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Pseudoaneurysm Formation following Carotid Endarterectomy: Two Case Reports and a Literature Review
Pseudoaneurysm Formation following Carotid Endarterectomy: Two Case Reports and a Literature Review Roman A. Litwinski, MD,1 Kenneth Wright, MD,2 and Peter Pons, MD,2 Torrance, California and Buffalo, New York
Arterial pseudoaneurysms lack all three layers of the arterial wall and are therefore prone to enlargement. They are common after injuries to the artery in the form of blunt trauma, puncture, or prior surgery. They present frequently with swelling, pain, thrombosis, and rupture and occasionally with infection. Options for repair include primary arteriorrhaphy, partial excision with patch angioplasty, and total excision with interposition grafting. We present two cases of pseudoaneurysm following carotid endarterectomy: one with infection, and one with sterile enlargement. A review of the literature suggests that pseudoaneurysm formation following carotid endarterectomy is an uncommon event, and infection of these lesions is even less likely. There appears to be no difference in incidence whether or not the patient had closure of the arteriotomy with a patch angioplasty. The principles of repair include removal of all infected tissue, reconstruction with autogenous vein if possible, and vascularized flap coverage.
Arterial pseudoaneurysms lack all three layers of the arterial wall and are therefore prone to enlargement. They are common after injuries to the artery in the form of blunt trauma, puncture, or prior surgery. They frequently present with swelling, pain, thrombosis, rupture, and occasionally, infection. Options for repair include primary arteriorrhaphy, partial excision with patch angioplasty, and total excision with interposition grafting. A review of the literature suggests that pseudoaneurysm formation following carotid endarterectomy is an uncommon event,1-5 and infection of these lesions is even less likely. There appears to be no difference in incidence whether or not the patient 1 Division of Vascular Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA. 2
Division of Vascular Surgery, Buffalo General Hospital, Buffalo, NY, USA. Correspondence to: Roman A. Litwinski, MD, Division of Vascular Surgery, Harbor-UCLA Medical Center, 1000 W. Carson Street, Box #11, Torrance, CA, 90509, USA, E-mail: [email protected] Ann Vasc Surg 2006; 20: 678–680 DOI: 10.1007/s10016-006-9060-9 Ó Annals of Vascular Surgery Inc. Published online: May 27, 2006 678
had closure of the arteriotomy with a patch angioplasty.1
CASE REPORT 1 This patient is a 75-year-old white female who presented to her primary-care physician with left-sided neck swelling and pain of several weeksÕ duration. The pain was severe, and she had hoarseness of the voice but no stridor. She had a history of left carotid endarterectomy without patch closure 10 years earlier, as well as coronary artery bypass grafting (CABG) 4 years earlier complicated by postoperative mediastinitis. At that time, she required pectoralis muscle flaps. Most recently, she has suffered with septic arthritis of the knee. Cultures of the aspirate grew methicillin-resistant Staphylococcus aureus (MRSA), as did later cultures of the blood. At the time of initial presentation, the mass was aspirated with a fine needle, with the immediate return of pulsatile, bright red blood. Pressure was held and Doppler examination confirmed a large aneurysm in the region of the carotid artery. The patient was transferred to our facility, and emergent arteriography was performed (Fig. 1). The arteriogram revealed a large pseudoaneurysm at the carotid bifurcation. The patient was immediately taken to surgery, given her impending airway obstruction.
Vol. 20, No. 5, 2006
Case reports 679
as well as aspiration of the septic joint. Intraoperative cultures and pathological examination of the carotid artery confirmed MRSA infection.
CASE REPORT 2
Fig. 1. Patient 1, preoperative arteriogram. The old endarterectomy incision was reopened, and vascular control was obtained with difficulty. It was immediately evident that the pseudoaneurysm was infected, with the presence of purulent material within the wound. The pseudoaneurysm was bleeding briskly from the prior puncture site, making visualization difficult and obscuring the planes of dissection. The previously endarterectomized vessel was completely resected, and the external carotid artery stump was oversewn. There was brisk back-bleeding noted from the internal carotid stump; therefore, a shunt was not placed. A reversed portion of the basilic vein was harvested and implanted as an interposition graft between the common and internal carotid arteries since all her saphenous vein had been previously harvested for CABG surgery. The wound was copiously irrigated, and a sternocleidomastoid muscle flap was mobilized to provide tissue closure over the repair. Doppler signals at the end of the case confirmed pulsatile perfusion of the distal internal carotid artery, with characteristic low-resistance signals. Unfortunately, the patient suffered an embolic left parietal stroke during the case, likely due to vessel manipulation when attempting to establish vessel control. This stroke manifested as right-sided arm and leg weakness. She began intensive physical therapy and rehabilitation, with near-total return of function. She completed a 6-week course of intravenous vancomycin
This patient was a 68-year-old white male with a history of diffuse aneurysmal disease. He had prior repair of a thoracoabdominal aortic aneurysm and has known intracranial aneursysms as well as bilateral popliteal aneurysms. He had undergone an uneventful left carotid endarterectomy with Hemashield patch angioplasty 18 months prior to presentation for stenotic disease. Subsequently, he presented with rapidly increasing pulsatile swelling of the left neck. There were no complaints of pain, drainage, or fever. Duplex scanning and magnetic resonance angiography (MRA) revealed a left carotid pseudoaneurysm, and the patient was taken urgently to the operating room. After gaining vascular control, the diseased common and internal carotid arteries were resected. He was also noted to have strong internal carotid stump back-bleeding. An interposition graft of reversed saphenous vein was used for vascular reconstruction, and the thrombus was sent for culture. The external carotid artery stump was oversewn. There was a strong pulse and Doppler signal in the distal internal carotid upon completion of the repair, and the wound was closed over a Jackson-Pratt drain. The cultures were ultimately negative, and the patient was neurologically intact. He recovered uneventfully and was discharged home on the third postoperative day. Interestingly, he revisited the emergency room 2 weeks later with rupture of his 7 cm left popliteal aneurysm, which required ligation and femoral-posterior tibial artery bypass grafting.
DISCUSSION A review of the literature suggests that pseudoaneurysm formation following carotid endarterectomy is an uncommon event, occurring in 0.30%2 of carotid endarterectomies. Of these, 33-40% are infected. In a recent larger series from the Texas Heart Institute (THI),1 the experience with 13 cases over a 35-year period was reviewed. Of 4,991 carotid endarterectomies performed in this time, only 37 (0.74%) developed a pseudoaneurysm. Of these, 13 (35%) were infected. This low incidence coincides with the low expected rate of infectious complication in a ‘‘clean’’ operation. Factors that favor pseudoaneurysm formation are those that promote infection. Prolonged endarterectomy (>2 hr), postoperative hypertension, inadequate hemostasis, adjacent infection, and bacteremia are all contributors. Surprisingly, use of foreign patch material for angioplasty did not result in an increased risk of pseudoaneurysm formation. In combining the THI groupÕs patients with those of
680 Case reports
four other papers,1-5 24 of 44 patients with infected carotid pseudoaneurysm had patch closure, while 20 of 44 did not. Of course, even the patients closed primarily necessarily had synthetic nonabsorbable suture implanted, and this may suffice as an infectious nidus. The presentation of these patients is a pulsatile neck mass, sometimes with signs of infection. There may be fever, cellulitis, abscess, drainage from the wound, overt hemorrhage, or neurological symptoms. In the THI meta-analysis,1 29 of 44 (66%) infected patients grew Staphylococcus species, with less common organisms including Streptococci and gram-negative bacilli. The recommended therapeutic strategy for these patients is urgent duplex carotid scanning to identify the lesion, with or without angiography (conventional, computed tomographic, or MRA) to delineate the anatomy. There are several surgical management options once the diagnosis is established. The overriding principle is wide debridement of all synthetic and infected material and reconstruction with autogenous tissue if possible.1-5 Antibiotic therapy is mandatory, and some authors feel that with the breadth of current antibiotic options, some patients without gross infection may tolerate synthetic graft interposition.1 Carotid artery ligation is associated with an unacceptably high risk of stroke (50%) and is to be condemned.1-4 If necessary, bypass procedures to the internal carotid are preferable to ligation.1 General anesthesia is recommended for repair as more distal control at the level of the mandible may be required. Shunt insertion is recommended if feasible in these suboptimal conditions, though the risk is increased in the face of gross thrombus and inflamed intima. Our two patients did not appear to need shunting. With the increasingly widespread usage of carotid stenting, this modality may be a reasonable alternative to open surgery,6,7 particularly in this patient population with a previously dissected neck. Covered stent placement has been used even in the setting of infection in one recent report.7
Annals of Vascular Surgery
Overall outcomes in the THI series showed 9 of 44 (20.1%) patients suffering perioperative cerebrovascular accident.1 Of these nine patients, five had internal carotid ligation and four underwent attempts at repair. There were no cranial nerve injuries encountered, compared to a 19% rate of injury in redo carotid endarterectomies for recurrent atherosclerotic narrowing. Our first patient presented with signs of infection as well as impending airway compromise. We operated to resect all infected tissue and reconstructed her carotid vasculature with autogenous tissue and flap coverage. Her stroke was likely due to vessel manipulation during a difficult dissection and attempt to gain vascular control, with subsequent cerebral embolization. The second patient had multilevel aneurysmal disease, and it is conceivable that he had an undiagnosed connective tissue disorder that contributed to his pseudoaneurysm formation. We also resected the diseased tissue and reconstructed him with autogenous tissue and flap coverage.
REFERENCES 1. El-Sabrout R, Reul G, Cooley DA. Infected postcarotid endarterectomy pseudoaneurysms: retrospective review of a series. Ann Vasc Surg 2000;14:239-247. 2. Branch CL, Davis CH. False aneurysm complicating carotid endarterectomy. Neurosurgery 1986;19:421-425. 3. Dougherty MJ, Calligaro KD, DeLaurentis DA. Infected false aneurysm after carotid endarterectomy: a case report and review of the literature. Vasc Surg 1997;31:791-796. 4. Raptis S, Baker SR. Infected false aneurysms of the carotid arteries after carotid endarterectomy. Eur J Vasc Endovasc Surg 1996;11:148-152. 5. Bonta MJ, Blackford JM. Ruptured carotid mycotic pseudoaneurysm after simple carotid endarterectomy: case report and brief literature review. Vasc Surg 1988;22:129-133. 6. Scavee V, De Wispelaere J-F, Mormont E, et al. Pseudoaneurysm of the internal carotid artery: treatment with a covered stent. Cardiovasc Intervent Radiol 2001;24:283285. 7. Baril DT, Ellozy SH, Carroccio A, et al. Endovascular repair of an infected carotid artery pseudoaneurysm. J Vasc Surg 2004;40:1024-1027.
Arterial pseudoaneurysms lack all three layers of the arterial wall and are therefore prone to enlargement. They are common after injuries to the artery in the form of blunt trauma, puncture, or prior surgery. They present frequently with swelling, pain, thrombosis, and rupture and occasionally with infection. Options for repair include primary arteriorrhaphy, partial excision with patch angioplasty, and total excision with interposition grafting. We present two cases of pseudoaneurysm following carotid endarterectomy: one with infection, and one with sterile enlargement. A review of the literature suggests that pseudoaneurysm formation following carotid endarterectomy is an uncommon event, and infection of these lesions is even less likely. There appears to be no difference in incidence whether or not the patient had closure of the arteriotomy with a patch angioplasty. The principles of repair include removal of all infected tissue, reconstruction with autogenous vein if possible, and vascularized flap coverage.
Arterial pseudoaneurysms lack all three layers of the arterial wall and are therefore prone to enlargement. They are common after injuries to the artery in the form of blunt trauma, puncture, or prior surgery. They frequently present with swelling, pain, thrombosis, rupture, and occasionally, infection. Options for repair include primary arteriorrhaphy, partial excision with patch angioplasty, and total excision with interposition grafting. A review of the literature suggests that pseudoaneurysm formation following carotid endarterectomy is an uncommon event,1-5 and infection of these lesions is even less likely. There appears to be no difference in incidence whether or not the patient 1 Division of Vascular Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA. 2
Division of Vascular Surgery, Buffalo General Hospital, Buffalo, NY, USA. Correspondence to: Roman A. Litwinski, MD, Division of Vascular Surgery, Harbor-UCLA Medical Center, 1000 W. Carson Street, Box #11, Torrance, CA, 90509, USA, E-mail: [email protected] Ann Vasc Surg 2006; 20: 678–680 DOI: 10.1007/s10016-006-9060-9 Ó Annals of Vascular Surgery Inc. Published online: May 27, 2006 678
had closure of the arteriotomy with a patch angioplasty.1
CASE REPORT 1 This patient is a 75-year-old white female who presented to her primary-care physician with left-sided neck swelling and pain of several weeksÕ duration. The pain was severe, and she had hoarseness of the voice but no stridor. She had a history of left carotid endarterectomy without patch closure 10 years earlier, as well as coronary artery bypass grafting (CABG) 4 years earlier complicated by postoperative mediastinitis. At that time, she required pectoralis muscle flaps. Most recently, she has suffered with septic arthritis of the knee. Cultures of the aspirate grew methicillin-resistant Staphylococcus aureus (MRSA), as did later cultures of the blood. At the time of initial presentation, the mass was aspirated with a fine needle, with the immediate return of pulsatile, bright red blood. Pressure was held and Doppler examination confirmed a large aneurysm in the region of the carotid artery. The patient was transferred to our facility, and emergent arteriography was performed (Fig. 1). The arteriogram revealed a large pseudoaneurysm at the carotid bifurcation. The patient was immediately taken to surgery, given her impending airway obstruction.
Vol. 20, No. 5, 2006
Case reports 679
as well as aspiration of the septic joint. Intraoperative cultures and pathological examination of the carotid artery confirmed MRSA infection.
CASE REPORT 2
Fig. 1. Patient 1, preoperative arteriogram. The old endarterectomy incision was reopened, and vascular control was obtained with difficulty. It was immediately evident that the pseudoaneurysm was infected, with the presence of purulent material within the wound. The pseudoaneurysm was bleeding briskly from the prior puncture site, making visualization difficult and obscuring the planes of dissection. The previously endarterectomized vessel was completely resected, and the external carotid artery stump was oversewn. There was brisk back-bleeding noted from the internal carotid stump; therefore, a shunt was not placed. A reversed portion of the basilic vein was harvested and implanted as an interposition graft between the common and internal carotid arteries since all her saphenous vein had been previously harvested for CABG surgery. The wound was copiously irrigated, and a sternocleidomastoid muscle flap was mobilized to provide tissue closure over the repair. Doppler signals at the end of the case confirmed pulsatile perfusion of the distal internal carotid artery, with characteristic low-resistance signals. Unfortunately, the patient suffered an embolic left parietal stroke during the case, likely due to vessel manipulation when attempting to establish vessel control. This stroke manifested as right-sided arm and leg weakness. She began intensive physical therapy and rehabilitation, with near-total return of function. She completed a 6-week course of intravenous vancomycin
This patient was a 68-year-old white male with a history of diffuse aneurysmal disease. He had prior repair of a thoracoabdominal aortic aneurysm and has known intracranial aneursysms as well as bilateral popliteal aneurysms. He had undergone an uneventful left carotid endarterectomy with Hemashield patch angioplasty 18 months prior to presentation for stenotic disease. Subsequently, he presented with rapidly increasing pulsatile swelling of the left neck. There were no complaints of pain, drainage, or fever. Duplex scanning and magnetic resonance angiography (MRA) revealed a left carotid pseudoaneurysm, and the patient was taken urgently to the operating room. After gaining vascular control, the diseased common and internal carotid arteries were resected. He was also noted to have strong internal carotid stump back-bleeding. An interposition graft of reversed saphenous vein was used for vascular reconstruction, and the thrombus was sent for culture. The external carotid artery stump was oversewn. There was a strong pulse and Doppler signal in the distal internal carotid upon completion of the repair, and the wound was closed over a Jackson-Pratt drain. The cultures were ultimately negative, and the patient was neurologically intact. He recovered uneventfully and was discharged home on the third postoperative day. Interestingly, he revisited the emergency room 2 weeks later with rupture of his 7 cm left popliteal aneurysm, which required ligation and femoral-posterior tibial artery bypass grafting.
DISCUSSION A review of the literature suggests that pseudoaneurysm formation following carotid endarterectomy is an uncommon event, occurring in 0.30%2 of carotid endarterectomies. Of these, 33-40% are infected. In a recent larger series from the Texas Heart Institute (THI),1 the experience with 13 cases over a 35-year period was reviewed. Of 4,991 carotid endarterectomies performed in this time, only 37 (0.74%) developed a pseudoaneurysm. Of these, 13 (35%) were infected. This low incidence coincides with the low expected rate of infectious complication in a ‘‘clean’’ operation. Factors that favor pseudoaneurysm formation are those that promote infection. Prolonged endarterectomy (>2 hr), postoperative hypertension, inadequate hemostasis, adjacent infection, and bacteremia are all contributors. Surprisingly, use of foreign patch material for angioplasty did not result in an increased risk of pseudoaneurysm formation. In combining the THI groupÕs patients with those of
680 Case reports
four other papers,1-5 24 of 44 patients with infected carotid pseudoaneurysm had patch closure, while 20 of 44 did not. Of course, even the patients closed primarily necessarily had synthetic nonabsorbable suture implanted, and this may suffice as an infectious nidus. The presentation of these patients is a pulsatile neck mass, sometimes with signs of infection. There may be fever, cellulitis, abscess, drainage from the wound, overt hemorrhage, or neurological symptoms. In the THI meta-analysis,1 29 of 44 (66%) infected patients grew Staphylococcus species, with less common organisms including Streptococci and gram-negative bacilli. The recommended therapeutic strategy for these patients is urgent duplex carotid scanning to identify the lesion, with or without angiography (conventional, computed tomographic, or MRA) to delineate the anatomy. There are several surgical management options once the diagnosis is established. The overriding principle is wide debridement of all synthetic and infected material and reconstruction with autogenous tissue if possible.1-5 Antibiotic therapy is mandatory, and some authors feel that with the breadth of current antibiotic options, some patients without gross infection may tolerate synthetic graft interposition.1 Carotid artery ligation is associated with an unacceptably high risk of stroke (50%) and is to be condemned.1-4 If necessary, bypass procedures to the internal carotid are preferable to ligation.1 General anesthesia is recommended for repair as more distal control at the level of the mandible may be required. Shunt insertion is recommended if feasible in these suboptimal conditions, though the risk is increased in the face of gross thrombus and inflamed intima. Our two patients did not appear to need shunting. With the increasingly widespread usage of carotid stenting, this modality may be a reasonable alternative to open surgery,6,7 particularly in this patient population with a previously dissected neck. Covered stent placement has been used even in the setting of infection in one recent report.7
Annals of Vascular Surgery
Overall outcomes in the THI series showed 9 of 44 (20.1%) patients suffering perioperative cerebrovascular accident.1 Of these nine patients, five had internal carotid ligation and four underwent attempts at repair. There were no cranial nerve injuries encountered, compared to a 19% rate of injury in redo carotid endarterectomies for recurrent atherosclerotic narrowing. Our first patient presented with signs of infection as well as impending airway compromise. We operated to resect all infected tissue and reconstructed her carotid vasculature with autogenous tissue and flap coverage. Her stroke was likely due to vessel manipulation during a difficult dissection and attempt to gain vascular control, with subsequent cerebral embolization. The second patient had multilevel aneurysmal disease, and it is conceivable that he had an undiagnosed connective tissue disorder that contributed to his pseudoaneurysm formation. We also resected the diseased tissue and reconstructed him with autogenous tissue and flap coverage.
REFERENCES 1. El-Sabrout R, Reul G, Cooley DA. Infected postcarotid endarterectomy pseudoaneurysms: retrospective review of a series. Ann Vasc Surg 2000;14:239-247. 2. Branch CL, Davis CH. False aneurysm complicating carotid endarterectomy. Neurosurgery 1986;19:421-425. 3. Dougherty MJ, Calligaro KD, DeLaurentis DA. Infected false aneurysm after carotid endarterectomy: a case report and review of the literature. Vasc Surg 1997;31:791-796. 4. Raptis S, Baker SR. Infected false aneurysms of the carotid arteries after carotid endarterectomy. Eur J Vasc Endovasc Surg 1996;11:148-152. 5. Bonta MJ, Blackford JM. Ruptured carotid mycotic pseudoaneurysm after simple carotid endarterectomy: case report and brief literature review. Vasc Surg 1988;22:129-133. 6. Scavee V, De Wispelaere J-F, Mormont E, et al. Pseudoaneurysm of the internal carotid artery: treatment with a covered stent. Cardiovasc Intervent Radiol 2001;24:283285. 7. Baril DT, Ellozy SH, Carroccio A, et al. Endovascular repair of an infected carotid artery pseudoaneurysm. J Vasc Surg 2004;40:1024-1027.