Left common carotid artery ostium iatrogenic dissection: A case report and systematic review of the literature

Abstract

Background: Common carotid artery dissections (CCADs) are rare but potentially life-threatening, often leading to ischemic events. Iatrogenic CCADs have been reported, but this is the first case of an ostium-located CCAD occurring during cerebral angiography. A systematic review was conducted to identify similar cases.

Methods: This case report followed the CAse REport (CARE) checklist, and the systematic review adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. A literature search was performed across PubMed, Embase, and Cochrane Library to identify case reports or series on iatrogenic CCADs.

Results: An 81-year-old female undergoing follow-up cerebral angiography postaneurysm clipping developed an 80% left common carotid artery ostium stenosis due to a Simmons 2 catheter. She remained asymptomatic and was treated with dual antiplatelet therapy (aspirin and clopidogrel). The systematic review included eight studies (13 patients, mean age 58.2 years), with diverse iatrogenic causes, including catheter misplacement (n = 2), puncture accident (n = 1), endarterectomy (n = 1), carotid stenting (n = 1), tumor resection (n = 1), radiotherapy (n = 1), and cerebral angiography (without ostium involvement) (n = 1). Four of seven symptomatic patients had ischemic events, whereas others had neck pain, sedation, or were asymptomatic. Treatment varied, with only one patient experiencing persistent deficit (Horner syndrome).

Conclusion: This is the first reported case of an ostium-located CCAD during routine angiography. The systematic review highlights the diverse etiologies and clinical courses of iatrogenic CCADs, underscoring the need for individualized management to optimize outcomes and reduce complications.

Keywords: Angiography; Case report; Common carotid artery dissection; Dissection; Ostium; Systematic review.

Figure 1:

Anteroposterior angiography of the left common carotid artery. (A) Road mapping and (B) fluoroscopic images obtained before the onset of left common carotid artery dissection.

Figure 2:

Oblique view of a digital subtraction angiography showing the (A) early and (B) intermediate (B) arterial phases following contrast injection into the left common carotid artery (CCA). The origin of the dissection is seen just a few millimeters from the ostium of the artery (blue arrow). A double layer (red arrow) has formed between the intimal and medial layers of the CCA, resulting in approximately 80% narrowing of the arterial lumen. In addition, the double lumen sign (yellow arrow) – a classic indicator of arterial dissection – is visible. (C) Fluoroscopic angiography demonstrates the contrast retention within the false lumen of the left CCA (White arrow).

Figure 3:

Follow-up computed tomography angiography on the day of discharge: (A) axial view; (B) coronal view; (C) sagittal view.

Figure 4:

Progression of dissection induced by a Simmons 2 catheter. (A) The diagnostic catheter creates a new lumen between the intima and media layers of the artery, resulting in the formation of a double-lumen appearance. (B) As this space develops, blood enters the newly created compartment, filling both the true and false lumens of the artery. At this stage, the double-lumen sign becomes visible on fluoroscopy. (C) As blood accumulates within the false lumen, it further distends this compartment, effectively obliterating the true lumen of the common carotid artery. This blood stasis in the false lumen initiates a coagulation process. (D) The expanding clot eventually reaches its maximum size, causing significant occlusion of the true lumen. (E) True lumen of the vessel occluded due clotting expansion.

Figure 5:

Follow-up computed tomography angiography at 2-month postdischarge: the red arrows indicate the ostium with complete recanalization. (A) Coronal view; (B) sagittal view.

Figure 6:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.