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).

 

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).
 

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

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

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

 

CONCLUSION
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.
 

References:

1. Mishwani AH, Haleem A, Kiani KA. Giant aneurysm of the extracranial internal carotid artery. Journal of the  college phycians and surgeons Pakistan. 2010;20:345-346
2. Longo GM, Kibbe MR. Aneuryms of the carotid artery. Seminars in vascular surgery 2005;18:178-183
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
4. Saatkci I, Cekirge HS, Oztur MH. Treatment of internal carotid artery aneurysms with a covered stent : Experience in 24 patients with mid-term follow up results. American journal of neuroradiology. 2004;25:1742-1749
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