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29 Open Repair ofLarge Symptomatic Subclavian/Axillary Artery Aneurysm withPartial Claviculectomy
118
Fig. 29.2 CTA showing large subclavian and axillary artery aneurysms with tortuosity
of the sternocleidomastoid, phrenic nerve was
mobilized and preserved, and scalenus anticus
muscle was divided at its insertion. Left subclavian artery proximal to the aneurysm was mobilized, and a silastic loop was doubly passed.
Through the infraclavicular incision, the dissection plane was developed between the sternal
and clavicular head of the pectoralis major muscle. The pectoralis minor muscle at its insertion
was divided, and axillary artery was exposed
and looped with a silastic loop. It had extreme
tortuosity. The middle portion of the clavicle
Fig. 29.3 Postoperative CTA showing patent interposi-
tion graft (within arrows) and partial claviculectomy
was divided with oscillating podiatry saw in
order to have an adequate tunnel for the passage
of the prosthetic graft. Following systemic heparinization, an 8mm INTERING® (W.L. Gore,
Newark, DE) PTFE graft was interposed using
6-0 cardiovascular polypropylene suture
(Ethicon Inc., Somerville, NJ) for proximal and
distal anastomosis following resection of the
aneurysm which was lled with recent thrombus. Postoperative CTA showed patent subclavian/axillary arterial reconstruction (Fig.29.3).
The patient had excellent postoperative results
with minimal restriction of overhead abduction
and restoration of normal ow to the left upper
extremity. However, patient developed mild discomfort 3 months following open repair, and
upper extremity arterial Doppler showed wrist
brachial index of 0.4 with probable occlusion of
interposition graft. In the following 3 months,
wrist brachial index improved to 0.6 with complete resolving symptoms as a result of collateral ow.
References
Discussion
Aneurysms of the subclavian artery are uncommon and are usually located in the intrathoracic
segment of the artery. Atherosclerosis is the most
common course followed by mycotic etiology
[1–3]. Poststenotic dilation of the subclavian
artery with thoracic outlet syndrome associated
with cervical rib is another common course.
Marfan syndrome, Behçet’s disease, cystic medical necrosis, and congenital etiology are uncommon causes of subclavian artery aneurysm.
Diagnosis is suspected on a plain chest X-ray and
conrmed by CT angiography. Aneurysms of the
third portion of the subclavian artery may present
as a pulsatile supraclavicular mass. Most subclavian aneurysms are asymptomatic; however, the
patient may develop acute thrombosis, distal
embolization, and rarely rupture of the aneurysm.
In spite of the increasing interest in endovascular
repair of subclavian artery aneurysm, open repair
of subclavian artery aneurysm is usually the preferred treatment modality. The patient described
in this report underwent open repair of the aneurysm because of its extensive tortuosity of the
axillary artery and recent thrombus. There was
minimal disability from partial removal of the
clavicle (Fig.29.4). In a patient with subclavian
artery aneurysm secondary to thoracic outlet syndrome, rst rib resection along with removal of
the cervical rib if present should be performed in
the presence to partial claviculectomy [4].
119
Fig. 29.4 Postoperative image showing minimal func-
tional limitation of the left upper extremity following partial claviculectomy
References
1. Dougherty MJ, Calligaro KD, Saverserp, De
Laurentiis DA.Atherosclerotic aneurysm of the intra-
thoracic subclavian artery. A case report and review of
the literature. J Vasc Surg. 1995;21:521–9.
2. Stahl RD, Lawerence PF, Bhirangi K.Left subclavian
artery aneurysm: two cases of rare congenital etiology.
J Vasc Surg. 1999;29:715–8.
3. Salo JA, Ala Kulju K, Heikkinen L, Bondestam
S, Ketonen P, Luostor. Diagnosis and treatment of
subclavian artery aneurysms. Eur J Vasc. 1990;4:
271–4.
4. Vemuri C, McLaughlin LN, Abuirqeba AA,
Thompson RW. Clinical presentation and manage-
ment of arterial thoracic outlet syndrome. J Vasc Surg.
2017;65:429–39.
Part VII
Open Repair of Carotid Aneurysm
Repair ofExtracranial Carotid
Artery Aneurysm withMandibular
Subluxation
30
Physical Examination andHistory
A 52-year-old female with cerebral palsy and seizure disorder presented to the emergency room
with a pulsatile mass in the right side of the neck.
Medical history included frequent falls.
Associated medical conditions included hypertension and dyslipidemia. CTA of the neck
showed a 3.0 × 2.5cm right internal carotid artery
aneurysm (Fig. 30.1). Carotid/cerebral arteriography via the femoral artery approach showed a
large internal carotid artery aneurysm with
marked tortuosity of the internal carotid artery
and lling of both anterior and middle cerebral
arteries (Fig.30.2).
Procedure
Under general anesthesia with nasotracheal intubation, a 3.2 mm Steinmann pin was threaded
through the buccal and lingual surfaces of the
mandible, and another pin was placed in the left
maxilla. The pins were placed at divergent angles
to facilitate stabilization of the intraosseous skeletal wire. The Steinmann pins were divided in
such a way that approximately a half-inch length
remained exposed beyond the tissues. The mandible was passively subluxated, deviating the
chin to the left. Intramaxillary xation was
achieved across the two threaded Steinmann pins
utilizing a 22-gauge-xation wire (Fig. 30.3).
The cut ends of the pin were coated with heavy
bodied dental registration material to protect the
soft tissues with a supplemental injection of the
bite registration material between the dentition to
facilitate additional protection. Oral gauze
sponges were wrapped in umbilical tape and
were rolled and packed into the oral cavity and
skeletal pin xation sites to assist in intraoral
tamponade. EEG monitoring was performed. An
oblique skin incision was made just behind the
lobule of the ear extending to the lower third of
the neck. The carotid sheath, common carotid
artery, and carotid bifurcation were exposed. The
vagus and hypoglossal nerves were preserved.
Proximal control of the common and external
carotid arteries was obtained with silastic surgical loops. The proximal internal carotid artery
was redundant (Figs. 30.4, 30.5, and 30.6).
Dissection was done up to the mastoid process,
and the posterior belly of the digastric muscle
was divided. The aneurysm was opened following systemic heparinization. There were no
changes in the EEG after common carotid artery
clamping. An arterial dilator (3.0 mm Pilling®
[Teleex, Wayne, PA]) was inserted distally to
obtain intraluminal control. A Yasargil® clip
(Aesculap Inc., Central Valley, PA) was applied
distal to the aneurysm. Following removal of the
arterial dilator, the internal carotid artery aneurysm was opened and resected, and a spatulated
end-to-end anastomosis was performed with
transposition of the distal internal carotid artery
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_30
123
124
30 Repair ofExtracranial Carotid Artery Aneurysm withMandibular Subluxation
Fig. 30.1 CTA showing large right internal carotid aneurysm
Fig. 30.2 Carotid arteriogram showing right internal
carotid aneurysm
anterior to the hypoglossal nerve. Heparin was
reversed with protamine. Steinmann xation was
removed, and the patient extubated after regaining consciousness.
Discussion
Extracranial carotid aneurysm is a rare vascular
entity comprising 0.1–1.9% of all carotid opera-
Fig. 30.3 Intraoral (maxillary and mandibular) wiring in
preparation for mandibular subluxation
tions. Endovascular or open surgical repair of
extracranial carotid aneurysm requires an
approach determined by its etiology, size, location, and morphology of the distal internal carotid
artery [1, 2]. Cerebral ischemia in the form of
stroke or transient ischemic attack is the most
common presenting symptom [1–5].
Percutaneous placement of a covered stent (stent
graft) is a feasible option in some carotid pseudoaneurysms, but surgical repair remains the
Discussion
125
Fig. 30.6 Spatulated end-to-end anastomosis. (Reprinted
with permission from Springer: Extracranial Carotid and
Vertebral Artery Aneurysms by Hans SS. ©2018)
Fig. 30.4 Diagrammatic representation of the carotid
artery aneurysm and surrounding XII and X nerves.
(Reprinted with permission from Springer: Extracranial
Carotid and Vertebral Artery Aneurysms by Hans SS.
©2018)
Fig. 30.5 Resection of the aneurysm. (Reprinted with
permission from Springer: Extracranial Carotid and
Vertebral Artery Aneurysms by Hans SS. ©2018)
main treatment modality for extracranial carotid
aneurysms [2]. Exposure of the aneurysm and
aneurysm resection may be difcult in large
aneurysms extending toward the base of the skull.
Obtaining distal exposure by extending the skin
incision to the earlobe and elevation of the lower
pole of the parotid gland and exposure of the
facial nerve may be helpful in some cases [1]. We
are reporting on repair of extracranial carotid
aneurysm aided by mandibular subluxation.
Carotid artery aneurysms are caused by arterial dysplasia, atherosclerosis, trauma, and dissection [1–4]. Post-carotid endarterectomy
pseudoaneurysms are uncommon. Other rare
causes of carotid artery aneurysms include neck
radiation, neurobromatosis, Marfan syndrome,
Behçet’s syndrome, and Takayasu arteritis [1].
The majority of carotid artery aneurysms are
asymptomatic, but two-thirds of patients present
with transient ischemic attack or stroke [1–4].
Local pressure symptoms such as hoarseness,
dysphagia, tongue deviation, and Horner’s syndrome may be present in patients with large
carotid artery aneurysms [1–4].
Duplex ultrasound is a simple, non-invasive
tool for diagnosing carotid artery aneurysms, but
it is signicantly less useful for diagnosing distal
126
30 Repair ofExtracranial Carotid Artery Aneurysm withMandibular Subluxation
internal carotid artery aneurysms. CT angiography is an extremely helpful diagnostic modality
for dening the anatomical relationship of the
aneurysm and greatly aids in treatment planning.
Carotid/cerebral arteriography is helpful in
assessing intracranial circulation [1–4].
Endovascular therapy with a covered stent via the
femoral artery approach can be useful for carotid
artery pseudoaneurysms, but, due to the extreme
redundancy and relatively small size of the internal carotid artery, stent graft is usually not feasible in the majority of patients with extracranial
carotid aneurysms. Surgical repair is indicated in
either symptomatic aneurysms or in asymptomatic aneurysms >2.0 cm in diameter [1–4].
Untreated carotid artery aneurysms have signicant morbidity and mortality (stroke rate is
30–50%; mortality is 70%) [1–4]. Ligation of an
internal carotid artery aneurysm is only recommended when no surgical reconstruction is feasible and stump pressure is high without changes
in EEG on carotid clamping [1–3]. The most
common type of carotid reconstruction following
resection of an aneurysm is with interposition
vein graft, although expanded PTFE graft or
Dacron graft may be an alternate conduit in some
instances [1–4]. Vein grafts do have a propensity
for postoperative dilatation or stenotic changes
[1, 2]. The tortuosity of the internal carotid artery
(as in the present case) may enable the surgeon to
perform primary end-to-end anastomosis after
resection. Saccular carotid artery aneurysms can
be treated with open aneurysm resection with
patch closure [2].
Many extracranial carotid aneurysms can be
treated with nasotracheal intubation without
resorting to mandibular subluxation or mandibular osteotomy. High exposure is obtained by
resection of the stylohyoid process and the tip of
the mastoid process with division of the posterior
belly of the digastric and stylohyoid muscles.
The use of an indwelling shunt is necessary only
in patients with low stump pressure (>40mmHg)
or ischemic changes on the EEG.
Surgical repair of an extracranial carotid aneurysm is associated with a perioperative stroke
rate of 6–9% and a mortality rate of 1–2% [1–4].
The reported incidence of cranial nerve palsy can
be as high as 44% [1–4]. Because of the high
morbidity, endovascular treatment with a covered
stent is suggested as an alternate, but carotid stent
collapse and distal embolization have been
reported following endovascular therapy [1].
Invited Commentary fromKaren
J.Ho, MD
Extracranial carotid aneurysms are rare, accounting for less than 1% of all arterial aneurysms [6],
and repair of these aneurysms comprises approximately 0.2–5% of all carotid procedures depending on the institution [2, 7]. Sir Astley Cooper at
Guy’s Hospital in London was the rst to attempt
treatment of a carotid artery aneurysm in 1805.
He described successful ligation of the common
carotid artery, but the patient died 48hours later.
In 1808, he performed a similar procedure for a
painful internal carotid aneurysm in a 50-yearold male who survived the operation and lived
until 1822 [8]. In 1952, Dimtza described two
cases of carotid artery aneurysm excision followed by end-to-end reconstruction [9]. In 1959,
Beall etal. described the use of prosthetic graft
material for carotid reconstruction [10].
Management of carotid aneurysms ideally consists of surgical repair, since conservative therapy
(anticoagulation) [11–13] and ligation [14–16]
are accompanied by substantial neurologic
morbidity.
True extracranial carotid aneurysms are most
commonly atherosclerotic and affect the bifurcation or proximal internal carotid artery, while the
mid- and distal internal carotid arteries are the
next most common sites [17]. As mentioned in
this chapter, carotid pseudoaneurysms can be
secondary to trauma or patch degeneration or
infection following carotid endarterectomy and
range in prevalence between 12 and 80% [18].
Extracranial carotid aneurysms have been
classied according to the affected segment,
which can be helpful for surgical planning: Type
I are isolated to the internal carotid artery, Type II
involve the internal carotid artery and the bifurcation, Type III are aneurysms of the carotid bifurcation, Type IV are aneurysms of the internal and
References
127
common carotid artery, and Type V are isolated
aneurysms of the common carotid artery [19].
Exposure of the distal internal carotid artery
for control of normal artery distal to the aneurysm can pose a particular challenge. While retrostyloid exposure of the carotid can be performed
by a vascular surgeon, a collaborative effort with
anesthesia, neurosurgery, and/or otolaryngology
is necessary for more distal exposure, as it can
involve nasotracheal intubation and mandibular
subluxation, potentially in combination with
mastoidectomy and division of the external auditory canal [3, 20]. The favorable neurologic
results of carotid reconstruction justify this
aggressive approach for a rare and challenging
problem.
References
1. Bakoyiannis C, Georgopoulos S, Tsekouras N,
Klonaris C, Skrapari I, Papalambros E, Bastounis
A. Surgical management of extracranial internal
carotid aneurysms by cervical approach. ANZ J Surg.
2006;76:612–7.
2. El-Sabrout R, Cooley D. Extracranial carotid artery
aneurysms; Texas heart institute experience. J Vasc
Surg. 2000;31(4):702–12.
3. Rosset E, Albertini JN, Magnan PE, Ede B,
Thomassin JM, Brancherau A.Surgical treatment of
extracranial internal carotid aneurysms. J Vasc Surg.
2000;31(4):713–23.
4. Painter T, Hertzer N, Beven E, Ohara P.Extracranial
carotid aneurysms: a report of six cases and review of
the literature. J Vasc Surg. 1985;2(2):312–8.
5. Rhodes EL, Stanley J, Hoffman G, Cronewett J, Fry
W. Aneurysms of extracranial carotid arteries. Arch
Surg. 1976;111(4):339–43.
6. Welling RE, Taha A, Goel T, etal. Extracranial carotid
artery aneurysms. Surgery. 1983;93(2):319–23.
7. Moreau P, Albat B, Thevenet A.Surgical treatment
of extracranial internal carotid artery aneurysm. Ann
Vasc Surg. 1994;8(5):409–16.
8. Cooper A.Account of the rst successful operation,
performed on the carotid artery for aneurism, in the
year 1808: with the postmortem examination in 1821.
In: GHaB B, James P, editors. Guy’s hospital reports,
vol. 1. London; 1836. p.53–8.
9. Dimtza A.Aneurysms of the carotid arteries; report of
two cases. Angiology. 1956;7(3):218–27.
10. Beall AC Jr, Crawford ES, Cooley DA, De
BM. Extracranial aneurysms of the carotid artery.
Report of seven cases. Postgrad Med. 1962;32:93–102.
11. de Jong KP, Zondervan PE, van Urk H. Extracranial
carotid artery aneurysms. Eur J Vasc Surg.
1989;3(6):557–62.
12. Zwolak RM, Whitehouse WM Jr, Knake JE, et al.
Atherosclerotic extracranial carotid artery aneurysms.
J Vasc Surg. 1984;1(3):415–22.
13. Busuttil RW, Davidson RK, Foley KT, Livesay
JT, Barker WF. Selective management of extracranial carotid arterial aneurysms. Am J Surg.
1980;140(1):85–91.
14. McCollum CH, Wheeler WG, Noon GP, DeBakey
ME. Aneurysms of the extracranial carotid
artery. Twenty-one years’ experience. Am J Surg.
1979;137(2):196–200.
15. Leikensohn J, Milko D, Cotton R. Carotid artery
rupture. Management and prevention of delayed
neurologic sequelae with low-dose heparin. Arch
Otolaryngol. 1978;104(6):307–10.
16. Perret G, Nishioka H. Report on the cooperative
study of intracranial aneurysms and subarachnoid
hemorrhage. Section VI. Arteriovenous malformations. An analysis of 545 cases of cranio-cerebral
arteriovenous malformations and stulae reported
to the cooperative study. J Neurosurg. 1966;25(4):
467–90.
17. Fankhauser GT, Stone WM, Fowl RJ, etal. Surgical
and medical management of extracranial carotid
artery aneurysms. J Vasc Surg. 2015;61(2):389–93.
18. Kraemer CJK, Zhou W.Carotid aneurysm review. Int
J Angiol. 2019;28(1):17–9.
19. Attigah N, Kulkens S, Zausig N, et al. Surgical
therapy of extracranial carotid artery aneurysms:
long-term results over a 24-year period. Eur J Vasc
Endovasc Surg. 2009;37(2):127–33.
20. Alimi YS, Di Mauro P, Fiacre E, Magnan J, Juhan
C. Blunt injury to the internal carotid artery at the
base of the skull: six cases of venous graft restoration.
J Vasc Surg. 1996;24(2):249–57.
Part VIII
Open Repair of SMA Aneurysm
Open Repair oftheSuperior
Mesenteric Artery Aneurysm
History andPhysical Examination
A 42-year-old man had epigastric pain of 4
months duration. The pain was not related to eating and he had not lost weight. Physical examination was normal. Abdominal X-ray studies
showed curvilinear calcication at the level of
L1-2. Selective superior mesenteric arteriography demonstrated a saccular aneurysm of the
superior mesenteric artery near its origin
(Fig. 31.1). In addition, incomplete obstruction
of the celiac axis was shown by retrograde lling
of this vessel from the superior mesenteric artery
by an enlarged pancreaticoduodenal artery.
31
Procedure
He was operated through a midline incision.
There was a saccular aneurysm of the superior
mesenteric artery measuring 4 cm in diameter,
with two jejunal branches arising from it.
Proximal and distal control of the superior mesenteric artery and its jejunal branches was
obtained, and the aneurysm opened. The opened
wall of the aneurysm was thin and contained atheromatous plaques. The upper jejunal branch was
totally occluded, but the lower branch showed
brisk retrograde bleeding.
The aneurysm was excised, and the lower jeju-
nal arterial branch was anastomosed to the lateral
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_31
Fig. 31.1 Selective arteriography showing large superior
mesenteric saccular aneurysm
wall of the superior mesenteric artery (original
neck of the saccular aneurysm). Since the inferior
mesenteric artery was patent, no attempt was
made to deal with the celiac axis occlusion. The
patient’s postoperative course was uneventful.
The patient was seen 10 years later in satisfactory
condition.
131