Interactive Cardiovascular and Thoracic Surgery 2:514-516(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Assisted circulation |
Rare association of a carotid pseudoaneurysm and coarctation of the aorta
Subash C. Reddya,1,*,
Gerard A. Boylea,
Frank A. Pigulab and
Sanjiv K. Gandhib
a Division of Pediatric Cardiology, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA
b Division of Cardiothoracic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA
* Corresponding author. Tel.: +90-40-23607777x4499; fax: +90-40-23608050
surabhireddy{at}yahoo.com
Received February 25, 2003;
received in revised form March 25, 2003;
accepted March 27, 2003
 |
Abstract
|
|---|
We describe the occurrence of a carotid pseudoaneurysm in a child 3 years following cannulation for extracorporeal membrane oxygenation. This lesion occurred in the context of a previously unsuspected coarctation of the aorta. This may likely predispose to the development of the pseudoaneurysm or may be an incidental association.
Key Words: Pseudoaneurysm; Coarctation of aorta; Mechanical assisted circulation
|
1. Introduction
|
|---|
Pseudoaneurysms (PA) involving the extracranial carotid arteries are uncommon in children [1]. This report describes a child in whom a PA of the right carotid artery developed 3 years following cannulation for extracorporeal membrane oxygenation (ECMO). At the time of evaluation, the patient was also diagnosed with a previously unsuspected coarctation of the aorta (COA). COA may likely predispose to the development of the PA. Both lesions were successfully surgically treated.
|
2. Case report
|
|---|
A 3 year-old male child presented for evaluation of a pulsatile mass over his right neck. He was born at term gestation but suffered from meconium aspiration syndrome. Secondary to severe hypoxia, he was placed on ECMO support for 5 days. Cannulation was via the right common carotid artery and right internal jugular vein. The artery was repaired primarily at the time of decannulation. He had an uneventful recovery and remained asymptomatic. On physical examination, his weight was 14.6 kg and height was 100 cm. His blood pressure was 130/x mmHg in the right arm and 100/x mmHg in the right leg. On cardiovascular evaluation, there were prominent right carotid pulsations accompanied by a thrill and a loud bruit. His heart sounds were normal. There was a grade 2/6 systolic ejection murmur at the right base. Femoral pulses were diminished and delayed bilaterally when compared to his upper limb pulsations. The remainder of his physical examination was normal. His electrocardiogram and chest X-ray were normal. An echocardiogram demonstrated normal intracardiac anatomy with preserved ventricular systolic function and a suspected coarctation of the aorta. Cardiac catheterization revealed a severe juxtaductal coarctation of the aorta with a 40 mmHg peak systolic gradient. A selective right carotid injection demonstrated a PA of the mid portion of the right common carotid artery (Figs. 1A,B).
View larger version (69K):
[in this window]
[in a new window]
|
Fig. 1 Selective right carotid angiogram demonstrating large pseudoaneurysm of the common carotid artery. (A) Anteroposterior view; and (B) lateral view.
|
|
A staged surgical repair was planned. Initially, the PA was addressed. After obtaining proximal and distal vascular control, a 3x3 cm PA was circumferentially dissected (Fig. 2). As a discrete PA neck was not identifiable, the PA was resected en bloc with a short segment of common carotid artery and a primary end-to-end repair completed. The patient was discharged home 48 h postoperatively. He was readmitted for COA repair 3 weeks subsequently. A standard resection and end-to-end anastomosis was performed and the child experienced an uneventful postoperative course. At histopathology, a pseudoaneurysm with adjacent segment of normal carotid artery was confirmed.
|
3. Discussion
|
|---|
PAs affecting the extracranial carotid arteries are rare lesions in the pediatric population [1]. The etiology is usually penetrating or blunt trauma or rarely infectious in nature [2]. The PA in our patient progressed slowly, ultimately presenting at 3 years of age with a pulsatile neck mass which led to the diagnosis as well as that of COA. This unusual association can be explained on the basis of; a direct result of trauma during ECMO cannulation and the smallness of PA masked early detection, or a causal relationship with COA, with its chronically elevated systolic pressure contributing to PA, or it may be a spurious association.
The management of these two lesions posed an interesting issue in terms of timing, sequence, and type of intervention. Although percutaneous endovascular procedures are feasible options for some types of PA, they are suboptimal in the cranial circulation of a child [3–5]. For fear of rupture or thromboembolic complications, the PA was repaired initially. Because of the extensive dissection and carotid artery resection required during repair of the PA, we felt it desirable to allow an interim period of healing prior to subjecting this area of the circulatory system to the high pressure that would result from aortic cross-clamping. Accordingly, the coarctation repair was completed several weeks following the PA operation.
An isolated case of PA following carotid artery decannulation has been reported in a newborn [6]. There are no reports of a carotid PA developing late after the inciting event in children, although the late development of PAs is not uncommon in adults [5]. A small asymptomatic PA following carotid repair may go unrecognized until associated with adverse events like thromboembolism, infection, or mass effects. In our case, gradual enlargement, in association with an unsuspected COA resulted in a sizable neck mass. This association has not been previously reported, although there is an isolated report of a PA of the internal mammary system in a child with COA [7]. Our case exemplifies this rare association.
|
Footnotes
|
|---|
1 Present address: Section of Pediatric Cardiology, Apollo Hospital, Jubilee Hills, Hyderabad, 500 033 India. 
doi:10.1016/S1569-9293(03)00080-X
|
References
|
|---|
- Hargraveaves DG, Baskerville DM. False aneurysm of the carotid artery. J R Soc Med. 1995;88:50–51[Abstract]
- Robinson NA, Flotte CT. Traumatic aneurysms of the carotid arteries. Am Surg. 1974;40:121–124[Medline]
- Lempert TE, Halbach VV, Higashida RT, Dowd CF, Urwin RW, Balousek PA, Hieshima GB. Endovascular treatment of pseudoaneurysms with electrolytically detachable coils. Am J Neuroradiol. 1998;19:907–911[Abstract]
- Bernstein SM, Coldwell DM, Prall JA, Brega KE. Treatment of traumatic pseudoaneurysm with endovascular stent placement. J Vasc Interv Radiol. 1997;8:1065–1068[Medline]
- El-Sabrout R, Cooley DA. Extracranial carotid artery aneurysms: Texas Heart Institute Experience. J Vasc Surg. 2000;31:702–712[CrossRef][Medline]
- Jacobs JP, Goldman AP, Cullen S, Rocco D, Samanli U, Macrae DJ, Elliot MJ. Carotid artery pseudoaneurysm as a complication of ECMO. Ann Vasc Surg. 1997;11:630–633[CrossRef][Medline]
- Balbay Y, Tikiz H, Demir D, Yalgec NS, Korkmaz S, Saritas A. Spontaneous false aneurysm of left internal mammary artery. Int J Cardiol. 2002;81:269–270[CrossRef]
|
|
Top
Abstract
1. Introduction