Hybrid Endovascular and Direct Surgical Approach for Treatment of Penetrating Common Carotid Artery Injury: A Case Report

Abstract

Although rare, penetrating cervical vascular injury poses significant challenges with a poor patient prognosis, often attributed to severe hemorrhage and accompanying injuries. We encountered a case of hemorrhagic shock resulting from a penetrating injury to the common carotid artery (CCA), which was successfully managed using a combination of endovascular therapy and direct surgical intervention. A 23-year-old man presented with a self-inflicted stab wound on the left side of his neck from a kitchen knife. This injury resulted in hemorrhagic shock and coma. Initial management included fluid resuscitation and transfusion, with continuous manual compression to control profuse bleeding. Contrast-enhanced neck and brain computed tomography (CT) showed a left CCA injury that was challenging to directly address due to its low anatomical location and continuous bleeding. Neurosurgeons initiated endovascular treatment by placing a guiding balloon catheter proximal to the left CCA for occlusion. Despite this, pulsatile bleeding persisted, prompting the distal placement of a balloon catheter to achieve better bleeding control. Cardiovascular surgeons then performed direct surgery, clearly identifying damage to the anterior and posterior walls of the CCA. The repair involved the use of a self-made cylindrical bovine pericardial patch, which resulted in successful revascularization. Following surgery, the patient regained independent mobility and was discharged. This case emphasizes the importance of a prompt and reliable approach involving endovascular intervention for initial bleeding control followed by precise repair through direct surgery, especially in challenging bleeding scenarios.

Keywords: common carotid artery injury; endovascular treatment; hemorrhagic shock; hybrid surgery; penetrating injury.

Fig. 1

(A) Preoperative photograph of the patient with severe bleeding from the left cervical wound. (B) Frontal view of the neck on contrast-enhanced computed tomography (CT). The arrow indicates the injured left common carotid artery (CCA). The trachea (intubation tube shown in light blue) and thyroid gland (shown in green) are significantly displaced to the right due to the hematoma. (C) Lateral view. The injured left CCA (arrow) is located 8 cm distal to the aortic arch and 6.5 cm proximal to the cervical carotid bifurcation, near the lower thyroid and close to the mediastinum. (D) Axial view of contrast-enhanced CT at the level of the CCA injury. The common carotid artery is injured (arrowhead). (E) Axial view of the intracranial contrast-enhanced CT. No vessels visible in the region of the superior trunk of the left middle cerebral artery.

Fig. 2

(A) Frontal view of the left common carotid angiography, with blood flow controlled using a balloon-guided catheter (large arrowhead). Contrast medium leakage from the injured common carotid artery (CCA) is indicated (arrow). (B) Balloon occlusion of the proximal (large arrowhead) and distal (small arrowhead) sites of the injured left CCA. (C) Intraoperative view of the penetrated left CCA. (D) Schematic representation of the CCA within the operative field, illustrating the anterior and posterior wall injury and the presence of a balloon catheter. (E) A bovine pericardial patch crafted into a conduit used as an interposition graft for the injured CCA (dotted box) and restoration of antegrade blood flow. (F) Postoperative left CCA, showing no apparent new intracranial vascular occlusion compared with his preoperative computed tomography scan.