Classical surgical approach and treatment with clips of extracranial internal carotid artery berry aneurysm

Introduction: We can define extracranial carotid artery aneurysm (ECAA) as bulb dilatation greater than 200% of the diameter of the internal carotid artery (ICA) or in a case of common carotid artery (CCA) greater than 150% of the diameter. Surgical intervention is required for the treatment of this disease. Case Report: This study presents an open vascular surgical procedure to resolve ECAA. We report a case of 61 years old woman with an extracranial internal carotid artery berry aneurysm, presented with a headache and dizziness when turning the head aside. Classic open surgery was performed and the lumen of berry aneurysm was separated with three clips from the lumen of ICA. Conclusions: The open surgical approach is the method of choice for the treatment of extracranial internal carotid artery pathological conditions.


INTRODUCTION
We can define an arterial aneurysm as increased diameter of an artery, at least 50% of the normal arterial diameter (1). Carotid bifurcation is 40% greater in diameter than the distal internal carotid artery (ICA). This threshold is not difficult to achieve. The definition of extracranial carotid artery aneurysm (ECAA) is bulb dilatation with a diameter greater than 200% of the ICA diameter or 150% of the common carotid artery (CCA) diameter (2). This definition is used in many reports and studies of ECAA and is helpful to delineate physiologic dilatation of the carotid bulb. Most of the ECA aneurysms are located at the bifurcation of the common carotid artery or at the proximal ICA, where atherosclerosis is expressed the most, and they tend to be fusiform. Atherosclerotic aneurysms that do not involve the carotid bifurcation are frequently berry and occur in patients with severe arterial

CASE REPORT Open Access
Classical surgical approach and treatment with clips of extracranial internal carotid artery berry aneurysm hypertension. Most bilateral, atraumatic ECAAs are of the berry type.
Although common surgical procedures performed on carotid arteries include stenotic lesions, vascular interventions on the aneurysms of carotid arteries are less frequent, include about 2% of all carotid artery interventions (2,3). The etiology of carotid artery aneurysms is not entirely known because only several vascular centers have accumulated sufficient data and experience to try to explain the genesis (3).
In a study conducted at the Texas Heart Institute, the most common symptoms regarding ICA aneurysms (43% of patients) were related to cerebrovascular ischemia (3). Considering the high risk of cerebrovascular incidents, in the case of carotid aneurysms, we can explain why many vascular surgeons prefer intervention for most of these aneurysms. We report a case of 61-year-old woman with an extracranial berry aneurysm of the internal carotid artery.

CASE REPORT
A 61 year old woman was admitted to the Clinic of Vascular Surgery of the University Clinical Centre in Sarajevo with symptoms: a headache and vertigo during rotation of the head. According to the color Doppler finding obtained from the patient, kinking and berry aneurysm of the left internal carotid artery were suspected. She was a smoker and had a history of hypertension, type 2 diabetes mellitus, and hypothyroidism treated with levothyroxine. There was no prior history of neck injuries, infections, cerebrovascular accidents, and allergies. The physical examination did not reveal a palpable pulsatile tumoroid formation. A berry aneurysm of the left ICA was confirmed by computed tomography angiography (CTA) with 3-D reconstructions, which revealed double kinking of the left ICA at 15 mm from the origin, partially thrombosed, and the berry aneurysm measuring 14.2x12.5mm in diameter, neck widths up to 4 mm. The distal portion of the left ICA preserved a width of circulating lumen ( Figure 1).
Classic open surgical approach to the carotid artery with preservation of the neural structures (cranial nerves X and XII) was performed under regional anesthesia (cervical block using a 2% Xylocaine).
After establishing vascular control by surgical dissection and preparation for clamping of the common, external, and internal carotid arteries, we approached and liberate the neck of berry aneurysm of 6 mm width from the neighboring structures. At that moment, there was a sudden deterioration of the patient general status. The patient began to complain of shortness of breath, chest pain, and numbness in the left hand. On the monitor there was ST depression and oxygen saturation decreased below 90%. The anesthesiologist urged speedy completion of the surgery and opened the possibility of thrombolytic treatment. The lumen of the berry aneurysm was separated from the ICA using three clips ETHICON LT 400.
Post-procedurally, the patient was confirmed termination of the problems that had appeared during the operation. The postoperative recovery laboratory findings (troponin, CK-MB and D-dimer) were in the range of reference values, the electrocardiogram (ECG) was normal, and there were no pathological findings or incidents in the cardiovascular and central nervous systems. The most significant postoperative complication, verified with laryngoscopy, was vocal paresis left for 5 days. On control laryngoscopy, hematoma in regression was found and both vocal cords were in phonation and respiratory moving.
Control color Doppler did not record the existence of a berry aneurysm (Figure 2), with the presentation of kinking that leaves no repercussions on the flow (PSV 93.16 cm/32.83 cm you EDV/s) inICA.
During regular controls, the patient did not have the same symptoms as before the surgical intervention. Mostly, she had the symptom of mild dizziness after sudden movement of the head. Control CTA was performed 6 months after the surgery (Figure 3). The left CCA had an adequate flow and preserved the width of the circulating lumen to 8 mm. In the area of bifurcation and the initial part of the ICA lamellar calcification was formed. After the surgical intervention, visualizing the area with metal clips no aneurysm was observed in the control physical examination. The distal ICA demonstrated preserved width of the circulating lumen and appropriate contours without visible defects in the contrast filling.

DISCUSSION
Aneurysms of the extracranial parts of the carotid arteries have incidence from 0.8 to 1% and make 5% of all peripheral aneurysms (4)(5)(6). In elderly patients the cause of the disease is usually atherosclerosis. The etiology in younger patients includes: infections, trauma, vasculitis (with dissection), and fibromuscular dysplasia. The symptoms are in direct correlation with the etiology, location, and size of an aneurysm. There are three categories of the symptoms: 1. Compression which can cause hoarseness and dysphagia (6-10).
2. Rupture occurs predominantly in mycotic aneurysms (11,12). 3. The most serious complication of carotid artery aneurysms is an increased risk of thromboembolic incidents that cause a stroke.
Diagnosis of ECAA can be achieved by combining clinical and radiological findings which include: radiological confirmation by color Doppler, computerized tomography, and magnetic or digital subtraction angiography. A neurological deficit in patients after neck injuries is an alarm for the presence of a carotid artery aneurysm and should be excluded by radiological examinations. Because of a high rate of cerebral embolic complications and mortality, for patients with ECAA surgical treatment is strongly recommended.
Treatment of aneurysms located in the distal part of the ICA or near the base of the skull includes endovascular stenting (13)(14)(15), because classical surgical repair is not possible in this case (7,10,16). However, the endovascular manipulation is associated with the risk of stroke and an inability to apply the surgical approach in a case of complications (i.e., bleeding) (16,17).
According to a systemic review (18), endovascular stenting of the ICA aneurysms resulted in a stroke risk of 1.8%, cranial nerve injury of 0.5%, and a mortality risk of 4.1%. When patients with ECAA were exposed to the endovascular procedure, results were successful with a low complication rate. used: end-to-end carotid anastomosis, vein graft, polytetrafluoroethylene graft, aneurysmorrhaphy and a vein patch, and GORE VIABAHN endoprosthesis. Perioperative minor stroke occurred in 1 patient and transient cranial nerve injuries were observed in 2 patients. This study showed that surgical treatment is feasible and have an acceptable rate of stroke and cranial nerve injuries (19).
A retrospective review by Szopinski et al. showed that endovascular procedures allow treating extracranial aneurysms when open surgery is not recommended or not possible in special cases (20).
In the beginning, endovascular balloon occlusion, coil embolization, graft stenting, and similar procedures demonstrated poor results because of different complications (the main complications were cerebral embolization and stent occlusion). Today, endovascular treatment offers more commotion for vascular surgeons in the treatment of ECAA with regard to surgical dexterity, especially in patients that were already exposed to open surgical interventions on carotid arteries (i.e., pseudoaneurysms as a complication).

CONCLUSION
Due to the findings that lay on the experience of neurosurgeons, we can look at this case as a pioneer step in proving that one surgical technique can be applied in various cases. After all, open surgical approach, with greater creativity for a vascular surgeon, is the method of choice for the treatment of extracranial internal carotid artery pathological findings.