Perforation of External Carotid Artery Branch Arteries during Endoluminal Carotid Revascularization Procedures: Consequences and
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Introduction
Over 12,000 carotid angioplasty and stenting (CAS) procedures have been performed worldwide.1 More than 130,000 carotid endarterectomies (CEA) are performed annually in the United States.2 The FDA has already approved CAS with distal protection for high-risk patients. With the emerging data from ongoing trials demonstrating at least clinical equipoise with CEA, it is only a matter of time before CAS becomes the procedure of choice for patients with atherosclerotic carotid artery disease.3,4 A wealth of experience in overcoming the technical difficulties and managing the complications that can be associated with endoluminal revascularization of the carotid artery has been accumulated, particularly at high-volume CAS centers, some of which have participated in the trials that have documented the safety of the CAS procedure.
The external carotid artery (ECA) branches are often used to support the guidewire during removal of the diagnostic catheter and insertion of the guide sheath or catheter prior to performing neurointerventions such as CAS. This maneuver is considered safer than exchanging these devices with the guidewire in the common carotid artery (CCA) because it lowers the risk of prematurely crossing the internal carotid artery (ICA) lesion or showering embolic material into the intracranial circulation. Although we have performed CAS safely in over 1,000 patients, we have encountered four ruptures of ECA branches during planned CAS, 3 from wire perforations and 1 from a misdeployed PercuSurge balloon (Medtronic, Minneapolis, Minnesota). In this case series, we review our experience and describe the management of this potentially life-threatening complication. A discussion of several agents that can be used for therapeutic embolization of the ruptured blood vessel is provided.
A review of our endovascular database consisting of more than 6,000 endovascular cases from 2001 to 2005 revealed 4 patients in whom an ECA branch rupture was encountered in the course of an endoluminal carotid artery revascularization procedure. The medical records and imaging studies of these patients were reviewed. Institutional Review Board approval (NSG0500104E) was obtained to conduct this retrospective study.
Cases
Case 1. A 61-year-old woman was found to have a severe left ICA stenosis during coronary angiographic evaluation before coronary artery bypass graft surgery (CABG). She was referred to our service for pre-CABG carotid artery revascularization. Diagnostic cerebral angiography documented an approximately 75% stenosis of the left ICA at the bifurcation as well as a high-grade stenosis of the petrous segment of the ipsilateral ICA and the proximal ECA. We decided to proceed with stenting immediately following the diagnostic angiogram. The patient received 3000 units of heparin, which resulted in an activated coagulation time (ACT) of 280 seconds, and a 135 mg bolus of Integrilin (Millennium Pharmaceuticals, Cambridge, Massachusetts), the later given due to concerns regarding the hemodynamic consequences of the stenosis in the petrous segment of the ICA. A 5 French (Fr) Vitek catheter (Cook, Bloomington, Indiana) inserted over a stiff exchange wire was used to gain access to the ECA in preparation for insertion of a 6 Fr Shuttle introducer sheath (Cook). At this point, the patient complained of difficulty clearing her throat and had difficulty swallowing. A left CCA angiogram was performed and documented a small amount of contrast extravasation as a result of perforation of a branch of the facial artery. Physical examination revealed significant parapharyngeal edema. An otolaryngologist and an anesthesiologist emergently evaluated the patient, and it was determined that she had a significant subglottic hematoma. The patient was electively intubated. The hematoma tamponaded the perforation, bleeding ceased, and no endovascular therapy was required. Protamine was not administered. After 48 hours, the hematoma had decreased in size enough to allow us to extubate the patient. The patient experienced no other symptoms, neurological or otherwise, related to this incident; and she recovered fully.
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