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Ann Thorac Surg 2005;79:1767-1769
© 2005 The Society of Thoracic Surgeons

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Case report

Deep Hypothermia and Circulatory Arrest for Surgery of High Extracranial Internal Carotid Aneurysm

^a Service of Cardiovascular Surgery, Hospital Clínico Universitario, Valencia, Spain

Accepted for publication October 30, 2003.

^* Address reprint requests to Dr Otero-Coto, Service of Cardiovascular Surgery, Hospital Clínico Universitario, Avda Blasco Ibañez 17, Valencia 46010, Spain
otero_edu{at}gva.es

	Abstract

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A large, high internal carotid artery aneurysm partially filled with thrombi in a young, 26-year-old male patient was treated by bypass grafting under deep hypothermia and circulatory arrest. This approach may be preferable to other alternatives in patients with high embolic risk and difficult exposure or inadequate space for distal carotid artery clamping.

	Introduction

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Aneurysms of the extracranial internal carotid artery are rare lesions usually due to arteriosclerosis or trauma (including surgery) [1]. The surgical management of these cases can be difficult, particularly when they are very large and high. Different techniques have been proposed, some involving complex otological or neurosurgical techniques. Carotid artery bypass under deep hypothermic circulatory arrest, a technique already used in some neurosurgical interventions [2, 3], is a possible approach [4] particularly for cases with high neurologic risk. This report describes our experience with 1 patient.

A 26-year-old white man presented with pharyngeal pain and fever in spite of antibiotic treatment. A lateral pharyngeal abscess was suspected, and unproductive drainage by direct puncture was performed at another hospital. The patient returned after 4 days with worsening pain and computed tomography showed a 6-cm vascular mass in the left carotid space (Fig 1A), partially filled with thrombi. The patient was referred to our hospital for further evaluation and an arteriogram (Fig 1B), which confirmed the presence of an aneurysm of the internal carotid artery extending up to the base of the skull. An iatrogenic pseudoaneurysm of the carotid artery was suspected and urgent surgery was recommended.

View larger version (83K): [in this window] [in a new window]   Fig 1. (A) Computed tomographic scan of the aneurysm, partially filled with clots and displacing the pharynx. (B) Arteriogram shows the aneurysm and distal filling of the intracranial carotid artery.

After sternotomy, heparinization, and cannulation of the distal ascending aorta and right atrium, cardiopulmonary bypass was initiated and deep hypothermia (20°C) was established. After circulatory arrest, the left common carotid was clamped, the aneurysm was entered, and the thrombi were aspirated. The proximal and distal orifices of the carotid artery were separated by approximately 6 cm and the wall showed no macroscopic signs of atheroma, trauma, or infection. Anastomosis of a 6-mm thin-walled, expanded polytetrafluoroethylene graft to the distal carotid artery was made with a continuous 6-0 Prolene suture (Ethicon, Somerville, NJ) from the inside of the aneurysm. Cardiopulmonary bypass and rewarming was started. After checking retrograde flow through the graft and absence of bleeding at the distal suture line, the graft was clamped. Proximal anastomosis of the graft to the origin of the internal carotid artery and complete removal of air were performed before unclamping the graft. The aneurismal wall adherent to surrounding structures was sutured around the graft for further protection. Cardiopulmonary bypass was terminated and all wounds were closed in the usual manner. Total circulatory arrest time was 9 minutes. The common carotid artery clamping time was 23 minutes.

After a normal postoperative course, the patient was discharged on postoperative day 5. Six months postoperatively, magnetic resonance angiography showed a normal functioning graft without residual stenosis or aneurysm, and the neurologic examination confirmed absence of neurologic sequelae with no cranial nerve deficits. Three years later the patient remains well with no evidence of other aneurysms or neurologic deficits.

	Comment

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The cause of the aneurysm in our patient is not known. We did not see atherosclerotic lesions, the patient was young and had no known risk factors or associated diseases like Marfan, and the arteriogram showed no signs of fibromuscular dysplasia. The patient did not refer to any traumatic antecedents other than the recent pharyngeal puncture, but the aneurysm was not ruptured on internal visualization and the wall did not show the typical aspect of a pseudoaneurysm. No signs of Behçet's disease were present. No microscopic examination of the wall was performed.

Carotid artery aneurysms are very rare in young people. An 18-year-old patient was reported by Rosset and colleagues [5]; however the cause was not reported. A posttraumatic aneurysm in a 26-year-old patient was reported by El-Sabrout and Cooley [1]. Although the exact cause in our case is unknown, it is important to remember that even large aneurysms of the carotid artery may be found in young people; age should not be construed as a definitive argument against this diagnosis.

The best surgical approach to a high internal carotid aneurysm is controversial. Some techniques as described by Fish and colleagues [6] or Purdue and colleagues [7] with resection of the mastoid and styloid processes and the inferior wall of the auditory canal sacrificed the middle ear or produced lesions of cranial nerves. Rosset and colleagues [5] used an anterior infratemporal approach for small aneurysms (cutting the external auditory canal, dissecting the facial nerve, luxating the mandibular condyle, and resecting the styloid process, the mastoid, and the vaginal process) without permanent facial nerve paralysis. We [4] reported distal control by dislocation of a high aneurysm after partial mobilization of the parotid gland, section of the digastric and stylohyoid muscles, and the styloid process, but this was not an option in the present case due to the risks of thrombi dislodgement and damage to the cranial nerves.

We have found it very easy to treat this difficult lesion under deep hypothermia and circulatory arrest by end-to-end anastomosis of a vascular graft working from the inside of the aneurysm. Due to the large size of the aneurysm, space for the anastomosis was adequate, but interrupted simple stitches may allow performing the anastomosis at a distance, simplifying the procedure for smaller or hidden aneurysms. Absence of distal carotid clamping and improved vision of the distal orifice may allow avoidance of bone resection and other otological techniques in most, if not all, patients with extracranial high carotid artery aneurysms.

	References

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1. El-Sabrout R, Cooley DA. Extracranial carotid artery aneurysms: Texas Heart Institute experience. J Vasc Surg. 2000;31:702–712[Medline]
2. Baumgartner WA, Silverberg GD, Ream AK, Jamieson SW, Tarabek J, Reitz B. Reappraisal of cardiopulmonary bypass with deep hypothermia and circulatory arrest for complex neurosurgical operations. Surgery. 1983;94:242–248[Medline]
3. Aebert H, Brawanski A, Philipp A, et al. Deep hypothermia and circulatory arrest for surgery of complex intracranial aneurysms. Eur J Cardiothor Surg. 1998;13:223–229[Abstract/Free Full Text]
4. Otero-Coto E, Orozco M, Lopez CM. Giant aneurysm of the high internal carotid artery: surgical treatment. Surgery. 1992;111:348–351[Medline]
5. Rosset E, Albertini JN, Magnan PE, Ede B, Thomassin JM, Branchereau A. Surgical treatment of extracranial internal carotid aneurysms. J Vasc Surg. 2000;31:713–723[Medline]
6. Fish UP, Oldring DJ, Senning A. Surgical therapy of internal carotid artery lesions of the skull base and temporal bone. Otolaryngol Head Neck Surg. 1980;88:548–554[Medline]
7. Purdue GF, Pellegrini RV, Arena S. Aneurysms of the high internal carotid artery: a new approach. Surgery. 1981;89:268–270[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Eduardo Otero-Coto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Botí, E. T. Articles by Otero-Coto, E. Search for Related Content PubMed PubMed Citation Articles by Botí, E. T. Articles by Otero-Coto, E. Related Collections Peripheral vascular