Treatment of Extracranial Carotid Artery Pseudoaneurysms withStent Grafts: Case Series

Rishi Gupta, MD, Ajith J. Thomas, MD, Amit Masih, MD, Michael B. Horowitz, MDFrom the Department of Neurology, Division of Cerebrovascular Disease, Michigan State University and Sparrow Health System, East Lansing, MI (RG, AM); Department ofNeurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA (MBH); and Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School,Boston, MA (AJT).

Keywords: Stent graft, carotid pseu-doaneurysm, angiography.

Acceptance: Received December 21,2006, and in revised form April 2, 2007;May 10, 2007. Accepted for publicationJune 18, 2007.

Correspondence: Address correspon-dence to Rishi Gupta, MD, Departmentof Neurology, Division of CerebrovascularDisease, Michigan State University, 138Service Road, A-217, East Lansing, MI48824. E-mail: Rishi.gupta@ht.msu.edu.

J Neuroimaging 2008;18:180-183.DOI: 10.1111/j.1552-6569.2007.00186.x

A B S T R A C T

BACKGROUND AND PURPOSEExtracranial carotid artery pseudoaneurysms are a rare entity with a poorly defined naturalhistory. Treatment has been limited to open surgical repair and limited experience withendovascular repair. We review our experience with the use of stent grafts to treat thisdisease entity.METHODWe retrospectively reviewed the interventional databases of two university hospitals(Michigan State University and University of Pittsburgh Medical Center) between 2004and 2006 to identify patients with carotid pseudoaneurysms that were treated with stentgrafts. A total of five patients were identified.RESULTSOf the five patients treated, four presented with acute bleeding secondary to carcino-matous invasion of the carotid artery, while one presented with thromboembolic events.Four of the five were successfully occluded with stent grafts. The one patient in whom thebleeding could not be stopped with the stent graft expired due to cardiac arrest. Therewere no peri-procedural complications noted as a result of stent graft placement.CONCLUSIONSStent grafts can be utilized to treat pseudoaneurysms safely, but may not always stopactive extravasation as an isolated therapy. Long-term data is required to determine thedurability of the treatment.

IntroductionThe development of extracranial carotid artery pseudoa-neurysms is an exceedingly rare clinical finding. The etiology ofthis unusual disease has been associated with infections leadingto a mycotic pseudoaneurysm,1 post carotid endarterectomy(CEA) blowout of a patch graft,2 trauma, and invasive carci-noma.3 Potential complications from the development of pseu-doaneurysms include thromboembolic complications, rupture,and mass effect on the trachea.4 The management of this entityis challenging as the natural history is not known due to its rar-ity. It has been presumed that treatment is the best approacheither with surgical repair or endovascular repair through stentplacement followed by coiling or by placement of a coveredstent to exclude the diseased portion of the artery. We presenta case series of five patients who were treated with endovas-cular placement of a stent graft to repair the carotid arterypseudoaneurysm.

MethodsWe retrospectively reviewed our experience with the use ofstent grafts to treat carotid artery pseudoaneurysms at two insti-tutions (Michigan State University and University of PittsburghMedical Center) between July 2004 and November 2006. Wereviewed the databases of both institutions and five patients

were identified as having undergone endovascular treatmentfor a carotid artery pseudoaneurysm.

Demographic, clinical, procedural, and radiographic imag-ing was reviewed on all patients by two authors (AJT and RG)and each patient is summarized in Table 1.

The technique used for these patients included placing a 5French diagnostic catheter in the ipsilateral common carotidartery. An angiographic run was performed to confirm locationof the pseudoaneurysm. A .035 inch wire was placed into theinternal carotid artery under roadmapping guidance. The diag-nostic catheter was then removed and a 9 French Cook 90 cmsheath was placed over the wire into the common carotid artery(CCA) proximal to the pseudoaneurysm. The stent graft wasthen navigated over the .035 inch wire and placed across theneck of the pseudoaneurysm using roadmapping guidance. Af-ter stent deployment and occlusion of the pseudoaneurysm wasconfirmed angiographically, a bolus of 180 mcg/kg of eptifi-batide was administered if the patient was not on clopidogrelpreprocedure. Heparin was not given to the four patients withactive extravasation, while one patient described below re-ceived heparin during the procedure. A 300 mg load of clopido-grel was then administered orally immediately after the proce-dure and patients were maintained on dual antiplatelet therapywith aspirin 325 mg a day and clopidogrel 75 mg a day for atleast a month.

180 Copyright ◦C 2008 by the American Society of Neuroimaging

Table 1. Summary of the Five patients treated with covered stents

Patient Age Pathology Size of Pseudoaneurysm Stent type/Stent Size

1 51 SCC, bleeding pseudoaneurysm in ICA 20 mm WallGraft 7 × 30 mm2 58 SCC, bleeding pseudoaneurysm in ICA 8 mm WallGraft 7 × 30 mm3 87 Post CEA pseudoaneurysm in CCA 80 mm WallGraft 8 × 30 mm4 56∗ SCC, bleeding pseudoaneurysm in CCA 26 mm WallGraft 8 × 30 mm, 8 × 30 mm, 9 × 20 mm5 75 SCC, bleeding pseudoaneurysm in ICA 38 mm iCast Atrium Stent Graft, 6 × 38 mm

SCC = Squamous Cell Carcinoma, ∗ Three stent were placed in this patient without occlusion of the bleeding vessel and patientexpired due to cardiac arrest.

Case Example

An 87-year-old man with a history of a right CEA 1 year priorpresented to our institution with loss of vision to his right eye, apulsating neck mass, dysphagia, and dysphonia. He had beenhospitalized 3 weeks prior with pneumonia and no notation of apulsatile neck mass was documented at that time. On the day ofadmission, he complained of right neck pain for 2 days with newonset hoarseness in his voice. He became concerned on the dayof admission when he lost vision in his right eye. Laryngoscopicexamination confirmed right vocal cord paralysis.

On clinical examination the patient was noted to have apulsating mass on the right side of his neck. A loud bruit wasappreciated upon auscultation of this lesion. He was also notedto have evidence of retinal artery ischemia on fundoscopicexamination. A computed tomography (CT) of the neck wasordered in the emergency room and revealed a large mass orig-inating from the right common carotid artery with mass effecton the trachea and right internal jugular vein. He was taken forcerebral arteriography and an 8 × 6 cm pseudoaneurysm wasdemonstrated originating from the distal right common carotidartery (Fig 1A). The aperture of this lesion was 4 mm. After a dis-cussion with the vascular surgery team it was felt that given thesize of the lesion and clinical deficits that there was a significantconcern for rupture or further expansion or thromboemboliccomplications resulting from this mass.

Technique

The patient was loaded with 450 mg of clopidogrel and as-pirin 325 mg prior to initiation of the procedure. A 9 Frenchsheath was placed in the right common femoral artery using theSeldinger technique. A 5 French diagnostic catheter was thenused to selective catheterize the right CCA. Under roadmap-ping guidance, a .38-inch stiff exchange length wire was placedin the right internal carotid artery. A bolus of intravenousheparin was given 80 units/kg to maintain an activated clottingtime of 250–300 seconds. The diagnostic catheter was removedand an 8 × 30 mm self-expanding Wallgraft (Boston Scientific,Fremont, CA) was navigated over the wire and deployed acrossthe aperture of the pseudoaneurysm (Fig 1B). This techniquewas used as there was a great deal of proximal tortuosity pre-cluding placement of a 9 French guide catheter. A bolus of180 mcg/kg of eptifibatide was given after the stent was de-ployed. There was adequate occlusion of the pseudoaneurysm.Post stent placement runs demonstrate exclusion of the pseu-doaneurysm with patency of the internal carotid artery (ICA).

A CT angiogram obtained the next day also confirmed thesefindings. The patient was maintained on aspirin and clopidogrelfor 3 months and then aspirin therapy indefinitely.

At 3-month follow-up the patient has noted improvementin his dysphagia and the neck mass has reduced markedly.A carotid duplex ultrasound confirmed the stent is still patentwithout evidence of recanalization of the pseudoaneurysm.

ResultsA total of five patients were identified as being treated withstent grafts for carotid artery pseudoaneurysm. Four of these pa-tients presented with active bleeding from the psudoaneurysmsecondary to squamous cell carcinoma invasion of the carotidartery while one patient (Case example) presented with an en-larging pulsatile mass after an endarterectomy. The pseudoa-neurysm was obliterated in four of the five patients. In the onepatient where an endoleak was apparent, two additional stentgrafts were placed without success in repairing the pseudoa-neurysm. The patient continued to have active extravasation ofthe carotid artery and eventually died from cardiac arrest. Allpatients were treated with clopidogrel and aspirin after place-ment of the stent graft. In the four patients with squamouscell carcinoma, therapy was offered as a life-saving measurealthough the overall prognosis for the patients was poor giventhe extensive nature of their disease.

Of the four surviving patients, three had end-stage squamouscell carcinoma and died within 4 weeks of treatment due to theirterminal illness. Only one patient had follow-up as described inthe case example.

DiscussionThis case series demonstrates that stent grafts can be uti-lized safely to treat carotid artery pseudoaneurysms in le-sions related to carcinomatous invasion and carotid patchblowout after endarterectomy. There are different approachesto treating a pseudoaneurysm of the extracranial carotid arteryincluding: surgical repair via aneurysmectomy with ligationor bypass around the aneurysm, placement of a noncoveredstent with coil embolization of the aneurysm, or sacrifice of thecarotid artery.

Surgical approaches have been extensively described in theliterature for patients with this condition, but the rates of strokeand death in the peri-procedural period can be as high as 7.7%5

and cranial nerve injuries as high as 44%.6 Unfortunately, no

Gupta et al: Carotid Pseudoaneurysms and Stent Grafting 181

Fig 1. (A) A carotid angiogram in lateral projection demonstrates a large right common carotid artery pseudoaneurysm with a small tearlikely at the site of the vein patch from the previous carotid endarterectomy. (B) Post Wallgraft stent deployment reveals exclusion of thepseudoaneurysm with patency of the carotid artery.

direct comparison trial exists comparing the endovascular ap-proach with the surgical approach. Other authors have utilizeduncovered stent with sequential coil embolization to treat theselesions with success.7 There are few reports of this techniqueand there is a theoretical concern that inflow to the pseudoa-neurysm may preclude the process of thrombosis to occur inorder to heal the aneurysm. The approach of occluding thecarotid artery is less desirable as the loss of an artery maypredispose patients to longer term risk of ischemic stroke. Ad-ditionally, the risk of a neurologic event during a balloon testocclusion to determine if the vessel can be sacrificed is 1.6% inthe peri-procedural period.8 The use of stent grafts to treat thiscondition may have a role considering the limitations of theother treatment modalities, but longer term safety and efficacydata is required before it becomes the mainstay therapy in thefuture.

The stent grafts used in this case series were all self-expanding except for one patient who was treated with a bal-loon expandable graft (patient 5). The self-expanding graftsmust be advanced through a 9 French sheath while the balloon

expandable stents can be placed through a 7 French sheath.This has the advantage of fewer complications related to bleed-ing at the puncture site. Self-expanding grafts may not opposethe arterial wall with the degree of radial force as a balloonmounted stent, but in patients with weakened arteries due tocarcinoma invasion there is a theoretical risk of rupture of thevessel with balloon inflation. Thus, we prefer using the self-expanding stent despite the limitations with the larger sizedsheath. In our patient in whom the bleeding would not stop,we tried three telescoping stent without success. It is not clearwhy this did not stop the extravasation in this patient. If the graftdoes not stop active bleeding, a balloon can be placed proximalto the site of extravasation for proximal control and the patientcan be taken to the operating room. In this particular patient,this was not possible to do as he went into cardiac arrest priorto attempting this maneuver.

Complications can occur with stent grafts. There is a concernfor thrombosis of the stent and thus the selection of antithrom-botic regimen may be important in preventing this complica-tion. We placed our patients on dual antiplatelet therapy with

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clopidogrel and aspirin for at least 4 weeks after placement ofthe stent graft. The rate of restenosis of these grafts is not known.A recent report of four patients followed for greater then 6months showed no evidence of restenosis in each patient oncarotid ultrasound.9 In 30 patients with iliac artery aneurysms,the rate of stent occlusion was 3% in greater than 3-monthfollow-up.10 As further experience is reported with the use ofstent grafts, longer term follow-up data will be available to betterunderstand the durability of this therapy. Another rare compli-cation that has been reported is fracture of the stent that maylead to recanalization of the pseudoaneurysm.11 Serial imagingwith carotid ultrasound should be performed to follow patientsfor stent restenosis and recanalization of the pseudoaneurysm.In patients with carotid blowout syndrome due to carcinomainvasion of the carotid artery, there have been reports of stentextrusion after placement of stent grafts.12 In such patients, thismodality of treatment is likely a temporizing measure given thepoor overall prognosis of the underlying illness. In four of ourpatients they developed an actively bleeding pseudoaneurysmas a result of invasion of squamous cell carcinoma and all diedwithin 4 weeks of the procedure.

In conclusion, we present five patients treated with stentgrafts for carotid pseudoaneurysm. This modality of treatmentis feasible and may be safe in the short term to treat this raredisease entity.

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