DISCUSSION

DISCUSSION

Pseudoaneurysms occur postoperatively with an incidence of 0.5- 1.5 % and infection is thought to be a major cause with Staphylococcus epidermidis or Staphylococcus aureus as the most common organism implicated. (6) The risk of rupture, embolization, or compression of cranial nerves means that prompt intervention is advised. Presentation is bimodal with the majority presenting either before 2 months or after 6 months with cases reported up to 20 years postoperatively. (7) (8) Unlike previously reported cases, our case had a known occluded internal carotid artery prior to developing a pseudoaneurysm. The gold standard treatment is excision of pseudoaneurysm and infected patch with interposition vein graft repair. However, carotid artery ligation is required in up to 22.7% of cases and has an associated death/ major stroke rate of 50%. (9) A number of alternatives to saphenous vein grafts have been proposed. Fatima et al. reported an acceptable outcome with their experience with femoral vein interposition graft. (10) They demonstrated excellent patency and good long-term survival of 82% at 5 years in their series of 24 patients treated with femoral vein interposition graft with 7% complaining of leg swelling and femoral nerve palsy that resolved in 3 months follow up. They propose the femoral vein as an option in carotid size mismatch or in limited availability. Morasch et el report their experience with autologous superficial femoral artery and preference to use this as a conduit. In their series of 6 patients they reverse the arterial conduit for best size match with the carotid artery and used a Goretex interposition graft to repair the harvested segment. Although a small sample size, they reported high durability and low re-infection rates. (11) Pseudoaneurysms occur postoperatively with an incidence of 0.5- 1.5 % and infection is thought to be a major cause with Staphylococcus epidermidis or Staphylococcus aureus as the most common organism implicated. (6) The risk of rupture, embolization, or compression of cranial nerves means that prompt intervention is advised. Presentation is bimodal with the majority presenting either before 2 months or after 6 months with cases reported up to 20 years postoperatively. (7) (8) Unlike previously reported cases, our case had a known occluded internal carotid artery prior to developing a pseudoaneurysm. The gold standard treatment is excision of pseudoaneurysm and infected patch with interposition vein graft repair. However, carotid artery ligation is required in up to 22.7% of cases and has an associated death/ major stroke rate of 50%. (9) A number of alternatives to saphenous vein grafts have been proposed. Fatima et al. reported an acceptable outcome with their experience with femoral vein interposition graft. (10) They demonstrated excellent patency and good long-term survival of 82% at 5 years in their series of 24 patients treated with femoral vein interposition graft with 7% complaining of leg swelling and femoral nerve palsy that resolved in 3 months follow up. They propose the femoral vein as an option in carotid size mismatch or in limited availability. Morasch et el report their experience with autologous superficial femoral artery and preference to use this as a conduit. In their series of 6 patients they reverse the arterial conduit for best size match with the carotid artery and used a Goretex interposition graft to repair the harvested segment. Although a small sample size, they reported high durability and low re-infection rates. (11)