Resection of a large carotid


Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Resection of a large carotid

  1. 1. Acta Cardiol 2008; 63(1): 81-83 doi: 10.2143/AC.63.1.2025336 81 CASE REPORTS Resection of a large carotid artery aneurysm under cervical epidural anaesthesia Saeid JAHANBAKHSH1, Hassan RAVARI2, Patricia KHASHAYAR3 1 Dept. of Anaesthesia, and 2 Dept. of Vascular Surgery, Medical Sciences/University of Mashad; 3 Research and Development Centre, Sina Hospital, Medical Sciences/University of Tehran, Iran. Carotid artery aneurysm is a rare arterial aneurysm that should be considered in the differential diagnosis of cervical and posterior pharyngeal masses. The purpose of the present article was to report a carotid artery aneurysm in a patient in whom cervical blockade, the common anaesthetic method, was not possible due to the location of the aneurysm. In this case, the surgeon decided to resect the aneurysm under cervical epidural anaesthesia.As the patient was awake during the oper- ation, the continuous evaluation of her neurological status was possible and thus, it was possible to diagnose insufficient perfusion or brain dysfunction promptly while the carotid artery was clamped. Cervical epidural anaesthesia provides careful monitoring of the neurological function and early diag- nosis of possible brain ischaemia.Therefore, the application of this method in resecting carotid artery aneurysm by an experienced anaesthetist is safe and acceptable. Keywords: carotid aneurysm – cervical epidural anaesthesia – cervical mass. Introduction mass had grown considerably during the past 4∞∞years and had resulted in difficulties in swallowing solid food Aneurysm of the carotid artery is one of the rare within recent months. She did not complain about any arterial aneurysms. McCollum et al. have reported the neurological symptoms or speech disorders. majority of the cases of this aneurysm; in their report, Medical examinations revealed a 5*10∞∞cm pulsatile only 37 cases of the carotid artery aneurysm had mass that was easily moved laterally with an audible undergone an operation in a period of 21∞∞years, whilst bruit on auscultation. Angiography showed a 5*9∞∞cm 8500 cases of other types of aneurysms were diagnosed aneurysm at the bifurcation of the carotid artery with and repaired during the same period1. Although two smaller aneurysms in the internal carotid artery aneurysm of the carotid artery is rare, it should be (figure 1). It was impossible to perform cervical block- considered in differential diagnoses of cervical and ade, as the aneurysm was located on the spot where posterior pharyngeal masses because of its variant the cervical plexus was not accessible. Moreover, insert- manifestations. The resection of an aneurysm and its ing a shunt before clamping the carotid artery would replacement with the saphenous vein is the surgical require an intracranial approach due to the extension procedure of choice in many cases2. Endovascular of the aneurysm to the base of the skull, which would treatment has been developed in recent years; however, be accompanied by a high risk of neurological damage. it has not yet resulted in an optimal outcome com- Considering the fact that general anaesthesia was not pared with the resection of the aneurysm. possible due to the absence of neurological monitor- ing facilities in our centre, cervical epidural anaesthe- sia appeared to be the preferable procedure. After Case history obtaining written informed consent, the patient was placed in the seated position with an ECG monitoring The patient was a 22-year-old woman, suffering and a pulse oximeter attached. After applying local from a painless mass in the right side of her neck. The anaesthesia, C6-C7 epidural space was determined by Touhy needle number 18 with a hanging drop and loss of resistance technique. Seven segments (C2-T1) block- Address of correspondence: Patricia Khashayar, M.D., Sina Hospital, 11367-46911 Tehran, Iran. E-mail: ade was carried out for ensuring the anaesthesia in the Received 20 July 2007; revision accepted for publication 5 September region. Twelve cc of the local anaesthetic solution 2007. containing 10 cc lidocaine 2% and 2∞∞mcg/kg fentanyl
  2. 2. 82 S. Jahanbakhsh et al. Fig.∞∞1 - Angiography of the mass showed a 5*9∞∞cm aneurysm Fig.∞∞2 - After the incision was performed on the SCM, a at the bifurcation of the carotid artery with two smaller large 15*8∞∞cm aneurysm causing the lateral displacement of the aneurysms in the internal carotid artery. internal jugular vein was revealed. was injected. The epidural catheter was then inserted and was discharged three days later in a good general and fixed. At the end of the procedure the patient was condition. placed in the supine position; and then, skin, subcu- taneous tissue and platysma were opened by a longi- tudinal incision in the front part of the right SCM. A Discussion large 15*8∞∞cm aneurysm causing the lateral displace- ment of the internal jugular vein was revealed. Carotid artery surgery is often performed by apply- The omohyoid muscle and the facial vein were lig- ing general anaesthesia or blocking the deep and super- ated and cut. The incision was then enlarged to the ficial cervical plexus3. The careful monitoring of the posterior region of the right ear. The aneurysm had neurological function is essential for preventing post- involved the bifurcation of the carotid artery, and two operative neurological sequels; it is also necessary to smaller aneurysms were also found in about one cen- diagnose brain ischaemia as soon as possible. This may timetre from the original aneurysm. The aneurysms be achieved via several methods all of which lack effi- were extended to the base of the skull on the right cient sensitivity and also require expensive facilities internal carotid artery (figure 2). and high experience4. In order to maintain the anaesthesia, 7 cc of lido- On the contrary, the continuous evaluation of the caine and epinephrine with a concentration of neurological status of the patient is possible with the 1/200,000 was infused hourly through the epidural method used in this operation, as the patient is awake. catheter. No haemodynamic or respiratory problem In addition, this method is more sensitive in revealing requiring intervention occurred during the operation. the insufficient perfusion or the brain dysfunction. The The patient’s consciousness, speech, and the mus- other stated advantages include no need for expensive cular power of the left hand were assessed incessantly facilities to monitor the cerebral function, a decreased while the carotid artery was clamped. After being need for shunt and vasoactive agents, more stable assured of the sufficient collateral circulation, the haemodynamic status and reduced hospital charges5. carotid clamp was fixed and the resection was accom- It can be concluded that the cervical plexus block- plished. ade is the anaesthetic technique of choice in carotid As the operation took more than two hours and artery operations such as carotid endarterectomy; how- the patient had become tired, general anaesthesia was ever, it could not be used to resect the aneurysm of the determined for the remaining time. The patient became carotid artery. It seems that cervical epidural anaes- hypotensive after the induction phase; dopamine was thesia performed by an experienced anaesthetist would infused at this time in order to prevent cerebral perfu- be a safe and an acceptable method in these cases. sion decrement. Subsequently, the effects of muscular relaxants were References reversed and the patient was extubated. In the recov- ery room, the patient underwent a complete neuro- 1. McCollum CH, Wheeler WG, Noon GP, DeBakey ME. logical assessment which did not reveal any neurologic Aneurysms of the extracranial carotid artery. Twenty-one defect. The patient was then transferred to the ICU years’ experience. Am J Surg 1997; 137: 196-200.
  3. 3. Large aneurysm of the carotid artery 83 2. Rockman CB, Riles TS, Gold M, Lamparello PJ, Giangola 4. Forssell C, Takolander R, Bergqvist D, Johansson A, Pers- G, Adelman MA, Landis R, Imparato AM. A comparison son NH. Local versus general anaesthesia in carotid surgery. of regional and general anesthesia in patients undergoing A prospective, randomised study. Eur J Vasc Surg 1989; 3: carotid endarterectomy. J Vasc Surg 1996; 24: 946-53. 503-9. 3. Corson JD, Chang BB, Shah DM, Leather RP, DeLeo BM, 5. Gabelman CG, Gann DS, Ashworth CJ Jr., Carney WI Jr. Karmody AM. The influence of anesthetic choice on carotid One hundred consecutive carotid reconstructions: local ver- endarterectomy outcome. Arch Surg 1987; 122: 807-12. sus regional anesthesia. Am J Surg 1983; 145: 477-82.