Surgical Repair of a Giant Pseudoaneurysm of the Right Common Carotid Artery Following a Gunshot Marcus Fokou,1 Jean J. Pagbe,1 Abel Teyang,1 Victor C. Eyenga,1 Bernadette Ngo Nonga,2 Emmanuel Fongang,3 Fidele Binam,4 and Wilhemn Sandmann,5 Yaounde, Cameroon, Düsseldorf, Germany Common carotid pseudoaneurysms are very rare. The authors report a case of a 18-year-old patient with 11 cm large posttraumatic pseudoaneurysm of the right common carotid artery caused by a gunshot in the neck. The patient also had a right hemiplegia, secondary to the left sylvian artery stroke and aphasia. A surgical repair was undertaken with an approach including a total sternotomy. The aneurysm was excluded and a saphenous vein patch was used to repair the 2-cm defect on the arterial wall. The postoperative period was uneventful. This is probably the largest carotid artery aneurysm ever described. The potential hazards of an aneurysm of the common carotid artery indicate that surgical treatment is warranted particularly in a patient with a past history of controlateral stroke. Pseudoaneurysms of the extracranial portion of the carotid arteries, such as common carotid artery (CCA), internal carotid artery (ICA), or external carotid artery (ECA), are extremely rare, but are well documented diseases.1 According to one of our previous report, less than 500 cases have been reported in the surgical literature and less than 30 cases in children.2 They account for less than 0.5% of carotid surgeries.3 Most of the pseudoaneurysms of the carotid system are secondary to a direct trauma to the vessel as a result of gunshot, stabbed wounds, or direct blow. In a recent report, Cox 1 Department of Surgery, Yaounde General Hospital, Yaounde, Cameroon. 2 Department of Surgery,The Yaounde University Hospital Centre, Yaounde, Cameroon. 3 Department of Radiology, Yaounde General Hospital, Yaounde, Cameroon. 4 Department of Anesthesiology, Yaounde General Hospital, Yaounde, Cameroon. 5 Former Direktor Klinik für Gefäßchirurgie und Nierentransplantation, Universität Düsseldorf, Düsseldorf, Germany. Correspondence to: Marcus Fokou, MD, The Yaounde General Hospital, BP 5408 Yaoundé/Cameroon, E-mail: mfokou@yahoo.com Ann Vasc Surg 2011; 25: 268.e3-268.e6 DOI: 10.1016/j.avsg.2010.07.029 Ó Annals of Vascular Surgery Inc. Published online: October 6, 2010 et al. described a major artery lesion in 18 of the 107 patients (16.8%) with neck injuries.1 Additionally, pseudoaneurysm was the most frequent finding on delayed evaluation.4 The complications of a pseudoaneurysm of the CCA can be life-threatening, including rupture with hemorrhage, distal embolization with the resulting transient ischemic attacks, or strokes.3,5 The authors present a rare case of a patient with a 11-cm large pseudoaneurysm of the right CCA secondary to a gunshot to the neck along with a neurologic defect of the same side after a left-side stroke. The patient was treated surgically. To the best of our knowledge, this is the largest pseudoaneurysm of a CCA ever reported. CASE REPORTS The patient, a well-built 18-year-old Chadian soldier, was examined at the Surgical Department of the Yaounde General Hospital in Cameroon. He presented with a 12-month history of a gradually increasing swelling on the anterior border of the right sternocleidomastoid muscle just above the sternum. There was a history of neck injury caused by a gunshot during a battle in which a right humeral fracture occurred, 6 months before the onset of the neck swelling. An osteosynthesis of the humerus was performed and the cervical wounds cleaned 268.e3 268.e4 Case reports Annals of Vascular Surgery Fig. 1. Clinical aspect of the aneurysm. and dressed. The patient suffered a second trauma 3 months after the onset of the swelling, wherein he developed a right hemiplegia, a rapid increase of the mass, and a gradual loss of speech. The second trauma was a result of a collective fall from a military car during a road traffic accident, which caused severe compression of the left side of the neck. No other past medical disease was known. Because of the lack of proper infrastructures in his home country, the patient was advised to come to our vascular department, where he showed up 9 months after the second trauma (18 months after the gunshot). On examination, the cervical mass which measured 14 cm was found to be firm, slightly painful, pulsatile, and a bruit was easily audible on auscultation (Fig. 1). The cervical computed tomography angiography (CTA) showed a right CCA pseudoaneurysm of 11 cm diameter before the bifurcation with local compressions on the jugular vein, the larynx, and trachea (Figs. 2, 3). The CCA, ICA, and ECA were patent. The opposite carotids were normal. The brain CTA (Fig. 4) showed a porencephaly resulting from an old left sylvian artery stroke explaining the right hemiplegia and partial the speech defect. It also showed a good patency of the Willis polygon. The electroencephalogram revealed only lesions corresponding to the brain CTA results. No emboligenic heart disease was reported on cardiac examination. The preoperative work-up showed no other abnormality. It was decided to exclude the aneurysm and carry out a vein patch vascular reconstruction. Under general anesthesia, exposure of the right CCA was achieved proximally using a total sternotomy, and distally using a classic presternocleidomastoid cervicotomy both as a single extended access. The innominate artery was first prepared and controlled. Then the carotid artery was identified and dissected revealing a large pseudoaneurysm of the CCA, which was about 4 cm before the bifurcation. The CCA was elongated by the mass and the neighboring organs were deviated. Clamping was performed after administration of 5,000 IU heparin intravenously. After the exclusion of the aneurismal sac, the vascular defect was 2 cm long and involved the lateral half of the vessel. Fig. 2. CCA aneurysm with a huge thrombus. Fig. 3. CCA aneurysm showing the patency of the CCA (arrow). A saphenous vein patch was performed using a 5-0 polypropylene running suture (Fig. 5). Although the back flow pressure of the distal carotid artery was very good, a carotid shunt was used before the 25-minute clamping. No intraoperative neurological monitoring was used. A huge thrombus was removed from the aneurismal sac and the latter left in place for spontaneous fibrosis. The postoperative period was uneventful and no neurologic deficit was noted on the left side. The Vol. 25, No. 2, February 2011 Fig. 4. Brain CT scan showing the left porencephaly. intervention site and the patency of the reconstructed CCA were evaluated clinically and with ultrasound everyday till discharge from the hospital (2 weeks), then monthly for one trimester, and subsequently after every 6 months. Till date, 13 months after the surgery, there is neither swelling of the carotid region nor neurologic event has been noticed on clinical examination. On ultrasound, the right CCA, the ECA, and the ICA are patent without stenosis or enlargement. Case reports 268.e5 aneurysms are likely to be asymptomatic despite there being no reports supporting such an assessment. Among the patients described in the surgical literature, a pulsatile mass of the neck is the common presentation; however, a transient ischemic attack is also encountered. Carotid artery aneurysm is one of the causes of stroke, although its occurrence is rare. The rupture of a carotid pseudoaneurysm has been described in less than 15 adults in the published data.3 In children, four cases of rupture leading to hematemesis or epistaxis have been reported.2 The risk of rupture depends on the cause; traumatic false aneurysm and infectious aneurysm seem to have the highest risk. However, the patient in the present case did not suffer this terrible event. Some patients with large pseudoaneurysms may suffer dyspnea, hoarseness, dysphagia caused by the compression of the surrounding organs (trachea, vagus nerve, and esophagus), and Horner syndrome which is common.5 However, none of these was observed in this case. A lymphadenopathy overlaying the carotid bulb or a carotid coiling may be considered as a differential diagnosis. The realization of an ultrasonography, a CTA or magnetic resonance imaging, and a cerebral angiography are particularly useful in establishing accurate diagnosis, proceeding to surgical therapy. Treatment DISCUSSION Epidemiology Carotid arteries pseudoaneurysms are very rare conditions. The causes are posttraumatic and/or mycotic. However, because of the increase in carotid surgery, aneurysms secondary to carotid endarterectomy are increasing in frequency nowadays and are estimated to be 13-16% of all pseudoaneurysms of that region,3 thereby rating second after traumatic aneurysms. Pure traumatic aneurysms have been reviewed by Cox et al.1 Penetrating and stabbed wounds are described in civilian practice, although they are frequently secondary to military munitions. Although the ICA, ECA, CCA can be involved, most cases reported the involvement of the ICA and the ECA.6,7 Cox et al.1 described no involvement of the CCA in the recently described 13 pseudoaneurysms of the neck region. Manifestations The natural history of pseudoaneurysm of the carotid arteries is poorly understood. Most Surgical intervention is recommended for all symptomatic carotid artery aneurysm or pseudoaneurysm with manifestations related to cerebral ischemia or local discomfort. A pseudoaneurysm with diameter >2 cm is the threshold in the asymptomatic cases of adults.1,3 Because its occurrence is rare, the natural history of asymptomatic pseudoaneurysm is not known. Therefore, a threshold is difficult to define. However, because of the high risk of rupture, surgical management at a smaller diameter is perhaps the best choice. Several types of carotid reconstructions have been proposed according to the size, location, and origin of the pseudoaneurysm. The most common type of carotid reconstruction is the resection of the aneurysm with reconstruction of the artery using an interposition with saphenous graft or a prosthetic material. Other options include a resection and primary reanastomosis or reimplantation of the carotid artery, aneurysmorrhaphy, and reconstruction using a venous or prosthetic patch.2,3 Ligations of the CCA or the ICA have also been performed by many authors.2,3 Although the endovascular therapy is being practiced increasingly, 268.e6 Case reports Annals of Vascular Surgery initial control of the innominate artery and the inferior side of the aneurysm was imperative. To obtain this, a large retraction was necessary leading to a sternal fracture in case of a ministernotomy. To avoid this complication, only a total sternotomy could be the procedure of choice. CONCLUSION Despite its clinical magnitude, carotid arteries pseudoaneurysms are uncommon conditions, with limited published experience. A surgical approach including a sternotomy can be helpful to control a huge aneurysm. Fig. 5. Surgical representation of the reconstructed CCA (short arrow) and the excluded aneurismal sac (long arrow). surgery is the traditional definitive treatment.8,9 Stent graft as well as coiling is also feasible. Recently, Gupta et al. reported a stent graft repair of an ICA pseudoaneurysm.5 In 2007, Cox et al. reported that embolization can also be used as an alternative for treatment of pseudoaneurysms, as per the report, seven of 11 pseudoaneurysms were treated with coiled embolization.1 In the present study, reconstruction using a venous patch was performed on the patient. A stent graft was also an alternative considering the high operative risk of this patient; however, because of the size of this aneurysm with a local compression, an endovascular approach was considered to be insufficient. The surgical exposure was a total sternotomy and cervicotomy as single extended access. Other possibilities, such as ministernotomy or an endovascular occlusion without sternotomy after the incision of the aneurismal sac, were discussed. However, considering that the anatomy of the region was reorganized by the large size of the lesion, and its close contact to the sternum, we assumed that the REFERENCES 1. Cox MW, Whittaker DR, Martinez C, et al. Traumatic pseudoaneurysms of the head and neck: early endovascular intervention. J Vasc Surg 2007;46:1227-1233. 2. Pourhassan S, Grotemeyer D, Fokou M, et al. Extracranial carotid arteries aneurysms in children; single-center experience in 4 patients and review of the literature. J Pediatr Surg 2007;42:1961-1968. 3. 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