1DepartmeCameroon.

2DepartmeYaounde, Cam

3DepartmeCameroon.

4DepartmeYaounde, Cam

5Former Dtation, Univer

CorrespondHospital, BP 5

Ann Vasc SurgDOI: 10.1016/� Annals of VPublished onli

Surgical Repair of a Giant Pseudoaneurysm ofthe Right Common Carotid Artery Followinga 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,

Dusseldorf, Germany

Common carotid pseudoaneurysms are very rare. The authors report a case of a 18-year-oldpatient with 11 cm large posttraumatic pseudoaneurysm of the right common carotid arterycaused by a gunshot in the neck. The patient also had a right hemiplegia, secondary to theleft sylvian artery stroke and aphasia. A surgical repair was undertaken with an approachincluding a total sternotomy. The aneurysm was excluded and a saphenous vein patch wasused 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 hazardsof an aneurysm of the common carotid artery indicate that surgical treatment is warranted partic-ularly 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

nt of Surgery, Yaounde General Hospital, Yaounde,

nt of Surgery,The Yaounde University Hospital Centre,eroon.

nt of Radiology, Yaounde General Hospital, Yaounde,

nt of Anesthesiology, Yaounde General Hospital,eroon.

irektor Klinik fur Gefaßchirurgie und Nierentransplan-sitat Dusseldorf, Dusseldorf, Germany.

ence to: Marcus Fokou, MD, The Yaounde General408 Yaounde/Cameroon, E-mail: mfokou@yahoo.com

2011; 25: 268.e3-268.e6j.avsg.2010.07.029ascular Surgery Inc.ne: October 6, 2010

et al. described a major artery lesion in 18 of the

107 patients (16.8%) with neck injuries.1 Addition-

ally, 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 pseudoa-

neurysm 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

Fig. 1. Clinical aspect of the aneurysm.

Fig. 2. CCA aneurysm with a huge thrombus.

Fig. 3. CCA aneurysm showing the patency of the CCA

(arrow).

268.e4 Case reports Annals of Vascular Surgery

and dressed. The patient suffered a second trauma 3

months after the onset of the swelling, wherein he devel-

oped a right hemiplegia, a rapid increase of the mass, and

a gradual loss of speech. The second traumawas 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 pastmedical diseasewas 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 anes-

thesia, exposure of the right CCAwas achieved proximally

using a total sternotomy, and distally using a classic

presternocleidomastoid cervicotomy both as a single ex-

tended 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.

A saphenous vein patch was performed using a 5-0 poly-

propylene running suture (Fig. 5). Although the back flow

pressure of the distal carotid arterywas very good, a carotid

shunt was used before the 25-minute clamping. No intra-

operative 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

Fig. 4. Brain CT scan showing the left porencephaly.

Vol. 25, No. 2, February 2011 Case reports 268.e5

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.

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 endarter-

ectomy are increasing in frequency nowadays and

are estimated to be 13-16% of all pseudoaneurysms

of that region,3 thereby rating second after trau-

matic 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 involve-

ment of the CCA in the recently described 13 pseu-

doaneurysms of the neck region.

Manifestations

The natural history of pseudoaneurysm of the

carotid arteries is poorly understood. Most

aneurysms are likely to be asymptomatic despite

there being no reports supporting such an assess-

ment. 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 pseu-

doaneurysm 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 pseudoa-

neurysms 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 differen-

tial diagnosis. The realization of an ultrasonography,

aCTAormagnetic resonance imaging, and a cerebral

angiography are particularly useful in establishing

accurate diagnosis, proceeding to surgical therapy.

Treatment

Surgical intervention is recommended for all symp-

tomatic carotid artery aneurysm or pseudoaneur-

ysm with manifestations related to cerebral

ischemia or local discomfort. A pseudoaneurysm

with diameter >2 cm is the threshold in the asymp-

tomatic cases of adults.1,3 Because its occurrence is

rare, the natural history of asymptomatic pseudoa-

neurysm 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 resec-

tion 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 per-

formed by many authors.2,3 Although the endovas-

cular therapy is being practiced increasingly,

Fig. 5. Surgical representation of the reconstructed CCA

(short arrow) and the excluded aneurismal sac (long

arrow).

268.e6 Case reports Annals of Vascular Surgery

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 possi-

bilities, 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

initial control of the innominate artery and the infe-

rior 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 pseu-

doaneurysms are uncommon conditions, with

limited published experience. A surgical approach

including a sternotomy can be helpful to control

a huge aneurysm.

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