Cas cliniques

DOI of or1Unit of V

Hospital, Ferra2Departme

of Ferrara, Fe

Correspondvascular Surg44100 Ferrara

Ann Vasc SurDOI: 10.1016/� Annals of V�Edit�e par ELS

Traitement d’un faux an�evrysme carotidienpar un stentgraft enduit d’h�eparine

Tsolaki Elpiniki,1 Elisabetta Salviato,2 Tiberio Rocca,1 Lucia Braccini,1 Roberto Galeotti,2

Francesco Mascoli,1 Ferrara, Italie

Les faux an�evrysmes carotidiens sont une cons�equence rare de la chirurgie, des traumatismes,et des infections carotidiens. Historiquement, les an�evrysmes et les faux an�evrysmes carotidiensont �et�e trait�es chirurgicalement. Cependant, les techniques endovasculaires sont r�ecemmentdevenues une alternative valide pour le traitement des faux an�evrysmes carotidiens. Le casd’un homme de 57 ans avec un faux an�evrysme de l’art�ere carotide interne droite est d�ecrit.Le malade �etait venu dans notre unit�e avec une masse indolore et pulsatile du cou, qui sed�eveloppait lentement. Cinq ans plus tot, il avait eu une chirurgie d’un an�evrysme sacculairesitu�e sur le segment extra-cranien distal de l’art�ere carotide interne droite. Le faux an�evrysme�etait trait�e avec succ�es avec un stentgraft Viabahn enduit d’h�eparine (WL Gore, Flagstaff, AZ,USA). Les stentgrafts enduits d’h�eparine peuvent etre employ�es pour le traitement des l�esionscarotidiennes et peuvent offrir une protection contre l’hyperplasie intimale et la thrombose.D’autres �etudes sont n�ecessaires pour �evaluer les r�esultats �a long terme.

Carotid pseudoaneurysms occur after carotid artery

surgery, traumas, neck surgery, and infections.1,2

They are usually painless, continue to grow slowly,

and manifest as a pulsatile mass in the neck.3

However, they can manifest with more severe

symptoms such as hemorrhage caused by rupture or

with neurological symptoms caused by cerebral

embolization.4,5 Although historically carotid

aneurysms and pseudoaneurysms were treated

surgically,6 covered stents or stent-grafts have

become a recent alternative treatment for this

pathology with encouraging mid-term results. This

iginal article: 10.1016/j.avsg.2010.02.046.

ascular and Endovascular Surgery, S. Anna Universityra, Italie.

nt of Vascular and Interventional Radiology, Universityrrara, Italie.

ence : Tsolaki Elpiniki, Unit Of Vascular And Endo-ery, S. Anna University Hospital, corso Giovecca 203, Italie, E-mail: niki.tsolaki@gmail.com

g 2010; 24: 952.e9-952.e12j.acvfr.2011.03.009ascular Surgery Inc.EVIER MASSON SAS

case report describes the use of a covered stent to

treat a carotid pseudoaneurysm.We believe that the

use of a covered stent with a heparinized surface

may have advantages as compared with other

stents, in terms of decreasing the risk of thrombosis

and perhaps intimal hyperplasia.

METHODS

A 57-year-old man came to our unit with a painless,

progressively growing and pulsating neckmass. Five

years earlier he had undergone surgery to remove a

saccular aneurysm located on the distal extracranial

segment of the right internal carotid artery (ICA).

The treatment consisted of aneurysmectomy and

end-to-end anastomosis. His medical history was

unremarkable and he did not show signs of dys-

phagia, fever, respiratory difficulties, or central

neurological symptoms such as transient ischemic

attack or stroke.

The ultrasound examination showed a partially

thrombosed pseudoaneurysm, involving the third

distal extracranial segment of the right ICA. It mea-

sured 40 � 60 mm and was caused by a dehiscence

1036.e1

Fig. 1. Preoperative computed tomography angio scan

showing the carotid pseudoaneurysm (arrow).

1036.e2 Cas cliniques Annales de chirurgie vasculaire

of the surgical anastomosis. The head and neck

computed tomography angio scan confirmed the

ultrasound findings (Fig. 1).

Urgent endovascular management was proposed

and the patient gave his informed consent after the

potential risks and benefits of the proposed treat-

ment had been explained to him. The patient was

not administered clopidogrel before surgery. In the

operating theatre, after administration of 5,000units

of heparin, a selective angiogramof the carotid bifur-

cationwas performed through a right femoral percu-

taneous access under local anesthesia. A 0.035 in

guidewire (Implants Super stiff, Boston Scientific,

Natick,MA)was placed in the external carotid artery

after a 7F introducer sheath was placed in the

common carotid artery and a roadmapwas obtained

to localize the lesion more precisely. After catheteri-

zation of the ICA by a 0.035 in Terumo guidewire

(Terumo Medical Corporation, Japan), a 5 mm �2.5 cm Viabahn stent-graft with heparin surface

(Gore AL, Flagstaff, AZ) was placed on the ICA to

cover the dehiscence (Figs. 2A, B). No cerebral pro-

tection device was used because there was no evi-

dence of atherosclerotic lesions or dissection. The

completion angiography demonstrated an endoleak

caused by incomplete expansion of the stent-graft,

which was successfully treated by dilation with an

angioplasty balloon catheter (Ultrasoft 5 � 2 mm,

Boston Scientific, Natick, MA). The final angio-

graphy showed the complete exclusion of the pseu-

doaneurysm and patency of the carotid arteries

(Fig. 2C). An Angio-seal closure device (St. Jude

Medical St. Paul, MN) was used to seal the femoral

artery puncture.

The postoperative stage was uneventful and the

patient was discharged on the second postoperative

day with double antiplatelet therapy (clopidogrel,

75 mg; aspirin, 325 mg).

Clinical and ultrasound follow-ups were per-

formed, as well as angiography, 1, 3, and 6 months

postoperatively. They showed complete exclusion of

the lesion and patency of the ICA, with no evidence

of stenosis or intimal hyperplasia (Figs. 3A-C).

DISCUSSION

Carotid pseudoaneurysms occur after carotid artery

surgery, traumas, neck surgery, and infections.1

Surgical treatment is not always feasible, especially

when lesions are situated near the base of the skull,

because of difficult exposure, distal vascular control,

and the high rates of associated cranial nerve inju-

ries (3-13%).

Recently, endovascular techniques have become

a valid alternative for the treatment of carotid

pseudoaneurysms. Hoppe et al. report encouraging

short- and mid-term results after stent-graft place-

ment in cases of carotid aneurysms, pseudo-

aneurysms, and carotid blowout syndrome.7

However, distal embolization,8 stent thrombosis,

dissection, and restenosis are some of the most

severe complications following carotid stenting,

even when antiplatelet therapy is administrated.9 It

is believed that intimal injury of the artery during

carotid stenting triggers platelet activation and

aggregation, as well as the inflammatory cascade

with subsequent smooth muscle proliferation. Fur-

thermore, thrombus formation immediately after

carotid stenting and embolization to distal sites can

cause serious postprocedural complications. The

most important factors contributing to stent

thrombosis include the small size of the vessel, stent

under-dilation, and the presence of proximal or

distal dissection.10 Chaturvedi et al. and McKevitt

et al.11,12 suggest that double antiplatelet therapy

after carotid stenting plays an important role in

reducing adverse neurological outcomes without

further complications of increased bleeding.

With our patient, the decision to give him endo-

vascular treatment was based on the perceived diffi-

culty of exposing the ICA because of previous

surgical repair and the distal extent of the lesion.

Thus, placement of a short, self-expanding stent-

graft was considered an applicable and minimally

invasive therapeutic approach as the pseudo-

aneurysm was caused by dehiscence on the ICA

anastomosis. The choice of a heparin-surface stent

was based on the possibility of additional protection

against intimal hyperplasia and thrombosis. In the

Fig. 2. A Preprocedure angiography showing the right

ICA pseudoaneurysm (arrow). B Intraoperative angio-

graphy highlighting the presence of an endoleak as the

stent-graft did not fully expand. C Final intraoperative

cervical and cerebral angiography showing exclusion of

the pseudoaneurysm after stent-graft expansion and

patency of the carotid arteries.

Fig. 3. A, B Three-month ultrasound examination

showing complete thrombosis and exclusion of the lesion

as well as hypertrophic branches of the external carotid

artery passing under the pseudoaneurysm B (arrow). C

Three-month angiographic control confirming patency of

the internal carotid artery.

Vol. 24, No. 7, 2010 Cas cliniques 1036.e3

published data, different studies report successful

carotid aneurysm or pseudoaneurysm exclusion

after placement of a Viabahn stent-graft. However,

little has been published on the use of human

carotid pseudoaneurysm being treated with a

heparin surface stent-graft.13

In conclusion, heparin surface stent-grafts may

be used for the treatment of carotid lesions and they

1036.e4 Cas cliniques Annales de chirurgie vasculaire

offer additional protection against intimal hyper-

plasia and thrombosis. Further studies are needed to

evaluate the long-term results for this new device.

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