Salvage of the carotid artery with covered stent after perforation with dialysis sheath. A case report

Abstract

We present a rare case of carotid tear caused by iatrogenic erroneous insertion of a dialysis sheath into the common carotid artery (CCA). This was treated by placement of a covered stent-graft in the CCA over the puncture site. This treatment achieved hemostasis while preserving the carotid artery with good outcome. The technical details are presented and the relevant literature regarding treatment of carotid blowout syndrome is discussed. This case suggests that placement of a covered stent-graft is a good option not only for the "usual" blowout syndrome due to head and neck tumors, but also for treatment of iatrogenic injury to the carotid artery.

Figure 1

A) Frontal projection of a left common carotid arteriogram shows the dialysis sheath (arrow heads) placed in the CCA with partial collapse of the CCA distal to the sheath. Filling defects from thrombus are noted superior to the sheath (arrows). B) Frontal plain film of the neck shows the covered stent in the left CCA after removal of the dialysis introducer sheath (arrows). C, D) Frontal left common carotid arteriogram after stenting and removal of the dialysis sheath, demonstrates a patent stent and CCA with no leak and preserved flow into the left internal carotid artery and towards the intracranial circulation.

Figure 2

DWI image from an MRI performed several days after stenting (A) shows a small lesion of restricted diffusion in the posterior left frontal lobe (arrow in A) in keeping with a small acute embolic infarct. Two more similar lesions were noted in the cortex of the posterior left frontal lobe and in the left occipital lobe. Follow-up Doppler US (B) and CTA (C, D) 6 months after stenting show that the left CCA is patent and that the stent is well opposed against the CCA wall (arrows in B and D).