Pseudoaneurysm of the common carotid artery due to ongoing trauma from the hyoid bone

We report a left common carotid artery pseudoaneurysm in a 47-year-old bricklayer with no prior surgical procedures or acute neck injury. At operation, the pseudoaneurysm was found to be related to ongoing injury to the carotid artery from the tip of the hyoid bone. The most likely explanation for this was that the patient's job required that he carry cement panniers weighing about 15 kg on his left shoulder and that these panniers repeatedly compressed the left side of his neck, thus forcing the carotid against the hyoid.     

Forty hours with a traumatic carotid transection: A diagnostic caveat and review of the contemporary management of penetrating neck trauma

Although penetrating neck trauma (PNT) is uncommon, it is associated with the significant morbidity and mortality. The management of PNT has changed significantly over the past 50 years. A radiological assessment now is a vital part of the management with a traditional surgical exploration. A 22 years old male was assaulted by a screwdriver and sustained multiple penetrating neck injuries. A contrast CT scan revealed a focal pseudoaneurysm in the left common carotid artery bulb. There was no active bleeding or any other vascular injuries and the patient remained haemodynamically stable. In view of these findings, he was initially managed conservatively without an open surgical exploration. However, the patient was noted to have an acute drop in his hemoglobin count overnight post injury and the catheter directed angiography showed active bleeding from the pseudoaneurysm. Surgical exploration 40 hours following the initial injury revealed a penetrating injury through both arterial walls of the left carotid bulb which was repaired with a great saphenous vein patch. A percutaneous drain was inserted in the carotid triangle and a course of intravenous antibiotics for five days was commenced. The patient recovered well with no complications and remained asymptomatic at five months followup.     

Non-infected carotid artery pseudoaneurysm 29 years after endarterectomy, endovascular management with covered stent

Pseudoaneurysm formation is a rare complication following carotid endarterectomy (CEA). Arterial pseudoaneurysms lack all three layers of the arterial wall that include the intima, media and adventitia. Pseudoaneurysms are most commonly seen after injuries to the artery in the form of blunt trauma and puncture, and are less common after surgeries such as carotid endarterectomy. These lesions present most frequently as enlarging, pulsatile, expandable masses associated with swelling and pain. Management of this complication is challenging. Traditionally, open surgical repair has been the preferred treatment. Recently, endovascular techniques using stent graft implantation alone or combined graft and coil embolization have offered a less invasive approach for the management of this lesion. Pseudoaneurysm development has been described within hours to several years after initial arterial injury, normally presenting within 5 years. To our knowledge, this is the first case report of pseudoaneurysm formation in a patient presenting 29 years after a carotid endarterectomy; during that time the patient remained completely asymptomatic until 2 months prior to his admission. The patient is an 84-year-old male with a history of stroke which prompted a left carotid endarterectomy in 1981. Twenty-nine years post procedure it was noted that the patient had a lump that was progressively enlarging on the left side of his neck, zone 1. It was pulsatile on examination. MRI/A imaging suggested a left carotid bulb aneurysm. The consulting vascular surgeon felt the patient would not be a good surgical candidate and so stenting was considered. Carotid and cerebral angiogram demonstrated a large 6 cm left carotid pseudoaneurysm off the carotid bulb. The diagnostic procedure was followed by a successful placement of an 8 x 10 cm Viabahn covered stent from the left common carotid artery to the left internal carotid artery. Following the procedure, the carotid artery was patent and there was minimal to no further residual filling of the pseudoaneurysm. Poststenting, the patient remained at his neurological baseline. This case demonstrates that pseudoaneurysm formation can occur as a long term complication after carotid endarterectomy. It may present as a rapidly expandable, pulsatile, vascular lesion in the absence of clinical and sub-clinical infection. Placement of an endovascular stent graft may be a safe and effective option for treatment of infected and non-infected carotid pseudoaneurysm.     

External-internal carotid artery transposition for repair of multiple pseudoaneurysms from penetrating injury in a pediatric patient

A 13-year-old boy was transferred to our trauma center after sustaining a shotgun wound to his neck and head. Workup revealed an injury to his tonsillar fossa, a pseudoaneurysm less than 4 mm in his internal carotid artery, and diffuse cerebral edema. After management of his intracranial hypertension, follow-up angiogram revealed 4 pseudoaneurysms in his internal carotid artery. In the operating room, the affected segment was resected, and a transposition of the external carotid artery to the internal carotid artery was performed. Workup of penetrating neck trauma and management options for internal carotid artery pseudoaneurysms in a pediatric patient are discussed.     

Are arteriograms necessary in penetrating zone II neck injuries?

The evaluation and management of potential arterial injuries in penetrating neck trauma are controversial. Routine surgical exploration or arteriography can be very expensive and time-consuming and can overburden available resources if used in all patients. We reviewed the records of 4035 patients seen in our trauma center during a 20-month period and identified a total of 110 patients (2.7%) with penetrating wounds to zone II of the neck; 50 were from gunshot wounds, 43 from stab wounds, 7 from shotgun injuries, and 10 from lacerations. In 42 (39%) patients there was no arteriogram or surgery based on location of the wounds or lack of any physical findings. None of these patients later had any evidence of an arterial injury. Forty-five patients (40%) had arteriograms based on proximity or a "soft" sign of vascular injury, which included evidence of significant bleeding or a stable hematoma. A total of 15 injuries to major arteries were identified: 3 common carotid, 5 internal carotid, and 7 vertebral. One patient died during initial resuscitation, and four patients went directly to surgery with no preoperative arteriogram for active bleeding and expanding hematoma (n = 1), an expanding hematoma (n = 2), and a large, stable hematoma (n = 1). Only one patient (of the 110) had a significant major arterial injury requiring surgery that was not predicted by physical findings. Nine arterial injuries were treated nonoperatively: six vertebral, two common carotid intimal flaps, and one small distal internal carotid pseudoaneurysm (diagnosed late). Three additional minor external carotid artery injuries were observed with no adverse sequelae.(ABSTRACT TRUNCATED AT 250 WORDS)     

Posterior tibial artery pseudoaneurysm following tibial fracture. A case report

The presence of distal pulses is often times misleading and the severity of the fracture roentgenographically is frequently unrelated to the possibility of a vascular injury. Pseudoaneurysms following long bone injuries, although not as commonly seen in blunt as in penetrating trauma, are potentially limb threatening injuries requiring a high index of suspicion and the liberal use of angiography for early diagnosis and repair. A case of a pseudoaneurysm of the posterior tibial artery associated with a grade I open fracture following blunt trauma and a review of the literature concerning arterial injury in blunt trauma are presented.     

Traumatic lesions of the bilateral middle meningeal arteries--case report

A 44-year-old man presented with traumatic injuries of the bilateral middle meningeal arteries after a traffic accident. Neurological examination found left visual impairment due to left optic nerve injury. Computed tomography demonstrated a small amount of left epidural hemorrhage and bilateral skull fractures. Left external carotid angiography revealed a pseudoaneurysm of the left middle meningeal artery at the sphenoid ridge. Right external carotid angiography demonstrated a dural arteriovenous fistula fed by the right middle meningeal artery colocated with the right frontal convexity fracture. Transarterial embolization of the left middle meningeal artery pseudoaneurysm with four fibered platinum coils and transarterial embolization of the right dural arteriovenous fistula with poly(2-hydroxyethyl methacrylate-co-methyl methacrylate) were performed, resulting in complete obliteration of both lesions. Angiographic cure was obtained and the postoperative course was uneventful.     

Traumatic pseudoaneurysm of the cervical carotid artery: the value of arteriography

A patient who sustained a gunshot wound to the neck and subsequent blunt trauma is presented. No angiogram was performed after the initial injury. Subsequently, the patient developed a cerebral embolus from a thrombus dislodged from a pseudoaneurysm of the cervical carotid artery, resulting in complete occlusion of the distal internal carotid artery. After antiplatelet therapy, the distal internal carotid artery recanalized, and the pseudoaneurysm occluded spontaneously. We stress the need for the use of arteriography in the initial evaluation of penetrating injuries to the neck and the utility of repeated arteriograms for further treatment planning as these traumatic lesions can change with time.     

Is there a potential role for hyoid bone compression in pathogenesis of carotid artery stenosis?

BACKGROUND

Blood flow turbulence and increased shear stress, particularly at sites of sudden, marked arterial wall changes, are significant hemodynamic parameters in the pathogenesis of atherosclerosis. We present a case in which we found the hyoid bone protruding into the carotid vessels and may have been contributing, in part, to atherosclerotic carotid stenosis.

CASE PRESENTATION

An 85-year-old woman presenting with left arm and leg weakness consistent with right hemispheric transient ischemic attack. Magnetic resonance arteriography (MRA) and carotid non-invasive studies revealed a 90% stenosis of the right internal carotid artery. At surgery, the hyoid bone on the right side was projecting into the internal carotid artery, causing indentation. There was associated rotation of the internal and external carotid arteries from their normal position. Right carotid endarterectomy was performed and the lateral one-third of the hyoid bone excised to alleviate the external compression. Postoperative spiral computerized tomography (CT) scan of the carotid vessels demonstrated the extent of hyoid resection as well as rotation of the external and internal carotid arteries.

CONCLUSIONS

We suggest the possible contribution of hyoid bone compression to the pathogenesis of atherosclerotic carotid artery stenosis. This report also highlights the diagnostic value of CT angiography in the assessment of carotid artery occlusive disease.     

Blunt trauma to the carotid arteries

Blunt carotid artery trauma is an uncommon but potentially dangerous clinical entity. We report eight patients from a 10-year interval who sustained blunt injuries to the carotid arteries. Six of eight patients suffered a hyperextension injury or had a cervical spine fracture or both. Arteriography revealed four arterial dissections and four thrombotic occlusions. Two asymptomatic common carotid artery occlusions and one dissection with transient ischemic attacks had successful arterial reconstructions. Five patients were treated nonoperatively: three internal carotid artery dissections with minor or no neurologic deficit; one asymptomatic thrombosis; and one internal carotid artery thrombosis with a major fixed neurologic deficit that did not improve. No patient died, and seven of eight made a complete neurologic recovery or remained asymptomatic. The diagnosis of blunt carotid artery injuries should be suspected in patients with neck hyperextension injuries or with cervical spine fractures as well as in patients with neurologic deficits not explained by intracranial trauma. Duplex scanning may be a useful noninvasive study. Surgery is indicated for selected patients with accessible lesions who have minor or no neurologic deficits. Asymptomatic patients with small intimal flaps or dissections may be successfully treated nonoperatively.     

Blunt traumatic superior gluteal artery pseudoaneurysm presenting as glutealhematoma without bony injury: A rare case report

Blunt traumatic injuries to the superior gluteal artery are rare in clinic. A majority of injuries present as aneurysms following penetrating trauma, fracture pelvis or posterior dislocation of the hip joint. We reported a rare case of superior gluteal artery pseudoaneurysm following blunt trauma presenting as large expanding right gluteal hematoma without any bony injury. The gluteal hematoma was suspected clinically, confirmed by ultrasound and the arterial injury was diagnosed by CT angiography that revealed a large right gluteal hematoma with a focal contrast leakage forming a pseudoaneurysm within the hematoma. Pseudoaneurysm arose from the superior gluteal branch of right internal iliac artery, which was successfully angioembolized. The patient was discharged on day 4 of hospitalization with resolving gluteal hematoma. This report highlighted the importance of considering an arterial injury following blunt trauma to the buttocks with subsequent painful swelling. Acknowledgment of this rare injury pattern was necessary to facilitate rapid diagnosis and appropriate treatment.     

Angiographic embolization of a post-traumatic splenic pseudoaneurysm

After the liver, the spleen is the second most commonly injured organ in blunt abdominal trauma. The past two decades have witnessed a trend towards non-surgical management of these injuries, and transarterial embolization (TAE) has greatly contributed to avoiding unnecessary laparotomies, especially in haemodynamically stable patients. We present the case of a 21-year-old male patient involved in a motor accident with subsequent injury of the left thorax and fracture of the left ulna. Abdominal computed tomography revealed the presence of a parenchymal haematoma and a pseudoaneurysm of the splenic artery. Since the patient was haemodynamically stable, he was admitted to the clinic and the pseudoaneurysm was treated with distal selective TAE. Six months later, he remains asymptomatic without signs of pathology on Doppler ultrasound at follow-up. The use of these modalities can contribute to better success rates of NOM and should be readily available at any hospital treating trauma patients.     

Isolated hyoid bone fracture: a case report and review of the literature

Isolated hyoid bone fractures secondary to trauma other than strangulation are rare and have few, if any, complications. We report a case of an isolated hyoid bone fracture that resulted in sudden and severe upper airway compromise. Diagnosis of these fractures is difficult and usually can be made only with a strong degree of suspicion. Patients who suffer neck injuries in whom a hyoid fracture is diagnosed or strongly suspected should be observed for 48 to 72 hours, considered for endoscopy, and treated as warranted.     

Infected carotid pseudoaneurysm and carotid-cutaneous fistula as a late complication of carotid artery stenting

Carotid stenosis after neck irradiation is a well-described entity. A 78-year-old man presented with left eye amaurosis fugax 11 years after radical neck dissection and neck irradiation for mucoepidermoid carcinoma. The patient underwent carotid artery stenting for a high-grade stenosis of the left internal carotid artery. Twenty months after the procedure, a pulsatile neck mass developed with intermittent arterial bleeding. After control of the bleeding, he underwent resection of the left carotid bifurcation, including the indwelling stent and reconstruction with a saphenous vein interposition graft. A pectoralis myocutaneous flap was used for wound closure. In this case, localized infection of the stented carotid artery led to mycotic degeneration, pseudoaneurysm formation, and erosion to the skin surface. As carotid artery stenting becomes more widely used, previously unreported late complications associated with this procedure are likely to become apparent, and continued close follow-up is warranted.     

Treatment of an iatrogenic petrous carotid artery pseudoaneurysm with a Symbiot covered stent: technical case report

OBJECTIVE AND IMPORTANCE: Surgery involving the middle ear or the temporal bone may cause an injury to the petrous carotid artery resulting in a pseudoaneurysm. Conventional treatment of such pseudoaneurysms has ranged from carotid occlusion to conservative management. The use of a balloon-expandable stent and/or Guglielmi detachable coils may be effective in a partially healed pseudoaneurysm. This report details the case of an acute petrous carotid pseudoaneurysm after a myringotomy procedure that was effectively treated with an expanded polytetrafluoroethylene-covered stent. CLINICAL PRESENTATION: During a right myringotomy procedure, pulsatile blood was encountered in a 42-year-old woman with a history of repeated ear infections and bilateral middle ear ventilation tube placement. The blood was adequately tamponaded with gauze packing. Computed tomography of the temporal bone demonstrated a dehiscent carotid artery, and cerebral angiography revealed a 6-mm right petrous carotid pseudoaneurysm. INTERVENTION/TECHNIQUE: An 8-French guide catheter was positioned via a transfemoral approach into the cervical right internal carotid artery, and the patient was systemically heparinized. A 4- x 31-mm Symbiot covered stent (Boston Scientific/Scimed, Maple Grove, MN) was passed over a Choice PT exchange wire (Boston Scientific/Scimed) to cover the neck of the pseudoaneurysm, obliterating the pseudoaneurysm. The patient was given aspirin and clopidogrel after stenting, and ear exploration was possible later the same day. Follow-up computed tomographic angiography performed 6 weeks later verified patency of the stent. CONCLUSION: The use of an expanded polytetrafluoroethylene-covered stent may effectively treat intracranial internal carotid artery pseudoaneurysms in an acute setting. This treatment allows preservation of the parent artery and immediate treatment by reconstruction of the incompetent arterial wall to prevent potentially life-threatening hemorrhagic complications.     

Management of carotid injuries in a hostile neck using endovascular grafts

Pseudoaneurysms and iatrogenic injuries of the extracranial carotid artery are not common but represent unique operative challenges with associated high morbidity and mortality. We report two cases in which a Wallgraft was used via percutaneous femoral access to treat such injuries. In the first, a 6-cm carotid pseudoaneurysm was successfully excluded by coil embolization of the external carotid artery and stent grafting across the carotid bifurcation. In the second case, an endovascular graft was used to treat an intraoperative common carotid injury in a re-operated, radiated neck. These cases demonstrate the utility of endovascular graft treatment of emergent carotid injuries.     

Chronic pseudoaneurysm of the popliteal artery after blunt trauma

Blunt trauma to the popliteal artery usually results in acute arterial damage that requires urgent repair. Most blunt trauma to the popliteal artery is associated with skeletal injuries. We report a patient who had a chronic pseudoaneurysm of the popliteal artery 10 years after minor blunt trauma to the popliteal fossa. The cause of the pseudoaneurysm and suggestions for the early recognition of these arterial injuries are discussed.     

Acute bilateral iliac artery occlusion secondary to blunt trauma: successful endovascular treatment

INTRODUCTION: Endovascular treatment of blunt vascular trauma has been infrequently reported. PRESENTATION: A 27-year-old man was crushed between a fork-lift truck and a concrete platform. The physical examination was remarkable for hemodynamic stability, significant lower abdominal ecchymosis and tenderness, obvious pelvic fracture, and gross hematuria. Vascular examination revealed no femoral pulses, no pedal signals bilaterally, and minimal left leg and no right leg motor function. Arteriograms revealed right common iliac artery and external iliac artery occlusion and a 2-cm near occlusion of the left external iliac artery. TREATMENT: In the operating room, bilateral common femoral artery access was obtained, and retrograde arteriogram on the right side demonstrated free extravasation of contrast material at the level of the proximal external iliac artery. An angled glide wire was successfully traversed over the vascular injury, and two covered stents (Wallgraft, 10 x 50 mm and 8 x 30 mm) were deployed. The left iliac injury was similarly treated with an 8 x 30-mm covered stent. After calf fasciotomy, exploratory laparotomy revealed a severe sigmoid colon degloving injury, requiring resection and colostomy. A suprapubic catheter was placed because of bladder rupture, and an open-book pelvic fracture was treated with external fixation. Postoperatively the patient regained palpable bilateral pedal pulses and normal left leg function, but right leg paralysis persisted secondary to severe lumbar plexus nerve injury. CONCLUSION: Endovascular repair of blunt intra-abdominal arterial injuries is possible and should be particularly considered when fecal contamination, pelvic hematoma, or multiple associated injuries make conventional repair problematic.     

Pseudoaneurysm of the cervical internal carotid artery secondary to blunt trauma

A case of pseudoaneurysm in the extracranial internal carotid artery secondary to blunt trauma is presented to corroborate reports of aneurysmal formation in association with ipsilateral mandibular fracture. Because of the possibility of rupture or the development of neurologic symptomatology due to embolization, pseudoaneurysms of the cervical internal carotid artery should be repaired. We recommend use of the autogenous interposition vein graft to restore arterial continuity.     

Unexpected complication of arteriovenous fistula of the left common carotid to internal jugular vein following central venous catheterization

Incidence of inadvertent arterial puncture secondary to central venous catheter insertion is not common with an arterial puncture rate of<1%.This is due to the advancements and wide availability of ultrasound to guide its insertion.Formation of arteriovenous fistula after arterial puncture is an unexpected complication.Till date,only five cases(including this case)of acquired arteriovenous fistula formation has been described due to inadvertent common carotid puncture.The present case is a 26-year-old man sustained traumatic brain injuries,chest injuries and multiple bony fractures.During resuscitative phase,attempts at left central venous catheter via left internal jugular vein under ultrasound guidance resulted in inadvertent puncture into the left common carotid artery.Surgical neck exploration revealed that the catheter had punctured through the left internal jugular vein into the common carotid artery with formation of arteriovenous fistula.The catheter was removed successfully and common carotid artery was repaired.Postoperatively,the patient recovered and clinic visits revealed no neurological deficits.From our literature review,the safest method for removal is via endovascular and open surgical removal.The pull/push technique(direct removal with compression)is not recommended due to the high risk for stroke,bleeding and hematoma formation.