March 21st 2018

Sacrifation of Right Carotid Artery With Giant Aneurysm: A Safe Bet?

Category: Peripheral,



Suci Indriani National Cardiovascular Center Harapan Kita



Suko Adiarto National Cardiovascular Center Harapan Kita

Writer's note: This case was performed by Suko Adiarto, MD, PhD and dr. Taofan, MD


Case Description

A 36 yo male came to our hospital with chief complain pulsatile mass in the neck that occured after lymph node biopsy and keep enlarging since 1 weeks before. He felt headache, and hard to move his head. The size: 4,9 x3,9 cm, located in the right neck (figure 1). He had history of lung  tuberculosis.

Figure 1. Mass in the right neck

Carotid doppler ultrasound revealed aneurysm in right distal common carotid artery and it was confirmed by carotid CT angio examination. Aneurysm in common carotid artery with increasing in size 54.8 x63.8 mm and obliteration of outflow tract (proximal of right internal carotid artery) (figure 2)


Figure 2. CT angiography showed large aneurysm of distal right carotid artery

Our Surgical and Vascular conference decided to perform carotid stent graft placement because of high risk for open surgical repair.


Procedural Step
Right and left femoral artery were punctured and 8F and 6F sheath were placed. 0.35 Terumo exchange wire was inserted. Catheher JR 3.5/5F was inserted and arteriography was performed. It revealed carotid artery aneurysm (video 1).

Wiring to the distal of the aneurysm was tried but it was failed (video 2).

Video 1. Angiography of right brachiocephalic and carotid artery

Video 2. Wiring to outflow tract


Since it was difficult to find the outflow tract, we could not inserted carotid stent graft. Then we decided to sacrifice the parent artery by performing  coiling of inflow tract.
Before coiling, we performed balloon occlusion test (4.0 x 40 mm) at right common carotid artery for 4 atm 120 sec, 5 atm 120 sec, 5 atm 120 sec to assess ischemic tolerance. Before and after balloon occlusion test, motoric and cognitive function were reviewed by neurologist. There were no worsening in neurological function (video 3).

Video 3a. Balloon occlusion test

Video 3b. Balloon occlusion test

The coil 10/4-TORNADO was inserted and deployed to the inflow tract but unfortunately it escape to the sac of aneurysm (video 4).

Video 4. Coil escaped to aneurysm sac

Amplatzer Endovascular plug  II 14 mm was deployed to the inflow tract (video 5). Vascular plug was in a good position (video 6).

Video 5. Deployment of Endovascular Plug

Video 6. Vascular plug was deployed in good position

On follow up, no neurologic symptoms, motoric and sensoric abnormality were found. The carotid aneurysm gradually involuted and decreased in size (figure 3).

Figure 3. The Aneurysm Gradually Involuted


A large aneurysm, like the one we found in this patient, is an indication for aggressive therapy. There are two option for treating carotid pseudoaneurysm such as open surgical and endovascular approach. The choice is depend on the mode of presentation, surgeon/interventionist experience, aneurysm location/accessibility and etiology. Carotid aneurysm can be treated with an endovascular stent graft. In a case with difficulty placing the stent, the alternative procedure is open surgical repair but the risk is higher.

Therapeutic artery occlusion is a simple, safe and effective treatment for a large aneurysm in patients who can tolerate sacrifice of the vessel which can reliably tested by angiographic balloon occlusion test. Most aneurysm involuted totally or decreased substantially in size over time after occlusion therapy.


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  3. deBorst GJ, Pourier VE. Treatment of aneurysms of the extracranial carotid artery: Current evidence and future perspectives. J Neurol Neuromed. 2016;1:11-14
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  5. Elhammady MS, Wolfe SQ, Farhat H, Aziz-Sultan MA, Heros RC. Carotid artery sacrifice for unclippable and uncoilable aneurysms: Endovascular occlusion vs common carotid artery ligation. Neurosurgery. 2010;67:1431-1436

what the experts say

RWM Kaligis
National Cardiovascular Center Harapan Kita

      First of all, I would like to congratulate dr. Suko and dr. Taofan for their successful approach in excluding an aneurysm from the circulation. One important lesson that can be highlighted from this case is about balloon occlusion test (BOT). Can it predict the long-term survival of this patient? Cascade of ischemic events following a proper BOT are as following:

1. Hemodynamic changes A decrease in Peak Systolic Velocity of the Middle Cerebral Artery (PSV MCA) occurred during the first seconds after balloon inflation. This hemodynamic change could be detected by transcranial Doppler (TCD). TCD stands out as a non-invasive bedside method providing real-time monitoring of the entire intracranial circulation during endovascular carotid BOT. It has been validated that a decrease in PSV MCA <30% relative to baseline during the occlusive period as a consistent predictive value of clinical tolerance (86% sensitivity and 93% specificity, positive predictive value of 86%) with no false negatives. TCD is able to show the early events in the ischemic cascade, allowing the diagnosis of hemodynamic intolerance prior to symptomatic manifestations.

2. Further decrease of cerebral blood flow (CBF) will induce perfusion decrease, which is still asymptomatic. This perfusion changes could be detected by perfusion imaging modalities

3. Prolonged perfusion changes will result in cellular dysfunction. It is still asymptomatic. Could be detected as electrophysiological dysfunction by an electroencephalogram recording

4. Irreversible changes occur in the late stage like cellular infarction. Symptoms will occur and could be detected clinically

Figure 1. Ischemic Cascade 

      Very glad to hear that on clinical follow up this patient has no neurological symptom with significant regression of the aneurysm. However, a safer approach in this case would be performing a balloon occlusion test with real-time TCD monitoring for a better predictive outcome.