Endovascular stenting is option that must be considered in the patients
with high predicted peri-operative mortality. Endovascular repair has
been successfully used to treat postoperative carotid artery
pseudoaneurysm in the past. Marin et al have described a case of known
infected pseudoaneurysm treated with good outcome with no re-infection
at 1 year follow up. (12) (13) While this will treat the immediate risk
of pseudoaneurysm rupture and eliminate the risk of continued expansion,
in the setting of an infected graft it is important to consider the risk
of embolization and thrombosis peri-operatively and the risk of
infection recurrence. A middle ground approach termed as the EndoVAC
Hybrid repair has been described in detail. In this 3-stage treatment
approach a stent is first deployed to treat the pseudoaneurysm. At a
later point surgical debridement is done followed by VAC therapy in
combination with long term antibiotics. In the study described by
Wanhainen et al. there was no infection recurrence in their cohort of 16
patients at 5 years. (14)
In our patient, the CT scan had demonstrated that the pseudoaneurysm was
very high in the neck. We had anticipated that there would be difficulty
in gaining distal control and need for ligation if unsuccessful. But we
felt that a completely conservative approach or endovascular approach
may not be the best given her relatively good activity of daily living.
We also wanted to avoid ligating the carotid artery as it measured 5mm
on CT scan and would be associated with high risk of neurological
deficit. After our vascular MDT discussion, we considered an
endovascular balloon to gain control but eventually agreed that a stent
placement will provide more durability and leave the artery patent
during dissection. After stent placement, when we had dissected down to
the carotid artery the bare metal stent was fully visible. We were then
able to perform dissection taking care to avoid nerve injury and safely
get distal control. To our knowledge, there is no reported case
describing a transcervical stent assisted carotid pseudoaneurysm repair.
Interestingly, our patient had a recently diagnosed occluded left
carotid artery on a CT scan as of September 2019. Her initial
presentation with a pulsatile mass neck in clinic was very unusual but
given her history of CEA we had considered pseudoaneurysm as likely. The
pathophysiology is likely inflammation secondary to infection causing
the vessel to re-canalize and evolve into a pseudoaneurysm. To our
knowledge, there have been no case reports describing a previously
occluded CEA site re-canalizing and developing into a pseudoaneurysm.