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Surgical and Medical Management of Extracranial Carotid Artery Aneurysms
Grant T. Fankhauser, MD1, William M. Stone, MD1, Richard J. Fowl, MD1, Mark E. O'Donnell, MD1, Thomas C. Bower, MD2, Fredric B. Meyer, MD2, Samuel R. Money, MD1.
1Mayo Clinic Arizona, Phoenix, AZ, USA, 2Mayo Clinic, Rochester, MN, USA.

OBJECTIVES:
Extracranial carotid artery aneurysms (ECCA) are extremely rare with limited information regarding management options. Our purpose was to review our institution’s experience with ECCA over 15 years.
METHODS:
A retrospective review of patients diagnosed with ECCA from 1998-2012 was performed. Symptoms, risk factors, etiology, diagnostic methods, treatments, and outcomes were reviewed.
RESULTS:
141 aneurysms were diagnosed in 132 patients (mean age=61, 69 men). There were 116 (82%) pseudoaneurysms and 25 (18%) true aneurysms. 114 (81%) aneurysms involved the internal carotid, 11(8%) common , 15 (10%) bifurcation, and 1(1%) external. 69 (49%) aneurysms were asymptomatic while 72 (51%) had symptoms (28 painless mass, 10 TIAs, 10 vision symptoms, 9 ruptures, 8 strokes, 4 painful mass, 1 dysphagia, 1 tongue weakness, 1 bruit). 61(43%) were diagnosed with MR, 40(28%) CT, 29(21%) ultrasound, 9(6.5%) angiography, and 2(1.5%) after rupture. Etiologies for true aneurysms included fibromuscular dysplasia in 15 patients, Ehlers Danlos in 3, Marfans in 1, and uncharacterized connective tissue diseases in 2.
11 of 25 (44%) true aneurysms were symptomatic. 15(60%) true aneurysms underwent open surgical treatment while 10(40%) were managed non-operatively. Surgical procedures included 14(93%) aneurysmectomies with reconstruction (7 end-to-end, 4 saphenous interposition, 3 prosthetic interposition) and 1(7%) aneurysmorrhaphy. Post-operative complications included 1 stroke during a mean follow-up of 31 months (range 0-166). No aneurysms managed non-operatively required intervention during a mean follow-up of 77 months (range1-115).
60 of 116(52%) pseudoaneurysms were symptomatic. 33(29%) pseudoaneurysms underwent open surgery, 18(15%) underwent endovascular intervention and 65(56%) were managed medically Pseudoaneurysm after endarterectomy (28 patients, 24%) presented at a mean of 82 months from the surgical procedure.
Mean follow-up for all aneurysms was 33.9 months. 1(0.7%) aneurysm-related death occurred (rupture treated palliatively). No patient undergoing non-operative management suffered death or major morbidity related to the aneurysm. Non-operative management was more common in asymptomatic patients(71%) than symptomatic patients(31%).
CONCLUSIONS:
ECCA are uncommon and may present with varying symptoms. All segments of the carotid artery are susceptible although the internal is most commonly affected. Open surgical intervention was more common in patients with symptoms and with true aneurysms. Patients with pseudoaneurysms were more likely to undergo endovascular intervention. Non-operative treatment is safe in selected patients.


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