Chapter 94 - Carotid artery aneurysms Flashcards
Incidence of extracranial carotid aneurysms
0.8-18% in autopsy
<1% of all carotid diseases
Normal carotid bifurcation size in relation to ICA
40% greater in diameter than ICA
Definition of carotid artery aneurysm
1) bulb > 200% ICA or
2) ICA > 150% of CCA
first carotid aneurysm operation
1806, 1808 Astley Cooper
ligation of CCA
Mortality of carotid ligation
28% historically
now more like 12%
first resection of carotid aneurysm with anastamosis primary
Dimitza 1952
Shea 1955 - first report
first prosthetic graft replacement of carotid aneurysm
Beall 1959
Mycotic carotid aneurysms
reduced frequency over years
1) syphilis
2) TB
3) middle ear infection
4) tonsillar infection
5) immunosuppression HIV
Contemporary causes of carotid aneurysms
1) atherosclerotic degen 36%
2) dissection 6%
3) trauma 13%
4) previous carotid surgery
5) radiation
6) pseudoaneurysm 33%
7) FMD 7%
8) infection 2%
Rate of bilateral carotid aneurysm
5%
gender difference degenerative carotid aneurysms and age
male > women 2:1
> 60 years old
Connective tissue disorders related to carotid aneurysm
special surgical consideration
1) EDS4
2) neurofibromatosis
3) Behcet
prosthetic conduits instead of vein due to high risk of psuedoaneurysm development
Post CEA aneurysm causes
1) suture line failure
2) infection
3) vein patch degeneration
Organism in CEA aneurysm infection
Staph
Cause for inward protrusion of ICA aneurysms
1) deep cervical fascia and muscles on styloid anteriorly
2) cervical vertebrae posteriorly
3) dilation towards tonsillar fossa
Symptoms of carotid aneurysm
1) painless pulsatile mass 93%
2) neurological deficits 43%
3) dysphagia
Cranial nerve dysfunction with carotid aneurysm
1) Horner
2) Vagus - recurrent laryngeal
3) facial - pain
4) trigeminal
5) abducens
Most common cause of a pulsatile neck mass
Tortuous or kinked carotid artery
Differential for pulsatile neck mass
1) cervical lymph node over artery
2) carotid body tumors
3) glomus jugulare tumors
4) cervical metastatic disease
5) brachial cleft cysts
6) cystic hygromas
Balloon occlusion test
1) 30 min time
2) stump pressure measurement (>50% of systemic pressure indicates adequate flow)
3) assess pt clinically
inaccurate 10-20% of time
Fankhauser Mayo Clinic on conservative mgnt of carotid aneurysm
None progressed to need treatment after 77 months
Size of aneurysm
12mm vs 21.2mm (got treated)
size of pseudoaneurysm
10.2 mm vs 20.9mm got treated
Indication to treat carotid aneurysms
1) > 2cm
2) mycotic
3) thrombus in aneurysm
4) symptomatic
5) enlarging aneurysm on imaging
Cranial nerve injury rate after complete excision of carotid aneurysm
4-20%
Patch type and pseudoaeurysm formation
1) most due to infection
2) one series pointed towards dacron patches
Endovascular options for treating carotid aneurysm
1) bare stent
2) bare stent with coiling
3) double stent
4) autogenous vein-graft covered stents
5) endo coil
6) covered stents
generally results favorable if anatomy suitable
El-Sabrout and Cooley data on carotid aneurysm
non-op
ligation
reconstruction
death/stroke rate
non-op 21%
ligation 12%
recon 9%
Carotid blowout
due to degeneration of carotid artery with previous cancer treatment or surgery
vasovasorum damage, adventitial skinning
Mycotic aneurysm organism
1) gram positive: staph aureus and epi
2) Gram negative: E coli, Klebsiella, corynebacterium, proteus, yersinia
