Emergency Endovascular Treatment of Recurrent Internal Carotid Artery False Aneurysm Complicated By Carotid-Cutaneous Fistula and Life-Threatening Bleeding

Background: Carotid pseudoaneurysms can generally be the result of arterial wall degeneration developed after carotid endarterectomy, previous spontaneous carotid dissection, post-traumatic neck injuries, non-vascular procedures and, rarely, infections. The ideal surgical management of extracranial carotid artery false aneurysms is still controversial and treatment should be tailored to the aneurysm’s aetiology, anatomy and presentation. Case presentation: We describe the case of an 81-year-old man presented with an enlarged pulsatile cervical mass coupled with a small cutaneous fistula, which had developed in roughly 1 year. He had undergone several carotid operations over the last 15 years (endarterectomy, venous-patch-angioplasty for restenosis and bovine-pericardial patch-angioplasty for a pseudoaneurysm). Methods: A CT-Scan revealed a recurrent pseudoaneurysm. Due to the previous multiple cervicotomies, the aneurysm wall was very closely adjacent to the skin plane; no gas bubbles or cervical fluid collections were evident. The patient rejected treatment at first, but six months later suffered major bleeding from the fistula. Results: The pseudoaneurysm was emergency excluded with a Viabhan-Stent-graft while the external carotid artery was occluded via vascular-plug. The fistula healed spontaneously in four months. There was no pseudo-aneurysm recurrence, endoleak or any sign of graft infection at 36-month follow-up. Conclusion: We present a singular case of emergency endovascular treatment of recurrent post-surgical internal carotid artery pseudoaneurysm complicated by a carotid-cutaneous and life-threatening bleeding. In these cases emergency endovascular treatment via covered-stent-graft represents the most effective, definitive or “bridge” management option. Carotid sheath protection via a myo-cutaneous flap could be considered in cases of previous multiple cerivcotomies.