A 20-year Experience with Surgical Management of True and False Internal Carotid Artery Aneurysms

Endovascular Treatment and Hybrid Surgery for Extracranial Internal Carotid Artery Aneurysms

BACKGROUND

Extracranial internal carotid artery aneurysms (EICAAs) are rare, and both endovascular treatment and hybrid surgery have been used to treat them. Herein, we evaluated the outcomes of endovascular treatment and hybrid surgery for EICAAs treated at our institution.

METHODS

Twenty-eight patients diagnosed with EICAA and treated with endovascular treatment or hybrid surgery in our center from January 2013 to June 2023 were retrospectively reviewed. Clinical characteristics, aneurysm features, perioperative outcomes, and follow-up results were collected and analyzed.

RESULTS

A total of 28 patients with 30 EICAAs received endovascular treatment and hybrid surgery. The mean age of patients was 61.0 years, and 21 patients (75.0%) were male. Fifteen true aneurysms (50.0%) and 15 pseudoaneurysms (50.0%) were detected. Fifteen patients with 15 aneurysms received endovascular treatment and 13 patients with 15 aneurysms received hybrid surgery. The overall technical success rate was 90.0% (27/30). During the perioperative period, one patient (1/15, 6.7%) in the endovascular group experienced a minor stroke. The median follow-up duration was 17.5 months (range, 2-100 months). Excluding the patient who received carotid ligation during surgery, the overall patency rate was 93.1% (27/29) during the follow-up period. One patient (1/15, 6.7%) in the endovascular group experienced a minor ipsilateral stroke. Of the 29 patients with aneurysms receiving stent employment, one (1/29, 3.4%) underwent endovascular reintervention 12 months after the procedure because of severe restenosis.

CONCLUSION

Endovascular treatment and hybrid surgery are feasible options in the treatment of EICAAs that achieve satisfactory short-term results.

Giant cell arteritis as a cause of extracranial internal carotid artery aneurysm: a case report

BACKGROUND

This report presents the management of patient with extracranial internal carotid artery pseudoaneurysm due to giant cell arteritis.

CASE PRESENTATION

Left internal carotid artery pseudoaneurysm was diagnosed in a 57-year-old Ukrainian woman, which became a direct indication for surgical treatment involving aneurysm resection and internal carotid artery reimplantation. The used reconstruction technique with oblique cutting of internal carotid artery, aneurysm resection, ellipse-form anastomosis formation, and distal intima fixation prevents the dissection, restenosis, and aneurysm of anastomosis in the long-term postoperative period. Histopathological examination revealed the giant cell arteritis of the internal carotid artery.

CONCLUSION

This case emphasizes the importance of open surgical treatment of extracranial carotid artery aneurysms, which allows to perform optimal carotid artery reconstruction and also define the rare etiology of disease.

Successful treatment of iatrogenic internal carotid artery pseudoaneurysm following carotid endarterectomy with thrombin injection: a case report

BACKGROUND

Iatrogenic pseudoaneurysms arising from the internal carotid artery subsequent to carotid endarterectomy are exceptionally infrequent. Herein, we present a case detailing an internal carotid artery pseudoaneurysm that manifested subsequent to a hybrid carotid endarterectomy and endovascular therapy intervention. Our approach to managing this condition involved a novel technique wherein thrombin was directly injected into the luminal cavity of the pseudoaneurysm under the guidance of a C-arm.

CASE PRESENTATION

A 66-year-old male patient of Chinese ethnicity exhibited a 4-month history of headache and a 20-day history of gait disturbance. Digital subtraction angiography revealed occlusion in the cervical region of the left carotid artery. Following a hybrid surgical procedure, the patient reported mild pain and bruising surrounding the incision site of the left internal carotid artery endarterectomy. Subsequent angiography identified the presence of a carotid artery pseudoaneurysm. Utilizing C-arm guidance, thrombin was then directly injected into the luminal cavity of the pseudoaneurysm, resulting in complete healing during follow-up.

CONCLUSION

For the management of pseudoaneurysms arising post carotid endarterectomy, the direct injection of thrombin into the aneurysm cavity under the guidance of a C-arm is deemed both safe and efficacious.

Extracranial Carotid Artery Aneurysms: 20-Year Experience of Surgical Management

Extracranial carotid artery aneurysm (ECAA) is a rare vascularpathology with reported incidence of 0.2-5.0% of all carotid artery surgical interventions. Most of ECAAs remain clinically asymptomatic, however, they can manifest in neurological symptoms as transient ischemic attack or stroke. The presence of a pulsating formation, swallowing disorders, signs of compression of cranial nerves may beindicative of the aneurysm growth, which is associated with higher risk of thromboembolic complications and less oftenwith rupture. Surgical treatment is a method of choice in symptomatic patients or in cases of the aneurysm growth and includes resection with arterial reconstruction, ligation of the artery or endovascular intervention. The aim. To improve the results of surgical treatment of ECAAs. Materials and methods. The results of clinical examination, laboratory, instrumental, intraoperative observations were analyzed in 39 patients (35 [89.7%] men and 4 [10.3%] women) with 44 ECAAs, who were admitted to the Vascular Surgery Department of Lviv Regional Clinical Hospital for the period from 2003 to 2022. To conϐirm the diagnosis of ECAA, preoperative instrumental examination included duplex ultrasonography and multispiral computed tomography angiography. Results. Etiological causes of ECAAs included: atherosclerosis (79.5%),ϐibromuscular dysplasia (7.7%), trauma (5.1%), previous operations in the neck region (5.1%) and infection (2.6%). The justiϐication of the choice of surgical tactics depended on the localization of aneurysm, concomitant carotid occlusive disease or pathological deviation of carotid arteries. Early results of surgical treatment were evaluated up to 30 days of the postoperative period. The postoperative complications included: transient ischemic attack in 1 (2.6%), ischemic stroke in 2 (5.1%), cranial nerve damages in 4 (10.3%), thrombosis of arterial reconstruction in 2 (5.1%), hematoma of postoperative wound in 4 (10.3%), infection of postoperative wound in 1 (2.6%) cases. Postoperative mortality was 2.6%. Conclusion. ECAA is a rare clinical disease that requires an active surgical approach to reduce the risk of ischemic stroke. Reconstructive surgery of ECAAs is a highly effective method of treatment that allows to achieve satisfactory results and prevent the development of severe complications.

Treatment Options for Pseudoaneurysm After Carotid Endarterectomy: A Systematic Review and Illustrative Case

BACKGROUND

The goal of this study was to systematically review the management and outcomes of patients who developed pseudoaneurysm (PA) after carotid endarterectomy (postendarterectomy PA [PEPA]).

METHODS

Following the PRISMA guidelines, a systematic literature review was performed using PubMed, Scopus, and Web of Science databases from date of inception to June 2022. Studies were selected based on predetermined inclusion and exclusion criteria. Simultaneously, a retrospective review was conducted of patients who underwent neurosurgical evaluation of suspected PEPA at our institution.

RESULTS

Of the 321 articles in the original literature search, 62 were selected. A total of 143 patients (93 men, 27 women; mean age, 70.7 years) diagnosed with PEPA were included. Mean time from carotid endarterectomy to PA diagnosis was 41.8 months. Primary repair data were available for 135 patients, including 19 with primary closures, 112 with patch or graft repairs, and 4 with eversion procedures. Fifty-five patients with PA (39%) presented with infection. Staphylococcal species were the most common causative organism. Of infected PAs, 89.1% were treated with open procedures. Overall complication rates of PAs treated via open, endovascular, and hybrid methods were 31%, 15.4%, and 0%, respectively. Open ligation (42.9%) and aneurysmectomy with grafting (36.4%) resulted in the highest rates of complications.

CONCLUSIONS

Despite higher complication rates after open repair strategies, use of these techniques remains a viable option in situations requiring removal of infected patches or evacuation of large extravascular collections. Endovascular treatment options are associated with low numbers of complications and can be considered for primary PEPA treatment when infection is not present.

Takayasu's Arteritis with a Thrombosed Aneurysm on the Common Carotid Artery Causing Ischemic Stroke

Takayasu's arteritis is an inflammatory disease of unknown etiology that causes stenosis, occlusion, or dilatation of the aorta and its major branches, the pulmonary arteries, and the coronary arteries. The incidence of extracranial carotid artery aneurysm in patients with Takayasu's arteritis is reportedly 1.8-3.9%. We herein report a patient with Takayasu's arteritis who presented with transient left hemiplegia immediately after neck massage. Carotid ultrasonography revealed a thrombus within the fusiform aneurysm on the right common carotid artery. We speculated that fragmentation from the intra-aneurysmal thrombus was caused by neck massage.

Ipsilateral carotid bypass outcomes in hostile neck anatomy

OBJECTIVE

To determine differences in outcomes among patients undergoing ipsilateral carotid bypass with hostile or normal neck anatomy.

METHODS

Single-center retrospective review of all ipsilateral extracranial carotid bypasses performed between 1998 and 2018.

RESULTS

Forty-eight patients underwent ipsilateral carotid bypass from the common carotid artery to either the internal carotid artery or carotid bifurcation during the study period. Seven patients were excluded owing to either a lack of follow-up or missing data. The indications for intervention included infected patches, aneurysmal degeneration, symptomatic and asymptomatic stenosis or restenosis, carotid body tumors, neck malignancy, and trauma. In 25 procedures (61%), there was a hostile neck anatomy defined as a prior history of external beam neck irradiation or neck surgery. Among this group, 12 pectoralis muscle flaps were performed for reconstructive coverage. Conduits included polytetrafluorethylene (n = 21), great saphenous vein (n = 9), superficial femoral artery (n = 7) and arterial homograft (n = 4). All superficial femoral artery conduits were used in the hostile neck group (P = .03). The overall mean time of follow-up was 22 months, with all bypasses remaining patent with no significant clinical stenosis. The 30-day ipsilateral stroke and myocardial infarction rates were 4.88% each, all within the hostile neck group, with no 30-day mortalities for the entire cohort. One-third of the muscle flaps were performed in the setting of infected patches (P = .02) with no significant differences in perioperative outcomes with use. The overall median hospital length of stay was significantly increased in patients receiving muscle flap coverage (3.0 vs 7.0 days; P = .04).

CONCLUSIONS

In patients with a complex carotid pathology, ipsilateral carotid bypass is an effective solution for carotid reconstruction. Different conduits should be used depending on the indication. Muscle flap coverage should be considered in hostile settings when primary wound closure is not feasible.

Open versus endovascular repair for extracranial carotid aneurysms

BACKGROUND

Extracranial carotid artery aneurysms (ECCAs) are rare; however, they are associated with a high risk of stroke and mortality if untreated. In the present review, we compared the major outcomes between open and endovascular repair of ECCAs.

METHODS

We systematically searched PubMed, Embase, Scopus, and the Cochrane Library for clinical studies reported online up to September 2020 that had evaluated major outcomes after both open and endovascular repair of ECCAs. Eligible studies were required to have evaluated at least the 30-day mortality or stroke and/or transient ischemic attack rates. The quality of the studies was also evaluated.

RESULTS

Overall, seven studies (three high quality, two medium quality, and two low quality) with 374 patients and 383 ECCAs were eligible. All the studies had been reported from 2004 to 2020. In total, 220 open repairs were compared with 81 endovascular repairs. The open and endovascular treatments showed similar 30-day mortality rates (4% vs 0%; pooled odds ratio [OR], 2.67; 95% confidence interval [CI], 0.291-24.451) and stroke and transient ischemic attack rates (5.5% vs 1.2%; pooled OR, 1.42; 95% CI, 0.412-4.886). Open repair was associated in six studies with a greater incidence of cranial nerve injury compared with endovascular repair (14.5% vs 0%; OR, 3.98; 95% CI, 1.178-13.471). The hematoma or bleeding rate was also similar between the two methods in six studies (5.2% vs 0%; OR, 1.92; 95% CI, 0.518-7.094).

CONCLUSIONS

Open and endovascular repair of ECCAs is associated with similarly low early mortality and cerebrovascular event rates, although open repair showed a greater risk of cranial nerve injuries. An endovascular approach could be more appropriate when the aneurysm is located distally or requires extensive dissection. More studies are needed with standardized follow-up durations to evaluate late outcomes.

Giant saccular aneurysm of the internal carotid artery with adhesion to the vagus nerve: A Case Report

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Aneurysm of the extracranial carotid artery with the adhesion to the vagus nerve is an extremely rare situation.

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Open surgery must be considered in the case of the immense size of the aneurysm and the tortuous anatomical path.

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Leaving parts of the aneurysmal wall may be necessary to avoid a permanent nerve injury.

Introduction and importance

Aneurysms of the carotid artery are rare and potentially a risk factor for developing neurological events. This case report describes the treatment of a giant saccular aneurysm of the right extracranial internal carotid artery (ICA) with adhesion to the vagus verve.

Case presentation

An 85-year-old female presented with an asymptomatic pulsating mass on the right neck. Ultrasonography and MR angiography revealed a giant aneurysm of the right internal carotid artery with a massive tortuosity. Intraoperatively, a massive adhesion of the vagus nerve to the aneurysm was found. A resection of the aneurysm followed by a spatulated end-to-end anastomosis was performed. Postprocedural neurological symptoms included a transient paralysis of the vagus nerve that recovered within six weeks.

Clinical discussion

The treatment options of ICA aneurysms include open surgical and endovascular interventions. Endovascular treatment may be a good option for aneurysms with a particular morphology. However, open surgery is the favorable option for immense ICA aneurysms with a tortuous anatomical path.

Conclusion

Aneurysm resection with end-to-end anastomosis is a possible surgical option in the case of tortuous extracranial ICA aneurysms. Leaving parts of the aneurysmal wall prevented occurring persisting damage of the adhesive vagus nerve.

Acute Nonruptured Expansion of Extracranial Carotid Artery Aneurysm. An Infrequent Clinical Presentation

The extracranial carotid artery aneurysms are a rare disease, representing a low percentage of peripheral aneurysms (0.4-4%). Their main symptoms are derived from cerebral events and local compression, with rupture being rare. We report the case of a 79-year-old woman who presented with a right Common Carotid Artery aneurysm with pain and local symptoms. The expansion of the aneurysm is documented with images and the surgical treatment consisting of bypass from Common Carotid artery to Internal Carotid artery with Dacron prosthesis and reimplantation of External Carotid artery is described and discussed. To the best of our knowledge, this is the first case of expansion directly documented in the literature.

Asymptomatic Internal Carotid Aneurysm: An Uncommon Disease of the Carotid Arteries

Despite a low-incidence extracranial carotid artery aneurysm (ECAA) disease has important clinical repercussion that obliges understanding and knowledge of correct treatment. The 2 dominant etiologies are atherosclerotic degeneration and pseudoaneurysm. The natural history of ECAAs is understood. Neck pain, a pulsatile mass and central or peripheral neurological manifestations are the most common symptoms. Recommendations for diagnosis and treatment are not uniform and still under discussion, representing a challenge for clinicians. We discuss a case of 2.5 cm asymptomatic saccular atherosclerotic ECAA treated surgically in light of the most recent literature.

Εndovascular Repair of Extracranial Carotid Artery Aneurysms: A Systematic Review

OBJECTIVE

Both true and false extracranial carotid artery aneurysms (ECAA) are a potential source of morbidity and mortality. While ECAA have historically been treated surgically, endovascular reconstruction with stenting is an emerging treatment option. The aim of our study was to report clinical/radiologic outcomes following endovascular repair of ECAAs.

METHODS

A comprehensive systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

A total of 68 case reports and case series, comprising 162 patients, were included. Most patients presented with at least one symptom or sign related to the ECAA (89.5%; N = 145/162). In 42.6% (N = 69/162) and 46.3% (N = 75/162) of the cases polytetrafluoroethylene covered and uncovered stents were deployed respectively. Immediate post-procedural imaging demonstrated complete aneurysm exclusion in 86.4% (N = 140/162) of the cases and minimal filling of the aneurysm sack in 10.5% (N = 17/162) of all cases. Perioperative adverse event rates were 3.1% for stroke, 1.2% for transient ischemic attack (TIA) and 4.3% for mortality. During a mean follow-up of 21.8months, there were additionally observed one stroke, two TIAs and three deaths. Overall 88.6 % of the patients (N = 117/132) remained asymptomatic, partially recovered or at least did not suffer from new neurologic deficits during follow up, with no signs of stenosis or occlusion of the carotid artery.

CONCLUSIONS

Endovascular stenting for the treatment of ECAAs is feasible with acceptable short- and long-term clinical and radiologic outcomes. Prospective real-world studies are needed to further validate the safety and the long-term patency of endovascular repair.

Bilateral Extracranial Internal Carotid Artery Aneurysms in a Patient with Marfan Syndrome: Case Report and Review of the Literature

Introduction

Aneurysms of the extracranial carotid artery are rare. They are often asymptomatic but can lead to disabling stroke. This report describes a case of bilateral internal carotid artery aneurysms in a patient with Marfan syndrome.

Report

A 65 year old woman with Marfan syndrome presented with an asymptomatic swelling in the right anterior triangle of the neck. Imaging revealed bilateral extracranial fusiform internal carotid artery aneurysms. Staged open repair was performed. The right side was repaired by aneurysm excision and primary end to end anastomosis. The left side was repaired with a great saphenous vein interposition graft. The patient is free from aneurysm related complications at six years, although recurrent dilatation is present on surveillance.

Discussion

Internal carotid aneurysms can be managed successfully by open repair. In patients with connective tissue disorders surveillance is required to monitor for post-operative aneurysmal dilatation.

Management of Extracranial Carotid Artery Aneurysms: A 6-Year Case Series

Background

We discuss the presentation and management of extracranial carotid artery aneurysms (ECAAs) and to develop a new type of classification.

Material/Methods

A retrospective review of 35 ECAAs patients who were admitted in our institution from January 2010 to June 2016 was conducted. The mean follow-up period was 25.58±22.13 months.

Results

During the study period, 35 aneurysms were diagnosed and treated (mean age, 50.8±15.6 years; 15 men). There were 28 true aneurysms, 5 false aneurysms, and 2 dissecting aneurysms. A total of 16 patients with true aneurysms underwent open surgical treatment (group 1), whereas 15 received endovascular management, including all false and dissecting aneurysms (group 2). The remaining 4 true aneurysms were treated with hybrid operation (group 3). The patency rates of groups 1, 2, and 3 were 100%, 93.3%, and 100%, respectively. According to the Peking Union Medical College Hospital (PUMCH) Classification, all 24 cases of type Ia aneurysms were treated by either open surgery and/or endovascular treatment, whereas all 3 type Ib cases were treated solely by open surgery. All 5 type IIa patients were treated by endovascular treatment, with the exception of 1 failure that was transferred to hybrid operation. All 3 type IIb patients were treated by hybrid operation.

Conclusions

Open surgery was more frequently feasible in true aneurysms, and endovascular surgery was the first choice for false and dissecting aneurysms. Hybrid operation was available for complicated cases. The PUMCH classification may be helpful for selection of management strategies for ECAAs.

Carotid Aneurysm Review

Aneurysms of the carotid artery are rare with multiple underlying etiologies. Treatment is largely open surgery but medical and endovascular therapies have been used based on presentation, anatomy, and etiology. There is a moderate amount of retrospective case series data on surgical results but no prospective data or data comparing open versus endovascular therapy exists. Much research is still needed but difficult to obtain in this rare disease process.

A Rare Cause of Juvenile Stroke: Extracranial Carotid Artery Aneurysm with Venous Complete Reconstruction of the Carotid Bifurcation

Extracranial carotid artery aneurysms (ECAA) are a rare cause of embolic stroke. The underlying etiology is variable, with atherosclerosis being the most common entity in older subjects. Several treatments have been developed over the last 20 years, but the preferred method remains unknown. Notwithstanding the widespread use of endovascular techniques, surgical reconstruction by means of a bifurcated venous bypass graft should be applied in younger patients. In this way, it is possible to avoid major concerns about the development of long-term intrastent restenosis, and also to spare the external carotid artery which represents the main branch for the ipsilateral cerebral and facial perfusion. We propose ECAA resection and interposition of the inverted great saphenous vein to both the internal and external carotid artery by means the use of a tributary, i.e., the Giacomini vein.

Open surgery versus endovascular approach in treatment of extracranial carotid artery aneurysms

OBJECTIVE

The objective of this study was to investigate and to compare the early and long-term results of open surgery with endovascular intervention in the treatment of extracranial carotid artery aneurysms (ECCAs).

METHODS

A retrospective review of patients diagnosed with ECCAs who underwent open surgical or endovascular treatment from 1997 to 2017 was performed. Clinical characteristics, aneurysm profile, and treatment outcomes were recorded. Early results (<30 days) were evaluated in terms of mortality, perioperative stroke or transient ischemic attack, and cranial nerve injury. Late results were analyzed in terms of both overall and stroke-free survival and freedom from reinterventions.

RESULTS

A total of 48 patients with ECCAs including 34 (70.8%) true aneurysms and 14 (29.2%) pseudoaneurysms were treated. The median age was 51 years, and 19 patients (39.6%) were men; 41 patients (85.4%) had symptoms, whereas 7 (14.6%) were asymptomatic. Among 48 patients, 32 patients (66.7%) underwent open surgery; endovascular repair was performed on 16 patients (33.3%). The 30-day stroke or transient ischemic attack rate was not significantly different between the open group (6.3% [2/32]) and the endovascular group (0% [0/16]; P = .307). Cranial nerve injuries occurred in eight patients in the open group (25%) and in no patient in the endovascular group (0%; P = .029). Median length of stay was significantly longer in the open group than in the endovascular group (20 vs 14 days, respectively; P = .013). Median follow-up was 46 months (range, 0-20 years), and no aneurysm-related death occurred during this period. Overall survival rates at 5 years were 88.7% (standard error [SE], 0.08) in the open group and 91.7% (SE, 0.08) in the endovascular group (P = .319; log-rank, .992). For the same time interval, stroke-free survival rates were 85.2% (SE, 0.10) in the open group and 92.2% (SE, 0.07) in the endovascular group (P = .653; log-rank, .201). One patient (1/28 [3.6%]) in the open group and two patients (2/16 [12.5%]) in the endovascular group underwent endovascular reinterventions because of restenosis during the follow-up period. Reintervention-free survival rates were 90.9% in the open group (SE, 0.09) and 69.2% in the endovascular group (SE, 0.21; P = .082; log-rank, 3.016).

CONCLUSIONS

In this single-institutional experience, both operative and endovascular interventions for ECCAs provided acceptable early and 5-year results. The endovascular approach had significantly less cranial nerve injury and shorter length of hospital stay.

Endovascular stenting for extracranial carotid artery aneurysms: Experiences and mid-term results

The aim of this study was to investigate the safety and effectiveness of endovascular stenting for extracranial carotid artery aneurysms (ECAAs) and evaluate the mid-term outcomes.Twelve consecutive symptomatic patients (mean age 43.8 ± 14.9 years; 8 men) with ECAAs who were treated with endovascular stenting between 1997 and 2015 were retrospectively analyzed. Clinical follow-up data including symptoms and neurological events were obtained from outpatient records. Imaging follow-up with duplex ultrasound and/or computed tomographic angiography (CTA) was performed to examine the aneurysm obliteration and patency of the stents at 3, 6, 12 months and yearly thereafter.A total of 5 true aneurysms and 7 pseudoaneurysms were included in our series. Neurological symptoms (n = 5, 41.7%) and a pulsatile neck mass (n = 5, 41.7%) were the most common presenting symptoms. Endovascular stenting procedures were technically successful in all cases; 3 patients received bare stents, and 9 patients received covered stents. No perioperative neurologic or cardiopulmonary complications occurred. Over a period of follow-ups (mean 21.8 ± 25.1 months), all patients were alive and free from neurological or other adverse events. All aneurysms were completely excluded except for 1 patient who was exposed to a residual medium leaking into the aneurysm sac. No reintervention was performed in this specific patient because aneurysm growth or significant clinical symptoms did not occur. Recurrent restenosis assessed by CTA imaging at 12 months occurred in 1 (8.3%) patient in our series. Target lesion revascularization for this hemodynamic restenosis was treated with placement of an additional stent.In our series, endovascular stenting for ECAAs was found to be safe, effective, and proved to have promising mid-term results. Although long-term results need to be further explored, advantages including less procedure-related complications and a shorter recovery time make endovascular stenting an attractive option for ECAAs, especially for the patients who are unfit for traditional open surgery.

Management of extracranial carotid artery aneurysm

INTRODUCTION

Aneurysms of the extracranial carotid artery (ECAA) are rare. Several treatments have been developed over the last 20 years, yet the preferred method to treat ECAA remains unknown. This paper is a review of all available literature on the risk of complications and long-term outcome after conservative or invasive treatment of patients with ECAA.

METHODS

Reports on ECAA treatment until July 2014 were searched in PubMed and Embase using the key words aneurysm, carotid, extracranial, and therapy.

RESULTS

A total of 281 articles were identified. Selected articles were case reports (n = 179) or case series (n = 102). Papers with fewer than 10 patients were excluded, resulting in the final selection of 39 articles covering a total of 1,239 patients. Treatment consisted of either conservative treatment in 11% of the cases or invasive treatment in 89% of the cases. Invasive treatment comprised surgery in 94%, endovascular approach in 5%, and a hybrid approach in 1% of the patients. The most common complication described after invasive therapy was cranial nerve damage, which occurred in 11.8% of patients after surgery. The 30 day mortality rate and stroke rate in conservatively treated patients was 4.67% and 6.67%, after surgery 1.91% and 5.16%. Information on confounders in the present study was incomplete. Therefore, adjustments to correct for confounding by indication could not be done.

CONCLUSIONS

This review summarizes the largest available series in the literature on ECAA management. The number of ECAAs reported in current literature is scarce. The early and long-term outcome of invasive treatment in ECAA is favorable; however, cranial nerve damage after surgery occurs frequently. Unfortunately, due to limitations in reporting of results and confounding by indication in the available literature, it was not possible to determine the optimal treatment strategy. There is a need for a multicenter international registry to reveal the optimal treatment for ECAA.

National experience with extracranial carotid artery aneurysms: epidemiology, surgical treatment strategy, and treatment outcome

OBJECTIVE

Extracranial carotid artery aneurysms (CAAs) are rare but confer risk of stroke, rupture, and local symptoms. Few cases have been reported, even from large centers, and therefore knowledge of the disease is limited. The purpose of this study was to review epidemiology, surgical treatment, and outcomes of CAAs in a nationwide setting using the Swedish National Registry for Vascular Surgery (Swedvasc).

METHODS

Data on all surgical interventions for CAAs from January 1997 to December 2011 were retrieved from the Swedvasc registry. Additional clinical information was collected from hospital records.

RESULTS

A total of 48 cases of CAAs were identified. The cause was atherosclerosis in 34 cases, infection in 2, and pseudoaneurysm in 12. The most common presentation was a pulsatile mass with or without local symptoms. Aneurysms isolated to the internal carotid artery predominated. Resection with end-to-end anastomosis was the most common technique used for treatment. Among true aneurysms, 24% had a known synchronous aneurysm elsewhere. Stroke-free survival (n = 48) was 90% after 30 days and 85% after 1 year. A total of 12.5% patients experienced permanent cranial nerve injury and 33% experienced any complication.

CONCLUSIONS

CAAs are rare entities in vascular surgery. In terms of stroke-free survival, the Swedish national results approach reports from large volume centers. The relatively high risk for permanent cranial nerve injury advocates caution when performing surgery on CAAs.

Peripheral arterial aneurysms: open or endovascular surgery?

Peripheral arterial aneurysms are uncommon; for some aneurysm types, data are limited to case reports and small case series. There is no Level A evidence in most cases to determine the choice between open or endovascular intervention. The evolution of endovascular technology has vastly improved the armamentarium available to the vascular surgeon and interventionalists in the management of these rare and unusual aneurysms. The choice of operative approach will ultimately be determined on an individual basis, dependent on the patient risk factors, and aneurysm anatomy. After consideration, some aneurysms (femoral, subclavian, carotid and ECAA) fare better with an open first approach; renal, splenic and some visceral artery aneurysms do better with an endovascular first approach. In our practice PAAs are treated with an endovascular first approach. For these rare conditions, both open and endovascular therapy will continue to work in harmony to enhance and extend the capabilities of modern surgical management.