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132
31 Open Repair oftheSuperior Mesenteric Artery Aneurysm
Discussion
The most common type of superior mesenteric
artery aneurysm is mycotic, secondary to bacterial endocarditis [1]. Atherosclerotic aneurysms
in this location are rare. Superior mesenteric
artery aneurysms though uncommon should be
treated urgently to prevent rupture and ischemic
and embolic complications [2]. Male patients and
patients with very non-calcied aneurysms are at
a greater risk of rupture [2].
Clinical diagnosis of a mesenteric arterial
aneurysm is difcult, and the diagnosis is usually
suggested by roentgenograms of the abdomen
CT imaging selective arteriography in useful
planning of endovascular or open repair. Of the
65 cases reported by DeBakey and Cooley, 63%
were mycotic, 14% were syphilitic, and 23%
were of unknown origin [1].
Operation is indicated for this condition, as one
half of the superior mesenteric artery aneurysms,
if left untreated, will spontaneously rupture [2]. In
most cases, it is not necessary to restore arterial
continuity after excision of aneurysm, since its
slow occlusion with clot usually promotes the
development of an extensive collateral circulation
[2]. However, the patient in this report had a partial
celiac axis occlusion, and the pancreaticoduodenal
collateral ow was reversed, resulting in a steal of
blood from the mesenteric circulation. Since the
bowel showed some discoloration, the jejunal
artery was anastomosed to the side of the superior
mesenteric artery after excision of the aneurysm.
The small intestine regained its normal color.
Endovascular repair with stent graft (balloonexpandable stent graft) has been described in highrisk patients [3].
References
1. Hans SS, Gordon M, Lee PT. Saccular atherosclerotic
aneurysm of the superior mesenteric artery. Arch Surg.
1977;112:854.
2. Stone WM, Abbas M, Cherry KJ, Fowl RJ, Gloviczki
P. Superior mesenteric artery aneurysms: is presence an indication for intervention? J Vasc Surg.
2002;36:234–7.
3. Schweigert M, Adamus R, Stadhuber RJ, Stein
HJ.Endovascular stent graft repair of a asymptomatic
superior mesenteric artery aneurysm. Ann Vasc Surg.
2011;25:841e5–8.
Part IX
Resection of Carotid Body Tumor
Resection ofaMalignant Carotid
Body Tumor withCarotid
Artery Resection
32
Physical Examination
A 39-year-old male was presented to his family
physician in 1999 with a mass in the right neck
just below the angle of the mandible. The patient
was referred to general surgery for possible cervical lymph node biopsy. During the biopsy, the
general surgeon encountered excessive bleeding. He closed the incision and referred the
patient to vascular surgery. CT scan of the neck
showed a large vascular mass at the right carotid
Fig. 32.1 Carotid
arteriogram showing
hypervascular carotid
body tumor
bifurcation consistent with carotid body tumor.
The patient’s main complaints were discomfort
from the mass and episodes of coughing on
turning the neck.
Procedure
He underwent selective carotid arteriography
(Fig. 32.1) and embolization of the external
carotid artery in preparation for its excision.
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_32
135
136
Fig. 32.2 Coil embolization of external carotid artery
32 Resection ofaMalignant Carotid Body Tumor withCarotid Artery Resection
External carotid artery was selectively cannulated along with its branches (Fig. 32.2). The
coils were placed in the proximal maxillary
artery, facial artery, and ascending pharyngeal
and occipital artery to achieve complete external
carotid artery occlusion. Gel-form particles were
placed in the superior thyroid artery. In addition,
PVA particles were also directed toward the vascular tissue. Under general anesthesia, the
patient underwent excision of a large carotid
body tumor via oblique neck incision. Dissection
planes were difcult because of recent neck surgery. Common carotid artery was controlled in
the inferior portion of the neck, and a silastic
vessel loop was passed. External carotid artery
was exposed and looped with vessel loop.
Internal carotid artery was carefully mobilized
along with mobilization of the hypoglossal and
vagus nerves. The hypoglossal nerve was looped
with vessel loop. An attempt to separate the
carotid body tumor from the adventitial plane of
the carotid bifurcation was difcult, and it was
decided to perform tumor resection along with
resection of the distal common carotid and proximal internal carotid artery and ligation of the
external carotid artery following systemic heparinization. It is to be noted that two rubbery
lymph nodes which measured 2.7 × 1.4cm were
removed with the specimen. The specimen itself
measured 3cm long bifurcated artery, 2cm segment of external carotid artery, and 2.5 cm segment of internal carotid artery. The excised mass
measured 3 × 2.5 × 2cm.
After the resection of the mass, a non-reversed
greater saphenous vein which was harvested
from the groin and upper thigh was used as an
interposition graft. Completion arteriogram
showed satisfactory result. Final pathological
diagnosis was metastatic paraganglioma into one
lymph node. A section of the carotid body tumor
showed histological features suggestive of paraganglioma with nuclei which were moderately
pleomorphic with increased mitosis. In addition,
there was evidence of recent and old hemorrhage
with foci of necrosis. The reticulin special stain
showed distinct clustering of the neoplastic cells
with variation in size of the cell nests.
The postoperative course was uneventful,
except for the development of temporary hoarseness of the voice. He subsequently saw an ENT
surgeon who diagnosed vocal cord weakness on
the right side which improved over the ensuing 3
months. The patient was referred to medical
oncology for further management of malignant
carotid body tumor, and he received radiation
therapy. However, the patient died 10 years later
from widespread metastatic paraganglioma.
Discussion
Carotid body tumor is more prevalent in patients
who are exposed to chronic hypoxemia including
high altitudes, smoking, and chronic obstructive
pulmonary disease. The majority of cases are
Discussion
137
sporadic; however approximately 10% occur
along familial lines [1–5]. Carotid body tumors
typically splay the carotid bifurcation and,
depending on their size, can encapsulate the
external or internal carotid artery or both. With
carotid duplex imaging, a hypervascular mass
with low ow resistance is demonstrated. Carotid
arteriography, CTA, or MRA best denes the
relationship of the tumor to the carotid bifurcation and location of the cranial nerves. The bulk
of the tumor is generally located at and more
often deep to the bifurcation and can extend over
the common carotid artery proximally to the
bifurcation. These tumors are slow growing with
a reported median double time of 4.2years [5].
Carotid body tumors are usually extremely vascular and secrete catecholamines on rare occasions and are usually benign. When malignant
(6–12.5%), carotid body tumors metastasize to
local lymph nodes [2, 5]. Metastasis to the liver,
lung, and bone does not occur in more than 5% of
cases [2, 5].
Preoperative embolization of carotid body
tumor is controversial [6]. Since these tumors are
highly vascular, selective embolization of the
ascending pharyngeal branch of the external
carotid artery to reduce intraoperative bleeding is
recommended. Many retrospective studies demonstrated no difference in blood loss or perioperative morbidity between embolized and
non-embolized patients with carotid body tumors.
Others have found reduced intraoperative
bleeding after embolization of tumors of more
than 3 cm diameter. Preoperative embolization
procedure may result in stroke due to embolization of the particles into cerebral circulation. If
preoperative embolization is decided, expeditious surgical resection should be performed
preferably within 24 hours and no later than
48hours to avoid additional surgical difculties
from inammatory reaction.
Injury to the cranial nerves, stroke, pseudoaneurysm, and death are uncommon complications
of carotid body tumors [1–5]. Baroreex failure
is an uncommon but important complication following bilateral carotid body tumor resection [5].
It should be suspected with the development of
tachycardia hypotension 24–72hours following
resection of the tumor. Cranial nerve injury is the
most common complication of carotid body
tumor and may occur up to 24% in contemporary
series. Most commonly injured cranial nerves
include the vagus and hypoglossal nerve [5].
Deep retraction of the mandible may result in
injury to marginal mandibular branch of the
facial nerve [5].
Following exposure of the common carotid
artery in the lower neck, the dissection should
proceed cephalad. Early identication of the
vagus nerve is important. Injuries to the cranial
nerve increase with the size of the carotid body
tumor and have been reported in up to 24% in
contemporary series. The dissection plane is carried out in the subadventitial plane with the use
of bipolar cautery. This avascular plane between
the tumor and the media was described as the
white line by Gordon-Taylor. Carotid body
tumors’ blood supply is primarily from the external carotid artery, and therefore the use of thrombin or regenerated cellulose helps in control of
surface bleeding. If the patient did not undergo
preoperative embolization of the external carotid
artery, it should be ligated during the earlier part
of the operation, thus decreasing overall bleeding
and facilitate dissecting the tumor from the internal carotid artery.
An internal to external carotid dissection
technique has also been described. This is performed by beginning the dissection from the
white line on the common carotid artery and
then dissecting the tumor free of the internal
carotid artery with dissecting scissors. The
external carotid artery is the last artery to be dissected. The advantage of this technique includes
shorter dissection time. Some authors have
advocated a cranial to caudal method of carotid
body tumor resection. This approach is based on
the course of ascending pharyngeal artery which
is considered to be a major source of blood supply to the tumor. Each approach has its own
advantage and disadvantages, and it is up to the
individual surgeon to know their skill set and
choose the approach which is most likely to
decrease the morbidity.
138
32 Resection ofaMalignant Carotid Body Tumor withCarotid Artery Resection
References
1. Pacheco-Ojeda LA. Carotid body tumor: surgical
experience in 215 cases. Jr Cranio- Maxillo– Facial
Surg. 2017;45:1472–7.
2. Hinojosa CA, Ortiz-Lopez LJ, Anaya–Ayalo JE,
Orozco–Sevilla V, et al. Comparison of retrocarotid
and caudocranial dissection technique for the surgical treatment of carotid body tumors. J Vasc Surg.
2015;62:958–64.
3. Davila VJ, Chang JM, Stone WM, Ford RJ, et al.
Current surgical management of carotid body tumors.
J Vasc Surg. 2016;64:1703–10.
4. Kim GY, Lawrence PF, Moridzadeh RS,
Zimmerman K, etal. New predictors of complications in carotid body tumor resection. J Vasc Surg.
2017;65:1673–9.
5. Davis FM, Obi A, Osborne N.Carotid body tumors.
In: Hans SS, editor. Extracranial carotid and vertebral artery disease. Cham: Springer; 2018.
p.253–60.
6. Power AH, Bover TC, Kasperbauer J, Link MJ,
et al. Impact of pre-operative embolization on
outcomes of carotid body resection. J Vasc Surg.
2012;56:979–89.
Resection ofaLarge Carotid Body
Tumor withMandibular
Subluxation
History andPhysical Examination
A 52-year-old male with history of hypertension came to the emergency room with vague
neurological symptoms. A CTA of the head and
neck was obtained which showed a large right
carotid body tumor. The upper extent of the
tumor was of the junction of C1 and C2 vertebral body (Fig. 33.1). The patient also underwent catheter- based carotid and cerebral
angiography which showed a very large vascular carotid body tumor extending toward the
base of the skull. The tumor was 5.3 cm in
length and 4.8cm in transverse diameter. As the
tumor was large and was extending toward the
base of the skull, it was decided to perform
mandibular subluxation.
Procedure
Under nasotracheal intubation, mandibular subluxation was performed by a maxillofacial surgeon. EEG monitoring and SSEP (somatosensory
evoked potentials) were performed as well. A
slightly curved hockey stick incision was made
behind the lobule of the ear extending along the
anterior border of the sternomastoid. In the inferior portion of the neck, the carotid sheath was
opened, silastic vessel loop was passed to the
common carotid artery, and the vagus nerve was
33
Fig. 33.1 Large carotid body tumor
preserved. In the cephalad portion of the dissection, the posterior belly of the digastric muscle
was exposed, and the hypoglossal nerve could be
seen coursing over the large carotid body tumor
(Fig. 33.2). The hypoglossal nerve was looped
with a silastic loop.
The dissection was started at the carotid
bifurcation, and the branches of the external
carotid artery were carefully exposed and
ligated. Bipolar cautery was used. Silastic loop
doubled on itself was passed around the external
carotid artery. Initial dissection was started
behind the external carotid artery to expose the
medial wall of the tumor. The tumor was carefully separated from the pharyngeal wall. The
tumor was then mobilized beneath the hypoglossal nerve, and all the feeding branches were
carefully controlled by silk ties. Dissection was
done along the lateral wall of the carotid artery.
There was a small amount of bleeding from the
internal carotid artery and arterial wall which
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_33
139
140
Fig. 33.2 CTA showing extent of large carotid body tumor
33 Resection ofaLarge Carotid Body Tumor withMandibular Subluxation
was controlled with a transversely placed suture
of 7-0 cardiovascular Prolene. The internal
carotid artery diameter was slightly smaller than
average, possibly from compression due to a
large carotid body tumor. As the dissection was
proceeding, there were ischemic changes in the
EEG, and one could not palpate the pulse in the
internal carotid artery. The patient was given
10,000units of heparin by the anesthesia. The
common carotid artery was controlled, and an
incision was made in the internal carotid artery
extending to the common carotid artery, and a
grayish-white platelet thrombus was removed
with brisk backbleeding from the internal
carotid artery.
At this stage, a Sundt shunt (3 × 4mm) was
inserted with the smaller end into the internal
carotid artery followed by larger end into the
common carotid artery. The ow from the shunt
was conrmed with Doppler probe. A bovine
pericardial patch was sutured to the internal
carotid artery and to the common carotid artery.
A completion arteriography was performed
through the branches of the external carotid
artery with a catheter to the common carotid
artery which showed satisfactory lling of the
anterior cerebral artery and superior branch of the
middle cerebral artery but poor lling of the
branches of inferior branches of the middle cerebral artery (Fig.33.3). There was some irregularity at the site of the patch grafting, but no denite
stenosis could be seen on the completion arteriogram (Fig. 33.4). The remaining tumor was
removed, and in the recovery room, the patient
was found to have weakness of the left upper
extremity. He required ventilatory support and
was seen by an interventional neurosurgeon, but
it was decided since the occlusion was in the distal branches of the middle cerebral artery (inferior branch) that mechanical retrieval of emboli
was not to be recommended. The patient underwent non-contrast MRI brain which showed in
fact in the distribution of the inferior branch of
the middle cerebral artery. The patient developed
deep venous thrombosis of the right lower
extremity and had inferior vena cava lter placement because anticoagulation was thought to be
contraindicated.
The patient remained on ventilatory support
with a nasogastric tube. The patient subsequently underwent tracheostomy and PEG tube
placement. He continued to improve over the
Discussion
141
Fig. 33.3 Carotid arteriography showing hypervascular carotid body tumor
next 3 months. He was ambulating; however he
had weakness of the left upper extremity (grade
stockings. Patient’s compliance for his medical
care has been poor.
3/5). His main difculty was pain and diminished range of movement in the left shoulder
from lack of use although he was receiving
Discussion
physical and occupational therapy. The patient
was non- compliant. The patient continued to
make improvement and was subsequently discharged home from an extended care facility
This tumor represented Shamblin type II tumor.
Shamblin classication of carotid body tumors
includes:
after 3 months of stay.
The patient was admitted to a correctional
facility on account of illegal drug possession
charge. The patient was last seen in January 2020
with minimal weakness of the left upper extremity. Attempted retrieval of an IVC lter was
unsuccessful on Jan 13, 2020, as IV cavagram
showed chronically occluded IVC. The patient
had minimal swelling of both lower extremities
and was recommended to wear compression
• Type I – tumors are small in location of the
carotid bifurcation and can be removed without difculty.
• Type II – tumors are large, splay the carotid
bifurcation, but do not circumferentially
encase the carotid arteries.
• Type III – tumors are large and encapsulate
the internal and external carotid arteries and
often adhere to adjacent cranial nerves.
142
33 Resection ofaLarge Carotid Body Tumor withMandibular Subluxation
In this patient, the extent of the dissection
(caudal to cranial) and the extent of the large
carotid body tumor probably lead to kinking of
the internal carotid artery during manipulation
and thrombosis which was diagnosed by EEG
monitoring. Risk factors for stroke during
removal of carotid body tumor include excessive
manipulation of tumor with possible kinking or
stenosis from the repair of the internal carotid
artery. Full-dose heparinization prior to manipulation of the internal carotid artery, a traumatic
vascular clamp, and shrink is required (based on
low stump pressure or EEG/SSEPs changes). In a
recent analysis of 500 contemporary cases, intraand postoperative stroke following carotid body
tumor occurred in about 4% of cases. Mortality
has been reported to be around 1% (30-day mortality) [1].
Reference
Fig. 33.4 Operative carotid arteriogram showing irregu-
larity at the site of carotid patch and absent lling of the
inferior branches of the middle cerebral artery with absent
ow in the external carotid artery
1. Davis FM, Obi A, Osborne N. Carotid body tumors.
In: Hans SS, editor. Extracranial carotid and vertebral disease – contemporary management. Cham:
Springer; 2018. p.253–60.