B. C¸ ınar, O. Fazlıogulları and O. Goksel*
Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center, Cardiovascular Surgery, Istanbul, Turkey
Introduction. In this report, we describe a very unusual case, true aneurysm of the internal carotid artery, in a child. Report. A 10-year-old boy with a pulsating mass on his right neck was admitted with the diagnosis of a 25 mm by 50 mm true aneurysm of the right internal carotid artery, which was resected, and a 5-mm ePTFE graft was interposed. He was discharged on day 3 without complications.
Conclusions. Prompt differential diagnosis of this pathology is crucially important. Open surgery yields acceptable results depending on the size, extension and the type of the aneurysm.
Keywords: Aneurysm; Internal carotid artery; Cerebrovascular disease; Carotid artery surgery.
Introduction
Although atherosclerotic occlusive disease in the ex-tracranial carotid arteries is relatively common, true aneurysms of these vessels are rare. Furthermore, true aneurysms in the paediatric population are ex-ceptionally rare, especially in those without any his-tory of relevant coexisting disease. In spite of their rarity, extracranial carotid aneurysms should be con-sidered in the differential diagnosis of a neck mass.1,2
Report
A 10-year-old boy with a pulsating mass on the right side of his neck was admitted to our outpatient clinic in September 2005, following referral from a general practitioner. His main complaints, besides the tender mass, were persisting neck pain and headaches for the last year. He had no previous history of trauma, vas-culitis or any coexisting condition, although he had an uneventful tonsillectomy procedure in early 2004. Upon examination, the mid-cervical mass on the right lateral side was pulsatile and had an audible bruit. Cervical doppler and contrast-enhanced CT studies showed a 25 50 mm true aneurysm of the right inter-nal carotid artery, just distal to the bifurcation (Fig. 1.).
He was admitted to hospital and given 10 000 IU sodium heparinate as an infusion over 24 hours and was scheduled for surgery for the next day. Standard anterior sternocleidomastoid incision was used for surgery, under general anesthesia, with 1mg/kg sys-temic heparinization. Shunt insertion was applied upon arteriotomy regardless of stump pressures, in anticipation of a long dissection time. Resection of the aneurysmatic segment was possible with careful dissections and a 5-mm ePTFE prosthetic graft (Impra ePTFE vascular grafts, Bard Peripheral Vascular, Inc., Tempe, AZ, USA) was interposed (Fig. 2.). A pragmatic shunting technique was used where the shunt was inserted first through the graft and then into the prox-imal and distal ends of the carotid artery. In this way, obliteration of the surgical field was minimal with easy manipulation and control of the shunt. The distal anastomosis was completed first; the shunt was re-moved just before completion of the proximal anasto-mosis for the sake of easy manipulation.
Low-dose heparin was continued for the first 12 hours post-operatively. The perioperative and post-operative course was uneventful and the patient was discharged on day 3 without complications.
Discussion
In contrast to atherosclerotic and ulcerative occlusive lesions of the carotid arteries, true aneurysms these vessels are rare and more difficult to manage. The internal carotid artery, next to common carotid bifur-cation is the second most common location for aneurysms.3 In adults, the aetiology is usually athero-sclerosis, penetrating or nonpenetrating trauma, dis-sections, previous surgery, vasculitis or infection. The latter was the principal cause before the antibiotic
However, a true cervical aneurysm of any aetiol-ogy in the paediatric population is very rare. The case report by Unal OF et al is one of the scarce instances of this situation in children.4
Starting with Sir Ashley Cooper, who ligated the common carotid artery for a cervical aneurysm for the first time, techniques such as wrapping, endoa-neurysmorraphy, resection and eventually endovas-cular interventions have been described. In our case, we resected the aneurysm and interposition of a syn-thetic graft was performed, although the primary in-tention was to use greater saphenous vein, but this was less than 5 mm in diameter at saphenofemoral junction. Our patient did not have any history of vas-culitis, congenital disorder eg Marfan syndrome or trauma. The previous uneventful tonsillectomy proce-dure in early 2004; raises the possibility that inadver-tent operative trauma was the cause of the aneurysm, although there was no evidence for this at operation. Microbiology and pathology provided no additional information.
Despite its rarity, prompt differential diagnosis of this pathology is crucially important for the natural history and therapeutic options. Misdiagnosis as a par-apharyngeal abscesss or a delayed diagnosis may re-sult in a disastrous scenario, with life-threatening haemorrhage or a debilitating stroke. As stroke rate as high as 50% and even higher mortality have been reported in untreated patients.5 In general, aneurysms at this location can be managed surgically with ac-ceptable results, although the results may vary de-pending on the size, extension and the type of the aneurysm. Autologous vein grafts for interposition are the first choice; however, synthetic grafts may be used when necessary. In this case, a slightly longer graft was inserted to allow for the normal growth of the patient (Fig. 2.). Follow-up with doppler ultra-sonography every three months was recommended for our patient for the first year; additional CT or MR angiograms may be used if indicated
