparesis. CT and MRI showed right hemisphere ischemia. Duplex Scan and MRA showed bilateral severe stenosis of the carotid arteries in the neck. A percutaneous angioplasty with stenting of the left carotid artery was performed. Two weeks after the procedure, he developed fever and swelling in the right leg and shoulder. An abscess, near where the groin had been punctured for the angioplasty was surgically drained. Blood samples were positive for S. aureus. After treatment the patient complained of a painful bulky pulsatile left cervical mass. Duplex scan and MRA showed a pseudoaneurysm of the left carotid artery. We excised the pseudoaneurysm and rebuilt the carotid artery with a saphenous vein graft. The postoperative period was uneventful, and the MRA revealed a patent saphenous graft.
Conclusion:Mycotic pseudoaneurysm of the carotid artery is a rare complication of percutaneous angioplasty and stenting. Surgical treatment with saphenous vein graft is the treatment of choice.
Keywords: Carotid artery, mycotic pseudoaneurysm, percutaneous angioplasty, stenting
Percutaneous carotid artery angioplasty and stenting is becoming a common alternative to endarterectomy for treatment of severe carotid stenosis. As the procedure becomes more widely used, more complications associated with this procedure are bound to occur. Mycotic pseudoaneurysm of the carotid artery is a rare complication of percutaneous angioplasty and stenting. We present a case of Staphylococcus septicemia after carotid artery stenting and the late development of cervical carotid pseudoaneurysm. We also discuss aspects concerning the diagnosis and the surgical treatment of this rare complication.
A 51-year-old man was admitted to the emergency room of Biocor Institute with left-side hemiparesis and dysarthria. Hypertension, chronic alcoholism, and cigarette smoking were his main comorbidities. CT and MRI scans showed ischemia of the right middle cerebral artery territory. Carotid and vertebral arteries duplex scan, MRA and digital angiography showed severe bilateral carotid stenosis in the neck[ (a) Angiography: severe stenosis of the left carotid artery. (b) Angioplasty with stenting – final result.
(a) Angiography: severe stenosis of the left carotid artery. (b) Angioplasty with stenting – final result.
He was discharged in good shape two days after the procedure. Two weeks later he was readmitted due to fever and swelling near the groin puncture site. He also had right shoulder swelling and pain. Blood cultures were positive for S. aureus. He had abscesses in the thigh and in the right shoulder, which were drained. He was treated with oxacillin for 24 days, linezolid for 25 days and cefepime for 14 days. At the end of treatment, with no signs of systemic infection, he complained of a painful cervical mass. Neck duplex scan and MRA showed_a pseudoaneurysm of the left carotid artery, over the stenting area. He was submitted to cervical mass exploratory surgery. The pseudoaneurysm was resected along with a segment of the common carotid and a proximal segment of the internal and external carotid arteries. The external carotid artery was ligated. Reconstruction of the internal carotid artery was accomplished with a saphenous vein graft between the common and internal carotid arteries[ Surgery: a saphenous vein graft was placed between the common and the internal carotid arteries. The pseudoaneurysm was isolated with a vascular clamp across the proximal common carotid artery and a clip was placed in the internal and external carotid arteries
Surgery: a saphenous vein graft was placed between the common and the internal carotid arteries. The pseudoaneurysm was isolated with a vascular clamp across the proximal common carotid artery and a clip was placed in the internal and external carotid arteries
He had an uneventful recovery and was discharged with no deficits related to the procedure. Pathological examination of the excised specimen revealed a pseudoaneurysm surrounding the stent, with inflammatory response. Bacterial cultures of the lesion were negative. A postoperative MRA showed saphenous graft patency[ Postoperative MRA of the cervical vessels showing the patency of the graft in the left side.
Postoperative MRA of the cervical vessels showing the patency of the graft in the left side.
Percutaneous angioplasty with stenting is now a widespread treatment option for severe carotid stenosis, as an alternative to carotid endarterectomy. However, as angioplasty with stenting becomes increasingly used, rare complications – such as infection associated with the procedure, may ensue.
Pseudoaneurysms in the carotid artery are commonly associated with trauma and have also been reported as endarterectomy complications.[
Endovascular stent reconstruction of the carotid artery is an option to repair traumatic injuries of the carotid artery.[
Therefore, it is important to distinguish infectious pseudoaneurysms from those related to surgical and endovascular procedures. In the hereby-reported case, the endovascular procedure was uneventful, with good immediate outcome. The pseudoaneurysm developed after documented skin infection at the puncture site and with positive blood cultures for staphylococci. Moreover, the pathological examination of the excised pseudoaneurysm showed an inflammatory response with neutrophils and fibrin, which points to a pathological response to infection[ Inflammatory response with neutrophils and fibrin (H and E, ×400)
Inflammatory response with neutrophils and fibrin (H and E, ×400)
The main treatment step for this complication is to excise the pseudoaneurysm. Reconstruction of the artery is desirable since carotid ligation carries a high risk of stroke.[
SHEA was the first to report the excision of a mycotic aneurysm followed by end-to-end anastomosis.[
Although stenting can be very useful to control acute hemorrhage or to treat traumatic pseudoaneurysm, it should be avoided in cases of mycotic aneurysms. It represents a foreign body and, as such, it may have a tendency to extrude through the vessel.
Warren et al., reported three patients with carotid blowout managed with endovascular stents, and they challenge the long-term safety of the device in the event of the patient developing head and neck malignancies.[
Simental et al., also reported delayed stent-related complications in two cases of carotid blowout in neck malignancies.[
Early revascularization after a stroke remains controversial. In patients with a recently symptomatic carotid stenosis, surgical or interventional treatment is often delayed for weeks to months. The inability to predict who is at higher early risk of developing recurrent strokes and hemorrhage after revascularization may explain the variation in the management of acute strokes across different institutions.
Kastrup et al., studied 131 patients who had been referred to their service within 14 days; during a median follow-up period of 7 days no patient had a stroke, 4 patients (3.1%) developed a hemispherical transient ischemic attack, and 15 patients (12%) had new asymptomatic DWI lesions present in the territory of the treated artery. A multivariate regression analysis revealed that motor symptoms or the presence of a contralateral carotid stenosis were significant independent predictors of further cerebral ischemic events. Therefore, they advocate urgent preventive treatment in these high-risk patients.[
Setacci et al., studying early revascularization in a series of 43 patients demonstrated that early treatment with protected carotid stenting is safe in selected patients. Major stroke or cerebral ischemic lesions greater than 2.5 cm, as documented by a computed tomography scan was excluded.[
Rerkasem and Rothwell performed a systematic review of all studies published from 1980 to 2008 reporting the risk of stroke and death due to carotid endarterectomy in relation to the time between symptom onset and surgery. Only 47 studies stratified risk by timing of surgery among 494 published series. They concluded that surgery in the first week in neurologically stable patients with TIA or minor stroke is not associated with a substantially higher operative risk when compared to delayed surgery.[
Further data is needed on the risk and benefit of more urgent surgery for TIA and minor stroke and on early versus delayed surgery in patients with major nondisabling strokes.
In our Institution we prefer to perform endarterectomy or angioplasty in patients with moderate to severe ischemic injuries after 2 weeks. In the case hereby reported we decided to perform early angioplasty in the left asymptomatic severe carotid stenosis and we planned on treating the symptomatic side latter on. The documented staphylococcal skin infection and the carotid artery pseudoaneurysm prevented us from following our plan. The patient refused further treatment until 6 months later, when a carotid endarterectomy of the right side was performed with good outcome.
Mycotic pseudoaneurysm of the carotid artery as an angioplasty complication is a rare condition.
Since it is a percutaneous procedure, Staphylococci infection should be suspected and treated appropriately.
Excision of the aneurysm is mandatory and reconstruction of the artery with autologous graft, when feasible, is the treatment of choice.
1. Ahuja V, Tefera G. Successful covered stent-graft exclusion of carotid artery pseudo-aneurysm: Two case reports and review of the literature. Ann Vasc Surg. 2007. 21: 367-72
2. Baril DT, Ellozy SH, Carroccio A, Patel AB, Lookstein RA, Marin ML. Endovascular repair of an infected carotid artery pseudoaneurysm. J Vasc Surg. 2004. 40: 1024-7
3. Berne JD, Reuland KR, Villarreal DH, McGovern TM, Rowe SA, Norwood SH. Internal carotid artery stenting for blunt carotid artery injuries with an associated pseudoaneurysm. J Trauma. 2008. 64: 398-405
4. Briguori C, Selvetella L, Baldassarre MP. Endovascular repair of a carotid pseudoaneurysm with fluency plus stent graft implantation. J Invasive Cardiol. 2007. 19: E254-7
5. Chaer RA, Derubertis B, Kent KC, McKinsey JF. Endovascular treatment of traumatic carotid pseudoaneurysm with stenting and coil embolization. Ann Vasc Surg. 2008. 22: 564-7
6. DuBose J, Recinos G, Teixeira PG, Inaba K, Demetriades D. Endovascular stenting for the treatment of traumatic internal carotid injuries: Expanding experience. J Trauma. 2008. 65: 1561-6
7. Kastrup A, Ernemann U, Nägele T, Gröschel K. Risk factors for early recurrent cerebral ischemia before treatment of symptomatic carotid stenosis. Stroke. 2006. 37: 3032-4
8. Kaviani A, Ouriel K, Kashyap VS. Infected carotid pseudoaneurysm and carotid-cutaneous fistula as a late complication of carotid artery stenting. J Vasc Surg. 2006. 43: 379-82
9. Khalil I, Nawfal G. Mycotic aneurysms of the carotid artery: Ligation Vs.reconstruction- Case report and review of the literature. Eur J Vasc Surg. 1993. 7: 588-91
10. McCready RA, Divelbiss JL, Bryant A, Denardo AJ, Scott JA. Endoluminal repair of carotid artery pseudoaneurysms: A word of caution. J Vasc Surg. 2004. 40: 1020-3
11. Nader R, Mohr G, Sheiner NM, Tampieri D, Mendelson J, Albrecht S. Mycotic aneurysm of the carotid bifurcation in the neck: Case report and review of the literature. Neurosurgery. 2001. 48: 1152-6
12. Nicholls SC, Bergelin R, Strandness DE. Neurologic sequelae of unilateral carotid artery occlusion: Immediate and late. J Vasc Surg. 1989. 10: 542-8
13. Remy P, Massin H, Blampain JP. Bacterial aneurysm of the internal carotid: A rare condition. Eur J Vasc Surg. 1994. 8: 524-6
14. Rerkasem K, Rothwell PM. Systematic review of the operative risks of carotid endarterectomy for recently symptomatic stenosis in relation to the timing of surgery. Stroke. 2009. 40: e564-72
15. Shea PC, Glass LF, Reid WA, Harland A. Anastomosis of common and internal carotid arteries following excision of mycotic aneurysms. Surgery. 1955. 37: 829-32
16. Setacci C, de Donato G, Chisci E, Setacci F. Carotid artery stenting in recently symptomatic patients: A single center experience. Ann Vasc Surg. 2009. 24: 474-9
17. Simental A, Johnson JT, Horowitz M. Delayed complications of endovascular stenting for carotid blowout. Am J Otolaryngol. 2003. 24: 417-9
18. Warren FM, Cohen JI, Nesbit GM, Barnwell SL, Was MK, Andersen PE. Management of carotid “blowout” with endovascular stent grafts. Laryngoscope. 2002. 112: 428-33