DOI: 10.5604/01.3001.0014.3019
POL PRZEGL CHIR, 2020: 92, 1-4 AHEAD OF PRINT 1
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ABBREVIATIONS
angio-CT – computed tomography of blood vessels ECAA – extracranial carotid artery aneurysm ICA – internal carotid artery
USG – ultrasonography
INTRODUCTION
The incidence of intracranial aneurysms on autopsy ranges from 0.8% to 18% [1, 2]. In the case of extracranial carotid artery aneurysm, or ECAA, it is largely unknown, and the reported corrective procedures represent only 1% to 1.5% of procedures performed for extracranial cerebrovascular disease at large ref- erence centers. The actual incidence of ECAA is much less than 1% of all carotid artery diseases [3–5]. De Jong et al. suggested that ECAA be defined as carotid bulb enlargement greater than 200% of the internal carotid artery diameter (ICA) or greater than 150% of the diameter of the common carotid artery [6].
This rigid definition is used in many modern ECAA reports and is an aid taking cognisance of normal physiological dila- tion of the carotid bulb. The causes of true aneurysms include:
atherosclerosis (about 90%), Marfan syndrome, fibromuscular hypertrophy, previous irradiation of the internal carotid artery, cystic medial necrosis, pseudoxanthoma elasticum, polyarteri- tis nodosa, congenital aneurysms. Atherosclerotic aneurysms usually occur in the proximal part of the artery, in patients aged 50–70, more often in men [7]. The causes of pseudoaneurysms are: injuries, complications after surgery, arterial wall injury due to atherosclerotic lesions, and bacterial infections. Aneurysms can compress surrounding organs such as the esophagus, tra- chea, and cranial nerves. They can also rupture down to the neck, throat and consequently through the skin to the outside
[8]. The most common symptom with which patients report to the doctor is a slowly growing and pulsating neck lump. Most patients with carotid aneurysms suffer from high blood pres- sure. Carotid aneurysms should be differentiated from: angu- lar curvature or looping of the internal carotid artery, common carotid or subclavian artery, swollen lymph nodes, peritonsil- lar abscess, salivary gland tumor, inflammation of the salivary gland, lateral cervical cyst, carotid body tumor, angioma, can- cer (of palatine tonsil, pharynx, skin and subcutaneous tissue, thyroid gland) [8]. The basic objective in treatment of such aneurysms is to prevent the persistent neurological deficits which may result from embolism or coagulation of the aneu- rysm. This goal might best be achieved through reconstructive procedures with flow restoration. The choice of therapy must be sized to fit each patient and base upon the location, size and
Endovascular coil embolization of the left internal
carotid artery aneurysm – case report
Adam Lipowski
1ABEF, Sleiman Sebastian Aboul-Hassan
2AEF, Zbigniew Krasiński
3AEF, Konrad
Woronowicz
4EF¹Department of Vascular Surgery, Multidisciplinary Hospital of SPZOZ in Nowa Sol, Poland; Head: Wojciech Gotlibowski MD
²Department of Cardiac Surgery, MEDINET in Nowa Sol, Poland
3Department of Vascular and Endovascular Surgery, Angiology and Phlebology, Medical University of Poznan, Poland; Head:
prof. Zbigniew Krasiński MD PhD
4Department of Vascular Surgery, Multidisciplinary Hospital of SPZOZ in Nowa Sol, Poland; Head: Wojciech Gotlibowski MD
Article history: Received: 17.09.2020 Accepted: 07.07.2020 Published: 08.07.2020
ABSTRACT: In the current case report we present a novel case of a successful coil embolization of the left internal carotid artery aneurysm.
The patient presented with neck pain and a palpable pulsating tumor and was admitted to the vascular surgery clinic where an angio-CT scan of the neck was performed. Angio-CT revealed a left internal carotid artery aneurysm with a narrow neck. The patient was admitted to the department of vascular surgery where she was enrolled into endovascular coil embolization. After the procedure, control angiography showed complete embolization of the aneurysm. Three months following the procedure, doppler ultrasonography of the carotid arteries showed no demonstrable flow into the aneurysm. Six months following the procedure, angio-CT confirmed complete aneurysm thrombosis. Based on this case, endovascular coil embolization of the carotid artery aneurysms is a safe and effective method of treatment.
KEYWORDS: aneurysm, coil, tumor
Fig. 1. Computed tomography with contrast showing left internal carotid aneurysm.
Authors’ Contribution:
A – Study Design B – Data Collection C – Statistical Analysis D – Manuscript Preparation E – Literature Search F – Funds Collection
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pathomechanism of aneurysm formation, as well as the gen- eral condition of the patient. Failure to treat internal carotid aneurysms leads to strokes in 50% of cases [7].
CASE REPORT
A 78-year-old woman reported to her family doctor with a pul- sating tumor on the left side of the neck. She had a history of hy- pertension, impaired glucose tolerance, and a past cerebral stroke.
The presence of the lesion prompted the family doctor to refer the patient to the Vascular Surgery Clinic. Computed tomography of Fig. 2. Carotid angiography showing left internal carotid aneurysm in lateral projection.
Fig. 3. Carotid angiography showing an aneurysm in posterior-anterior projection. Fig. 5. Computed tomography with contrast showing status after embolization of left internal carotid artery aneurysm.
Fig. 4. Carotid angiography, status after aneurysm embolization.
the carotid arteries with contrast revealed a saccular aneurysm of the left internal carotid artery, dimensions 20 x 19 x 26 mm with a narrow neck with a diameter of 5 mm (Fig. 1.). The aneurysm was directed medially and inferiorly, slightly to the front; it be- gan approximately 57 mm above the division of the left common carotid artery. Left internal carotid artery with a meandering pattern, partially tightened over the aneurysm sac.
The patient was referred to the Department of Vascular Surgery for treatment and she was qualified for endovascular treatment. Ca- rotid angiography revealed a 22 mm-diameter saccular aneurysm of the left internal carotid artery with a narrow neck (Figs. 2., 3.).
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DISCUSSION
The presented case of a large internal carotid aneurysm rep- resents a rare cervical tumor. After palpation, each pulsating cervical tumor should be referred to the Department of Vascular Surgery as soon as possible for further urgent imaging diagnos- tics. Treatment of carotid aneurysms is intended to safeguard patients against serious neurological complications. The meth- od of embolization without stenting used by ourselves is very rare [9, 10]. We found stenting too risky due to kinking and the meandering pattern of the carotid artery, and the narrow neck promoted safe coiling without the risk of falling into the lumen of the artery. The above method of treatment may be considered an effective and safe method under certain conditions. Due to the rarity of extracranial carotid artery aneurysms and the lack of prospective research into their treatment, we believe that every case report for this condition contributes to the development of knowledge. More research and observations are needed to evaluate endovascular methods in the treatment of extracranial carotid aneurysms as very effective.
Due to the patient’s age and the morphology of aneurysm, includ- ing the narrow neck, as well as the high placement, hampering the dissection of the distal segment of the internal carotid artery, it was decided to embolize the aneurysm.
After the left common carotid artery was cannulated and the Rebar 27 microcatheter was inserted into the aneurysm, it was obliterated using the Penumbra embolization coils. The follow- ing sizes were used (24 mm x 57 cm – two pieces, 18 mm x 57 cm – one piece, 14 mm x 60 cm – two pieces, packing coil 60 cm – two pieces, packing coil – one piece). Control angiogra- phy showed complete embolization of the aneurysm sac (Fig. 4.).
The procedure was uneventful, with proper maintenance of he- mostasis at the injection site. The patient was released from hos- pital in good general condition, with the recommendation to use clopidogrel 75 mg 1 x 1 and acetylsalicylic acid 75 mg 1 x 1 for further follow-up to the Vascular Surgery Clinic. Examinations after 3 (Doppler ultrasound) and after 9 months (angio-CT) revealed complete clotting of the aneurysm (Fig. 5.).
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Word count: 1461 Page count: 4 Tables: – Figures: 5 References: 10
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Adam Lipowski; Department of Vascular Surgery, Multidisciplinary Hospital of SPZOZ in Nowa Sol, Poland;
Chałubińskiego street 7, 67-100 Nowa Sol, Poland; Phone: +48 68 388 23 52; E-mail: adamlipowski@icloud.com Lipowski A., Aboul-Hassan S., Krasinski Z., Woronowicz K.: Endovascular coil embolization of the left internal carotid artery aneurysm – case report; Pol Przegl Chir 2020; 92; 1–4; DOI: 10.5604/01.3001.0014.3019 (Advanced online publication).
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