Carotid pseudoaneurysm is a rare finding, especially after a remote history of endarterectomy. We present a case of an 88-year-old man was referred to vascular surgery following workup for a new painless, pulsatile left neck mass associated with fevers. This otherwise healthy, independent patient had undergone a left CEA with Dacron patch angioplasty fifteen-years prior for asymptomatic carotid artery stenosis. Computed Tomography Angiography (CTA) was ordered showing a hypodense left mid-neck lesion abutting the sternocleidomastoid muscle and carotid with arterial outpouching (Figure 1).
The patient was found to have a leukocytosis with positive blood cultures for staphylococcus. He was presumed to have an infected left internal carotid pseudoaneurysm and was started on broad-spectrum empiric antibiotic coverage. The patient underwent urgent repair of the carotid pseudoaneurysm in the operating room. There was copious necrotic debris and a hole in the anterior wall of the Dacron patch (Figure2A). The prior dacron patch was completely excised and all infected surrounding tissue was debrided. Thearteriotomy in the carotid artery was then closed with a Great Saphenous Vein (GSV) patch angioplasty repair (Figure 2B).
Postoperative course was unremarkable. His blood cultures remained negative, his fevers resolved, and he was discharged home on postoperative day six. On follow-up, the patient continues to have full neurologic function and remains free of any signs of infection. Prompt identification and treatment of carotid pseudoaneurysm is vital; though prevalence is very low, morbidity from this condition remains high, and delays in identification could prove catastrophic.
Figure 1: Preoperative Computed Tomography Angiography (CTA) showing a pseudoaneurysm of the left carotid artery.
Figure 2: A. Intraoperative imaging of carotid pseudoaneurysm; B. Intraoperative imaging after repair of carotid artery with vein patch angioplasty.