Covered Stent Exclusion of Blunt Traumatic Carotid Artery Pseudoaneurysm: Case Report and Review of the Literature Glenn E. Fusonie, MD, John D. Edwards, MD, and Amy B. Reed, MD, Cincinnati, USA
Injury to the carotid artery from blunt trauma, when not lethal, will often go unrecognized. A 37year-old male was the belted driver in a motor vehicle accident 15 years prior to presenting with intermittent left upper extremity parasthesias and weakness. A large, calcified distal right internal carotid artery (ICA) pseudoaneurysm was diagnosed and successfully excluded with a 7 · 30 mm covered stent.
Traumatic injury to the carotid artery is a rare but serious complication following blunt trauma. Pseudoaneurysm formation occurs in nearly onethird of blunt carotid injuries (BCI).1 Other types of BCI include dissection, thrombosis, and complete disruption. Historically, carotid pseudoaneurysms have been managed operatively with repair, ligation, and anticoagulation, with percutaneous angioplasty and stenting emerging over the past decade. We present a case of delayed neurologic sequelae from a right carotid pseudoaneurysm managed endovascularly that illustrates the risk of delayed presentation and further supports the percutaneous approach for lesions difficult to access surgically.
CASE REPORT A 37-year-old male presented to his primary care physician with a complaint of intermittent left upper extremity weakness and numbness associated with an illdefined pain and stiffness. These episodes occurred three times over a 4-month period. The duration varied from a few minutes to 1 to 2 hr. His past medical history was remarkable for a high-speed motor vehicle accident 15 years previously in which he was the belted driver. By
Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA. Correspondence to: Amy B. Reed, MD, Division of Vacular Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, Suite 2563, Cincinnati, OH 45267-0558, USA, E-mail: [email protected]
Ann Vasc Surg 2004; 18: 376-379 DOI: 10.1007/s10016-004-0037-2 Annals of Vascular Surgery Inc. Published online: 21 April 2004
report from the patient, evaluation at that time failed to reveal any extracranial cerebrovascular injury or cervical bony injury. He did sustain multiple fractured ribs and a long-bone fracture. Further details of the work-up at the time of the accident were not available as he was cared for at an outside facility. His medications included only occasional acetaminophen. He was employed as an office manager. A cervical magnetic resonance imaging (MRI) obtained suggested a mass in the right C1 to C2 cervical region. The images of the brain showed no evidence of stroke, mass, bleed, or ischemia. He was referred to an ear-nose-throat surgeon who obtained a magnetic resonance angiogram (MRA) which demonstrated that the mass was vascular, highly suggestive of a right internal carotid artery pseudoaneurysm. He was then referred for a vascular surgery evaluation. On presentation, he was noted to be a young, healthyappearing male with a physical exam remarkable only for a bruit high in the right neck. A mass was not appreciated on exam. His strength, muscle tone, and sensation were all normal. After confirming the presence of the pseudoaneurysm by carotid duplex, the patient was taken to the catheterization suite with the intent to better delineate the location of the mass and treat it endovascularly, if appropriate. Through a transfemoral approach, guidewire access with a 0.035 wire to the aortic arch was first obtained. After performing an arch angiogram and four-vessel cerebral angiogram, the right common and internal carotid arteries were selectively catheterized. Multiple angiographic views confirmed the distal location of the pseudoaneurysm at the base of the skull (Fig. 1). The patient was systemically heparinized with 5000 units of unfractionated heparin. Guidewire traversal of the lesion was successfully obtained with a SV8 (0.018) guidewire. A 7 · 30 mm Wallgraft, a self-expanding, stainless steel stent covered with polyester mesh, was then deployed with 1.5 cm overlap both proximally and distally. Initial proximal leak around the stent was successfully resolved by dilation of the graft’s proximal as-
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Fig. 1. A series of pictures demonstrating the size and location of the pseudoaneurysm.
pect with a Marshall 6 · 20 mm balloon (Fig. 2). The balloon was inflated to 4 atmospheres of pressure for 15 sec. The patient was given clopidogrel 300 mg immediately following the procedure and then started on 75 mg/ day. He was discharged home the following day after an uneventful overnight admission to the hospital for observation. He suffered no adverse sequelae from the procedure and has remained asymptomatic with complete resolution of the left upper extremity numbness and weakness. The patency of the covered stent and successful exclusion of the pseudoaneurysm have been confirmed with carotid duplex imaging at 1- and 3month follow-up. Successful exclusion was determined by evidence of complete thrombosis of the pseudoaneurysm. He will have a repeat of this study at 3-month intervals for the first year. He continues on clopidogrel at 75 mg/day. On the basis of studies of clopidogrel used following coronary stenting, he will remain on this regimen for at least 6 months. The optimal use of clopidogrel beyond 6 months will require further investigation.2
DISCUSSION Blunt carotid injury is uncommon. Four mechanisms of injury are recognized: cervical hyperex-
tension/rotation, direct blow to the neck, intraoral trauma, and basilar skull fracture.2 Many individuals with blunt carotid injury are asymptomatic at presentation. Fabian et al.1 found that 43% of their patients were not diagnosed until a neurologic deficit developed. This study found an incidence of 0.33% among blunt trauma victims, suggesting that it is likely more common than formerly reported. Previous reports by Davis and colleagues3 were closer to the 0.08% incidence. The diagnosis is often made more difficult by confounding factors such as intracranial lesions or ethanol or drug intoxication. However, the patient’s neurologic status does not necessarily help make the diagnosis. In the multicenter study of Cogbill et al.4, the diagnosis of BCI was more common in patients with an essentially normal neurological exam (49%) than in individuals with a Glasgow Coma Scale of <8 (37%). Fabian’s findings suggest that a higher vigilance in surveillance is necessary, particularly if the mechanism is rapid deceleration with hyperextension and rotation of the neck. However, broad screening is impractical because of the low inci-
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Fig. 2. Top row (A,B) of pictures demonstrates stent graft deployment and initial proximal leak. Bottom row (C,D) of pictures demonstrates successful exclusion after balloon dilation of the proximal aspect of the stent graft.
dence and the potential risks of angiographic evaluation. Still, patients who present with or develop neurologic deficits whose cerebral computed tomographic scans do not account for these deficits should undergo further angiographic investigation. Injuries to the carotid can lead to complications from hemorrhage, thrombosis, and/ or embolization. Morbidity following carotid injury is possibly as high as 80%.5 Our patient experienced transient ischemic attacks (TIAS) caused by microthromboembolism from the pseudoaneurysm. In one study, all post-traumatic carotid pseudoaneurysms were producing symptoms related to embolic ischemia.6 Fabian’s study further established the efficacy of anticoagulation for the majority of BCIs: 62% percent of dissections in this study group reverted to normal on follow-up angiograms. However, there was no resolution of pseudoaneurysms on follow-up angiograms. Six of 66 patients followed in their study had pseudoaneurysms. Furthermore, 29% of carotid dissections progressed to pseudoaneurysm. Mokri et al.6 found that only 3 of 14
pseudoaneurysms decreased in size or resolved. As with our patient, many of these individuals with pseudoaneurysms present with neurologic symptoms weeks, months, or even years later. The findings in both these studies are evidence for intervention when a pseudoaneurysm is found initially or develops during the follow-up. The potential interventions include surgical repair, surgical ligation, and endovascular exclusion, thrombosis, or balloon occlusion. Most authors recommend surgical repair when it is technically feasible.4,7,8 Inaccessible pseudoaneurysms have been managed by anticoagulation and proximal ligation with and without extracranial-intracranial bypass. However, the best definitive management remains controversial. Increasingly, endovascular techniques are being used for these difficult-access cases. Coldwell et al.9 have the largest series of BCIs managed with percutaneous placement of stents. This series included 14 patients with pseudoaneurysms who were treated with self-expanding or balloon-expandable stents. They reported no complications. However,
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successful exclusion with noncovered stents is questionable. In an earlier report by Marks et al.,10 angiography continued to demonstrate partial opacification of the pseudoaneurysms as long as 8 months after stent placement.This finding means that the risk of rupture is still present following noncovered stent deployment. Our search found previous reports of successful exclusion of pseudoaneursyms with covered stents.11-14 The success was confirmed either by angiographic evidence or noninvasive duplex demonstration of thrombosis of the pseudoaneurysm. Marotta et al.15 reported a case of successful exclusion with autologous vein-covered stent for management of a pseudoaneurysm formation following a gunshot wound to the neck. Our case is additional evidence that placement of a covered stent may be the optimal method for exclusion or repair of traumatic pseudoaneurysms of the carotid that are less easily accessible by standard surgical approaches. Although randomized prospective trials would be ideal in evaluating the efficacy of covered stents, these types of trials may not be practical or needed. However, series with welldocumented, long-term follow-up are important. Efforts to further elucidate the role of percutaneous versus surgical approaches should be encouraged. Anticoagulation alone is clearly not the answer for patients with traumatic carotid pseudoaneurysms because they do not resolve with this approach.1 REFERENCES 1. Fabian TC, Patton JH, Jr, Croce MA, et al. Blunt carotid injury: importance of early diagnosis and anticoagulant therapy. Ann. Surg. 1996;223:513-525. 2. Waksman R, Ajani E, White RL, et al. Prolonged antiplatelet therapy to prevent late thrombosis after intracoronary cradiation in patients with in-sent restenosis: Washington
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Radiation for In-Stent Restenosis Trial Plus 6 Months of Clopidogrel (WRIST PLUS). Circulation 2001;103:23322335. Davis JW, Holbrook TL, Hoyt DB, et al. Blunt carotid artery dissection: incidence, associated injuries, screening and treatment. J. Trauma 1990;14:967-973. Cogbill TH, Moore EE, Meissner M, et al. The spectrum of blunt injury to the carotid artery: a multicenter perspective. J. Trauma 1994;37:473-479. Shames M, Davis J, Evans A. Endoluminal stent placement for the treatment of traumatic carotid artery pseudoaneurysm: case report and review of the literature. J. Trauma 1999;46:724-726. Mokri B, Peipgras DG, Houser OW. Traumatic dissections of extracranial internal carotid artery. J. Neurosurg. 1988;68: 189-197. Li MS, Smith BM, Espinosa J, et al. Nonpenetrating trauma to the carotid artery: seven cases and a literature review. J. Trauma 1994;36:265-272. Parikh AA, Luchett FA, Valente JF, et al. Blunt carotid artery injuries. J. Am. Coll. Surg. 1997;185:80-86. Coldwell D, Novak Z, Ryu R, et al. Treatment of posttraumatic internal carotid artery pseudoaneurysms with endovascular stents. J. Trauma 2000;48:470-472. Marks MP, Dake MD, Steinberg GK, Norbash AM, Lane B. Stent placement for arterial and venous cerbrovascular disease: preliminary experience. Radiology 1994;191:441446. McNeil JD, Chiou AC, Gunlock MG, et al. Successful endovascular therapy of a penetrating zone III internal carotid injury. J. Vasc. Surg. 2002;36:187-190. Parodi J, Schonholz C, Ferreira L, Bergan J. Endovascular stent-graft treatment of traumatic arterial lesions. Ann. Vasc. Surg. 1999;13:121-129. Van Nieuwenhove Y, Van den Brande P, van Tussenbroek F, Debing E, von Kemp K. Iatrogenic carotid artery pseudoaneurysms treated by an autologous vein-covered stent. Eur. J. Vasc. Endovasc. Surg. 1998;16:262-265. Duke BJ, Ryu RK, Coldwell DM, et al. Treatment of blunt injury to the carotid artery by using endovascular stents: an early experience. J. Neurosurg. 1997;87:825-829. Marotta T, Buller C, Taylor D, Morris C, Zwimpfer T. Autologous vein-covered stent repair of a cervical internal carotid artery pseudoaneurysm: technical case report. Neurosurgery 1998;42:408-412.