Delayed Cervical Carotid Revascularization After Missile Injury: A Technical Case Report

Abstract

BACKGROUND AND IMPORTANCE:Penetrating missile injury to the carotid arteries may lead to catastrophic hemorrhagic and/or ischemic complications. The incidence of carotid injury in patients with penetrating cervical trauma (PCT) is 11% to 13%, with most cases involving the common carotid artery (73%), followed by the internal carotid artery (ICA) (22%) and external carotid artery (5%). Approximately 50% of PCT cases result in mortality, with specific injury to the carotid arteries carrying nearly a 100% mortality rate. Although historically limited because most patients do not survive these serious injuries, treatment has become more feasible with advancements in endovascular techniques and technologies.CLINICAL PRESENTATION:A young man presented to our trauma center after sustaining a gunshot wound to the right neck, leading to significant hemorrhage and ultimately a Biffl grade IV ICA injury. He was taken emergently to the operating room for cervical exploration and hemostasis. A computed tomography stroke study performed after initial stabilization revealed complete right ICA occlusion with increased time-to-peak in the right hemisphere. The patient was resuscitated to maintain sufficient cerebral perfusion pressure. Later, once hemodynamic stability was achieved, the patient underwent confirmatory angiography, followed by complete ICA revascularization using a balloon guide catheter to achieve flow arrest and placement of multiple carotid stents. He made a good neurological recovery.CONCLUSION:Endovascular carotid artery revascularization may be performed successfully in the subacute phase after PCT. The use of flow arrest obtained with a balloon guide catheter assists in preventing catastrophic hemorrhage in the event of rupture.

Expansion and Subsequent Rupture of Carotid Pseudoaneurysm After Tandem Carotid and Middle Cerebral Artery Occlusion Treated With Mechanical Thrombectomy and Carotid Stenting

“…Different treatment options for carotid pseudoaneurysms have been described, including Wallstent alone, Wallstent with coil embolization, flow diversion, and covered stents. 1,6,7,[11][12][13] In addition, treatment of carotid rupture with covered stents, specifically after penetrating cervical trauma, has been previously described and is generally effective when the stent is deployed over regions of active extravazation 14 ; however, this is not routinely performed because of the risks associated with the required lifelong dual antiplatelet medications. Interestingly, the development of a carotid pseudoaneurysm is rare, and we identified only 2 pertinent reports in the literature: a small case series of pseudoaneurysms caused by self-expandable stents that did not involve the cranial circulation and a short case report detailing the development of a carotid pseudoaneurysm several years after carotid stenting.…”