Non-infected carotid artery pseudoaneurysm 29 years after endarterectomy, endovascular management with covered stent

Abstract

Pseudoaneurysm formation is a rare complication following carotid endarterectomy (CEA). Arterial pseudoaneurysms lack all three layers of the arterial wall that include the intima, media and adventitia. Pseudoaneurysms are most commonly seen after injuries to the artery in the form of blunt trauma and puncture, and are less common after surgeries such as carotid endarterectomy. These lesions present most frequently as enlarging, pulsatile, expandable masses associated with swelling and pain. Management of this complication is challenging. Traditionally, open surgical repair has been the preferred treatment. Recently, endovascular techniques using stent graft implantation alone or combined graft and coil embolization have offered a less invasive approach for the management of this lesion. Pseudoaneurysm development has been described within hours to several years after initial arterial injury, normally presenting within 5 years. To our knowledge, this is the first case report of pseudoaneurysm formation in a patient presenting 29 years after a carotid endarterectomy; during that time the patient remained completely asymptomatic until 2 months prior to his admission. The patient is an 84-year-old male with a history of stroke which prompted a left carotid endarterectomy in 1981. Twenty-nine years post procedure it was noted that the patient had a lump that was progressively enlarging on the left side of his neck, zone 1. It was pulsatile on examination. MRI/A imaging suggested a left carotid bulb aneurysm. The consulting vascular surgeon felt the patient would not be a good surgical candidate and so stenting was considered. Carotid and cerebral angiogram demonstrated a large 6 cm left carotid pseudoaneurysm off the carotid bulb. The diagnostic procedure was followed by a successful placement of an 8 x 10 cm Viabahn covered stent from the left common carotid artery to the left internal carotid artery. Following the procedure, the carotid artery was patent and there was minimal to no further residual filling of the pseudoaneurysm. Poststenting, the patient remained at his neurological baseline. This case demonstrates that pseudoaneurysm formation can occur as a long term complication after carotid endarterectomy. It may present as a rapidly expandable, pulsatile, vascular lesion in the absence of clinical and sub-clinical infection. Placement of an endovascular stent graft may be a safe and effective option for treatment of infected and non-infected carotid pseudoaneurysm.