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Chapter 14
Extracranial Carotid Artery Aneurysms
SachinderSinghHans
Aneurysms of the extracranial carotid artery are rare and account for less than 1%
(0.3–0.6%) of all arterial aneurysms. The aneurysm is most often located in the
common carotid artery (CCA) and the internal carotid artery (ICA) junction. The
mid to distal ICA is the second most common location of such aneurysms.
Atherosclerosis is by far the most common cause, but bromuscular dysplasia (dysplastic) trauma and prior surgical intervention, congenital anomaly and infection
can result in the formation of true carotid aneurysm as well as pseudoaneurysm.
Extracranial carotid aneurysm can be fusiform or saccular. Fusiform carotid
artery aneurysms are often bilateral and degenerative in etiology and are located
near the carotid bifurcation. Saccular aneurysms are more often unilateral and occur
in the midsegment in the ICA in the neck. Pseudoaneurysm results from the disruption of the vessel wall, usually occurring at the site of patch grafting secondary to
infection of the prosthetic patch, arterial dissection, and/or blunt/penetrating carotid
artery trauma.
Patient may present with asymptomatic neck mass or symptoms of TIA or stroke
secondary to embolization. Large aneurysms may cause compression of the surrounding nerves and upper aerodigestive tract. Dysphagia, headache, occipital pain,
and retro-orbital pain may occur. Patient may present with Horner syndrome or
voice hoarseness. Tracheal compression from ruptured carotid aneurysm can result
in airway compromise.
On physical examination, a pulsatile mass in the neck may be palpable. Patient
should undergo carotid duplex study followed by CT angiography of the neck.
Catheter-based carotid/cerebral arteriography is often helpful in evaluating crossover intracranial circulation in the event: ICA ligation may become necessary in
patients with inaccessible location of the aneurysm.
S. S. Hans (*)
Vascular and Endovascular Services, Henry Ford Macomb Hospital,
Clinton Twp, MI, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_14
163
164
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S. S. Hans
Operative Repair
The primary aim of the treatment is resection of the aneurysm and maintaining the
ow through the ICA.The incision in the neck is like the one used for carotid endarterectomy (see Chap. 17). The internal jugular vein is mobilized after ligating and
dividing of its branches. The hypoglossal vagus nerve and, in patiens with aneurysms extending cephalad, glossopharyngeal nerve are preserved if the dissection
extends close to the stylohyoid muscle and the stylohyoid process.
During preoperative planning, if there is any concern for the necessity of exposure of the distal ICA, a mandibular subluxation should be considered, and patient
should have nasotracheal intubation and have an ENT surgeon or a maxillofacial
surgeon available for performing the subluxation (Figs.14.1 and 14.2). Mandibular
subluxation helps in obtaining distal exposure, which otherwise, may not have been
be possible in patients with large aneurysms extending towards the base of the skull.
Fig. 14.1 Intraoral wiring
for mandibular subluxation
Fig. 14.2 Nasotracheal
intubation with mandibular
subluxation
14 Extracranial Carotid Artery Aneurysms
Fig. 14.3 Internal carotid
artery aneurysm and its
relationship to the vagus
nervewith Hypoglossal
nerve seen cephaled near
the two retractors
165
Intraoperative shunting is rarely necessary. EEG monitoring, median nerve
evoked potentials, and back pressure of the ICA are necessary if shunt placement is
required. Heparin is administered intravenously by the anesthesia to keep the ACT
250–300s. After mobilization of the carotid bifurcation in patients with mid-ICA
aneurysms, the external carotid artery (ECA) is looped with a silastic loop and is
pulled with the tape caudally. The internal carotid artery with the aneurysm is very
carefully mobilized, and this mobilization helps in obtaining distal exposure of the
ICA (Fig.14.3).
Small aneurysms with redundant ICA can be resected in an end-to-end anastomosis performed using 6-0 or 7-0 cardiovascular polypropylene suture (Ethicon,
Somerville, NJ). The internal carotid artery should be spatulated so that an end-toend (functional side-to-side) anastomosis is performed (Figs.14.4 and 14.5).
Partial resection of the aneurysmal wall with patch angioplasty using prosthetic
patch is another option available in patients with anatomically high lesions. All the
thrombotic material in the aneurysm should be carefully removed in such instances.
In most patients, the anterior wall of the aneurysm should be resected to prevent
injury to the nerves lying posterior to the aneurysm.
In some patients, interposition grafting may be necessary A synthetic graft
(ringed PTFE WL Gore, Newark, DE) should be considered. A greater saphenous
vein or supercial femoral artery harvested from the groin and upper thigh can also
be used as a conduit following resection of the aneurysm. In mycotic aneurysms
involving CCA/ICA, autologous conduit is preferred. In patients with large extracranial ICA aneurysm extending to the base of the skull, ICA ligation may be the
166
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Fig. 14.4 Resected ICA
aneurysm
S. S. Hans
Fig. 14.5 Spatulated end
to end ICA anastomosis
following resection of ICA
aneurysm. Hypoglossal
nerve is placed behind
the ICA
14 Extracranial Carotid Artery Aneurysms
167
only option available for repair. Preoperative arteriography and intermittent balloon
occlusion of ICA at its origin should be performed to evaluate the cross circulation
in the circle of Willis. This treatment option is rarely necessary, as in most patients,
arterial reconstruction following resection of the carotid aneurysm is feasible.
Complications
The most common complication of carotid artery aneurysms repair is cranial nerve
injury. Perioperative stroke is the second common complication.
Chapter 15
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Subclavian Artery Aneurysm
MitchellR.Weaver
Presentation
Asymptomatic subclavian artery aneurysm may be found on physical exam as a
pulsatile mass or incidentally on an imaging study. Symptoms of subclavian aneurysms include upper extremity ischemia from distal thromboembolization, hemorrhage from rupture, or compressive symptoms. Compressive symptoms may include
brachial plexopathy, ipsilateral Horner’s syndrome, or dysphagia lusoria, which
may be seen with subclavian artery aneurysms developing at the origin of aberrant
right subclavian arteries (Fig.15.1a, b).
Several imaging modalities including computed tomography angiography
(CTA), magnetic resonance angiogram (MRA), and catheter-based digital subtraction angiography, which are available and may be of use in the diagnosis and management of subclavian artery aneurysms. In planning subclavian artery aneurysm
repair, imaging studies must dene the extent of the aneurysm and identify any
arterial disease proximal or distal to the aneurysm. CTA is the author’s preferred
imaging modality for this. Upper extremity segmental pressures and Doppler waveform analysis, along with digital photoplethysmography (PPG) are obtained to
objectively document physiologic limb perfusion in case of ischemia.
M. R. Weaver (*)
Henry Ford Hospital, Detroit, MI, USA
Wayne State University School of Medicine, Detroit, MI, USA
e-mail: mweaver1@hfhs.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_15
169
170
ab
Fig. 15.1 (a) Image demonstrating typical aortic arch anatomy. (b) Image demonstrating aortic
arch anatomy with aberrant right subclavian artery with aneurysm at origin
M. R. Weaver
Management
Given the rarity of subclavian artery aneurysms, the exact size at which asymptomatic aneurysm should be repaired is not clearly dened; however, the presence of
symptoms is an indication for repair. Aneurysms of the proximal subclavian artery,
which are intrathoracic such as those associated with an aberrant right subclavian
artery, prior to the development of endovascular therapies, required direct repair via
a left thoracotomy and aortic replacement. This operation would typically be preceded by a right carotid subclavian artery bypass or transposition (see Chap. 22). In
current practice, a hybrid approach is often used with performance of right carotid
subclavian artery transposition followed by deployment of a thoracic stent graft
(Fig.15.2). Given difculty in exposure of the subclavian artery secondary to the
bony structures around it, endovascular repairs with stent grafting have been increasingly utilized especially in emergent settings with hemorrhage (Fig.15.3a, b).
However, cases of aneurysms involving the more distal subclavian artery, especially those secondary to external compression as in arterial thoracic outlet, require
open repair. Open repair is required not only to the repair of the artery but also for
resection or repair of the compressive elements that led to the arterial injury, which
are typically cervical rib, anomalous rst rib, or clavicle. Most of these aneurysms
extend beyond the lateral border of the rst rib and thus are subclavian–axillary
aneurysms. Open repair of subclavian–axillary aneurysms associated with cervical
rib requires supra- and infraclavicular exposure (Fig.15.4).
ab
15 Subclavian Artery Aneurysm
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Fig. 15.2 Image
demonstrating hybrid
repair of aberrant right
subclavian artery aneurysm
with right carotid
subclavian transposition
and thoracic endograft
171
Fig. 15.3 (a) Digital subtraction angiogram demonstrating ruptured traumatic left subclavian pseudoaneurysm. (b) Digital subtraction angiogram following repair of pseudoaneurysm with stent graft
172
Fig. 15.4 Image
demonstrating sites of
supra- and infraclavicular
incisions for exposure of
subclavian and axillary
arteries
M. R. Weaver
Anatomy
The right subclavian artery arises from the innominate artery posterior to the sternoclavicular joint. Near the subclavian artery’s origin, the right recurrent laryngeal
nerve branches off of the vagus nerve, which is coursing anteriorly and wraps
around the subclavian artery to ascend in the neck. The subclavian artery from its
origin passes upward and then laterally behind the anterior scalene muscle, with the
subclavian vein coursing anterior to the anterior scalene muscle. The subclavian
artery then exits through the thoracic outlet between the clavicle and the rst rib
with the subclavian vein anterior and the brachial plexus posterior to the artery.
Once past the outer boarder to the rst rib, it becomes the axillary artery. Branches
of the subclavian artery include the vertebral artery, internal thoracic artery, thyrocervical trunk, costocervical trunk, and dorsal scapular artery. An exception to the
anatomy is cases of aberrant right subclavian arteries, which usually arise distally
and posteriorly on the aortic arch coursing posterior to the esophagus, which may
lead to compressive symptoms. The left subclavian artery typically is the last great
vessel to arise from the aortic arch, which st travels cephalad and then laterally
posterior to the anterior scalene muscle. The thoracic duct ascends in the chest
behind the aortic arch and left subclavian artery as it eventually courses anterior to
the anterior scalene muscle and drains in the venous system near the junction of the
left internal jugular and subclavian veins.
15 Subclavian Artery Aneurysm
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173
Open Repair
After general anesthesia is induced with the patient in a supine position, a rolled-up
sheet is placed underneath the patient’s shoulder and the table positioned with the
head and torso raised approximately 30°. The neck is extended and rotated slightly
to the contralateral side. The supraclavicular incision is made starting approximately 1cm lateral to the midline and continued laterally approximately 6–8 cm,
approximately 1–2 cm above the clavicle. The platysma muscle is divided with
cautery and aps are developed superiorly approximately 5cm and inferiorly to the
clavicle. The sternocleidomastoid muscle is mobilized along its lateral border, and
if necessary, the clavicular head of the sternocleidomastoid muscle is freed off at the
clavicle to allow for extended medial exposure. The omohyoid muscle is encountered and divided, furthering exposure of the anterior scalene fat pad. Starting on the
medial edge of the anterior scalene fat pad is separated from the internal jugular
vein and then its inferior border mobilized while carefully ligating all lymphatics as
they are divided. On the left side, care is taken not to injure the thoracic duct; however, if injured or divided, it is meticulously oversewn with ne monolament polypropylene suture. Once mobilized, the anterior scalene fat pad is retracted laterally
and superiorly.
The anterior scalene muscle is then exposed along with the phrenic nerve, which
runs lateral to medial, anterior to, and within the investing fascia of the muscle
(Fig.15.5). The nerve is carefully mobilized off the muscle, incising the fascia a few
millimeters on either side of it. The edges of the anterior scalene muscle are then
freed, and the muscle is divided exposing the subclavian artery (Fig.15.6). Further
dissections of the subclavian artery proximally can be performed, if necessary, by
continuing medially and identifying and mobilizing the internal mammary and vertebral arteries. The vertebral vein is often encountered supercial to the subclavian
artery and is divided to facilitate exposure. On the right side, additional exposure
can be obtained with resection of the clavicular head, which will allow exposure to
the distal innominate artery. Laterally abnormal brous band and the cervical rib if
present are freed from around the artery and resected.
Infraclavicular exposure is obtain through incision starting just lateral to the sternal head of the clavicle overlying the deltopectoral groove, beginning about 1cm
below the clavicle and ending laterally about 2cm below the clavicle (Fig.15.4).
The pectoralis major muscle bers are split exposing the clavipectoral fascia with
the pectoralis minor muscle in the lateral half of the incision. Care is taken to preserve nerve branches to the pectoralis major muscle. The cephalic vein may also be
encountered as it passed between the heads of the pectoralis major muscle to join
the axillary vein. Dividing the clavipectoral fascia will expose branches of the thoracoacromial trunk, which can be followed down to the rst portion of the axillary
artery (Fig.15.7). The axillary vein that runs inferior and supercial to the artery is
usually encountered rst. Laterally, the pectoralis minor muscle is divided near its
insertion to the coracoid process where the muscle is more tendinous to further
expose the axillary artery as necessary.
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