Infected pseudoaneurysm after carotid endarterectomy: mismatch between clinical presentation and origin

Pseudoaneurysm after carotid endarterectomy (CEA) is a rare complication, with an incidence lower than 1%. Infection as a cause of carotid pseudoaneurysm is uncommon, and is mostly caused by staphylococci. An 81-year-old woman, treated with right carotid endarterectomy 7 years earlier, presented with a diagnosis of right carotid pseudoaneurysm. The patient was neurologically asymptomatic; clinical status, laboratory, and imaging findings were negative for infection. She was referred to surgical treatment consisting of patch excision and a carotid polytetrafluoroethylene bypass grafting. During intervention a purulent fluid collection was discovered, and therefore an inverted great saphenous vein carotid bypass was performed. The postoperative course was normal. Microbiological examination on the purulent fluid collection and excised patch showed the presence of Staphylococcus epidermidis. Carotid pseudoaneurysms after CEA often arise in asymptomatic patients. Despite this common clinical presentation, an infective origin must always be taken into account before any intervention is planned.