Management of extracranial carotid artery pseudoaneurysms

Extracranial carotid artery pseudoaneurysm (ECAPA) is a rare vascular pathology most commonly associated with trauma, infection, spontaneous dissection, iatrogenic injury, or prior surgery. Management of ECAPAs still remains uncertain, without specific recommendations included in the most recent guidelines. The aim of the study was to review the experience of a single center with ECAPAs during a 20-year period.

For the period from December 2003 to February 2024, 14 patients with ECAPAs were prospectively included and retrospectively reviewed. Clinical signs, aneurysm profiles, and treatment outcomes were recorded. Patients underwent open surgery or endovascular intervention.

The underlying etiology of ECAPAs was infection in five patients (35.7%), trauma in four patients (28.6%), dissection in four patients (28.6%), and giant cell arteritis in one patient (7.1%). All patients were symptomatic, presenting with neck mass, swallowing disorders, transient ischemic attack, stroke, rupture, or postoperative wound infection. Surgical interventions included resection of the pseudoaneurysm with primary anastomosis in three patients (21.4%), carotid artery reimplantation in two patients (14.3%), carotid artery ligation in three patients (21.4%), extra-anatomic autogenous subclavian-carotid bypass in two patients (14.3%), prosthetic graft interposition in two patients (14.3%), and endovascular treatment in two patients (14.3%). Perioperative complications included: ischemic stroke in three patients (21.4%), transient cranial nerve dysfunction in two patients (14.3%), thrombosis of arterial reconstruction in two patients (14.3%), and wound infection in two patients (14.3%). The postoperative mortality rate was 7.1%. Long-term outcomes were assessed in 13 patients. Median follow-up was 21 months (range, 1-222 months). During follow-up, nine patients (69.2%) experienced no new neurological events, whereas one patient (7.7%) suffered a stroke. Seven patients (53.8%) showed no carotid stenosis or occlusion. Two patients (15.4%) were lost to follow-up, and one patient (7.7%) died due to cancer progression.

ECAPA is a rare but potentially life-threatening condition that requires timely surgical intervention. The findings of this study suggest that reconstructive surgery can be an effective treatment, often resulting in favorable long-term outcomes. Further studies with larger cohorts and longer follow-up are needed to optimize management strategies and compare surgical vs endovascular approaches.