Carotid blowout treated by direct percutaneous puncture of internal carotid artery with temporary balloon occlusion

Abstract

Direct percutaneous puncture of a cervical carotid pseudoaneurysm for coil placement or acrylic embolization is described for the endovascular management of acute carotid blowout. However, direct puncture of the internal carotid artery (ICA) for the endovascular management of carotid blowout has not been described. We report a difficult case of acute carotid blowout syndrome in a patient who had radiation- induced occlusion of the right common carotid artery with vasculopathy and pseudoaneurysm in the right cervical ICA. Collaterals from the branches of the controlateral external carotid artery (ECA) anastomosed with branches of right ECA supplied the vasculopathy. We performed direct percutaneous puncture of the bulb of the right ICA using a spinal needle and placed fiber coils to occlude antegrade flow of the artery. During the injection of a mixture of N-butyl cyanoacrylate and lipiodol oil for embolization of the remaining carotid bulb, we transiently inflated an occlusion balloon in the controlateral common carotid artery to further arrest antegrade flow in the ICA. The vasculopathy and pseudoaneurysm of the right cervical ICA were successfully embolized, with preservation of the distal branches of the right ICA.

Figure 1

Selective angiograms. (A) Image of the innominate artery shows total occlusion of right common carotid artery (arrow). (B) Anteroposterior view of the left carotid artery in the early arterial phase shows numerous collaterals from branches of the left ECA crossing the midline to branches of the right ECA. (C) Anteroposterior view of the left carotid artery in the late arterial phase shows radiation-induced vasculopathy and pseudoaneurysms, which cause irregular stenosis and focal dilatation of the right cervical ICA (arrowheads); this is supplied by the reversed flow of the right proximal ECA.

Figure 2

(A) Right ICA angiogram from the punctured spinal needle (arrowheads) showed the first 2 fiber coils placed in the pseudoaneurysm of the carotid bulb. (B) After deployment of 15 fiber coils in the distal portion of right carotid bulb, an occlusion balloon (arrowheads) was temporarily inflated in the left common carotid artery during the injection of NBCA and lipiodol oil. The mixture refluxed to the proximal branches of the right ECA (thin arrows ) and minimally flowed to proximal right cervical ICA (thick arrow). (C) Control left carotid angiogram shows successful embolization of the radiation vasculopathy and pseudoaneurysms of the right cervical ICA, with preservation of the distal branches of the right ICA. Delayed and decreased perfusion of right ICA territory indicates the poor intracranial collateral circulation in this territory.