Abstract
Radiation induced carotid vasculopathy may present as steno-occlusive disease or less commonly as a pseudoaneurysm. The latter most often presents with a pulsatile mass but is a potential cause of life threatening hemorrhage. We present a case of a small common carotid artery (CCA) pseudoaneurysm that was initially dismissed as the cause of the patients presenting epistaxis given its small size and location. After standard bilateral internal maxillary artery embolizations failed to prevent significant subsequent pharyngeal and tracheal blood loss and serial imaging demonstrated a progressive enlargement of the pseudoaneurysm, a stent graft was successfully placed across the lesion. At five months post stenting, follow-up imaging of the neck showed a stable obliteration of the pseudoaneurysm, good arterial patency, and the patient remained free of recurrent hemorrhage. This case demonstrates that even a small carotid pseudoaneurysm, can present with pharyngeal hemorrhage and should be treated aggressively – with endovascular stent grafting being a preferred treatment modality for arterial lesions in the irradiated neck.
1
Introduction
Carotid pseudoaneurysms are relatively uncommon vascular lesions that may present after carotid endarterectomy, trauma to the neck, mycotic infection, tumor invasion, chemotherapy, radiation, or iatrogenic injuries . These patients may present with a painless pulsatile neck mass, symptoms related to hemorrhage, or from embolic strokes . Although less common, upper respiratory tract hemorrhage can be torrential, requiring emergent diagnosis and treatment. Usually the source of hemorrhage is obvious on conventional or computed tomography/magnetic resonance angiography. Open surgical treatment carries a substantial risk with rates of stroke and death of up to 9% and with cranial nerve injury in as many as 23% .
2
Case report
A 68-year-old woman presented with hemorrhage from her tracheostomy site. She had a history of tongue base carcinoma treated by chemotherapy and radiotherapy 14 years before admission and a subsequent tracheostomy for radiation-induced tracheal fibrosis 10 years later.
On arrival to the emergency department, an endotracheal tube was placed and ventilator respiratory support was initiated. Examination showed blood in the oropharynx and nares. Flexible fiberoptic laryngoscopy showed no active bleeding, ulcerations, or masses in the nares, nasopharynx, or subglottic area. She also underwent bronchoscopy and esophagoscopy, during which she discharged several hundred milliliters of blood from her mouth without a focal bleeding source visualized.
Two days after admission, she had gross bleeding through her tracheostomy, requiring a transfusion of 2 U of blood. She underwent further fiberoptic laryngoscopy, which showed oozing of blood from the right nasopharynx suggesting a sphenopalatine arterial source and was referred for endovascular embolization. Angiography showed a small right common carotid artery (CCA) pseudoaneurysm measuring 5 × 6 × 9 mm, which given its location and small size was felt to be unrelated to her hemorrhagic episodes and likely a chronic abnormality. Both internal maxillary arteries were embolized uneventfully; the patient was stabilized and discharged 4 days later.
She returned the day after discharge with renewed bleeding from her tracheostomy and oropharynx. A neck Computed Tomographic Angiogram (CTA) was performed which showed interval enlargement of the right CCA pseudoaneurysm (8 × 9 × 9 mm) compared to the conventional angiogram.
The patient was transferred to the neurointerventional suite urgently. Right carotid angiography confirmed enlargement of the CCA pseudoaneurysm ( Fig. 1 A ). She was then loaded with aspirin 650 mg and Plavix (clopidogrel, Bristol-Myers Squibb/Sanofi-Synthelabo, New York, NY) 300 mg and administered IV heparin to achieve an activated clotting time of 250. A Magic Torque wire was navigated over a diagnostic catheter into the right external carotid artery and used to exchange a 7F sheath into the mid CCA. A 7 × 40 mm Fluency covered stent was then navigated over the exchange wire, through the sheath, and delivered across the pseudoaneurysm, immediately excluding it from the circulation. The distal end of the covered stent deployed close to the carotid bifurcation with several tines projected over the internal carotid artery (ICA) origin. As a precaution, a 7 × 40 mm fenestrated Precise stent was navigated over a balanced middle weight exchange wire into the right ICA and deployed from the ICA back into the CCA stent graft to prevent potential compromise of the ICA origin (Fig. 1B).
The patient had no further episodes of pharyngeal/upper airway hemorrhage and was discharged 4 days later. She remained on 81 mg aspirin indefinitely and 75 mg Plavix for 3 months. A follow-up neck CTA 5 months later showed no residual or recurrent carotid pseudoaneurysm and no evidence of in-stent stenosis.
2
Case report
A 68-year-old woman presented with hemorrhage from her tracheostomy site. She had a history of tongue base carcinoma treated by chemotherapy and radiotherapy 14 years before admission and a subsequent tracheostomy for radiation-induced tracheal fibrosis 10 years later.
On arrival to the emergency department, an endotracheal tube was placed and ventilator respiratory support was initiated. Examination showed blood in the oropharynx and nares. Flexible fiberoptic laryngoscopy showed no active bleeding, ulcerations, or masses in the nares, nasopharynx, or subglottic area. She also underwent bronchoscopy and esophagoscopy, during which she discharged several hundred milliliters of blood from her mouth without a focal bleeding source visualized.
Two days after admission, she had gross bleeding through her tracheostomy, requiring a transfusion of 2 U of blood. She underwent further fiberoptic laryngoscopy, which showed oozing of blood from the right nasopharynx suggesting a sphenopalatine arterial source and was referred for endovascular embolization. Angiography showed a small right common carotid artery (CCA) pseudoaneurysm measuring 5 × 6 × 9 mm, which given its location and small size was felt to be unrelated to her hemorrhagic episodes and likely a chronic abnormality. Both internal maxillary arteries were embolized uneventfully; the patient was stabilized and discharged 4 days later.
She returned the day after discharge with renewed bleeding from her tracheostomy and oropharynx. A neck Computed Tomographic Angiogram (CTA) was performed which showed interval enlargement of the right CCA pseudoaneurysm (8 × 9 × 9 mm) compared to the conventional angiogram.
The patient was transferred to the neurointerventional suite urgently. Right carotid angiography confirmed enlargement of the CCA pseudoaneurysm ( Fig. 1 A ). She was then loaded with aspirin 650 mg and Plavix (clopidogrel, Bristol-Myers Squibb/Sanofi-Synthelabo, New York, NY) 300 mg and administered IV heparin to achieve an activated clotting time of 250. A Magic Torque wire was navigated over a diagnostic catheter into the right external carotid artery and used to exchange a 7F sheath into the mid CCA. A 7 × 40 mm Fluency covered stent was then navigated over the exchange wire, through the sheath, and delivered across the pseudoaneurysm, immediately excluding it from the circulation. The distal end of the covered stent deployed close to the carotid bifurcation with several tines projected over the internal carotid artery (ICA) origin. As a precaution, a 7 × 40 mm fenestrated Precise stent was navigated over a balanced middle weight exchange wire into the right ICA and deployed from the ICA back into the CCA stent graft to prevent potential compromise of the ICA origin (Fig. 1B).
