Chapter 27

### PATIENT STORY

A 70-year-old man with stable coronary artery disease presented to the emergency department (ED) with new onset of right arm and leg weakness, as well as dysphasia.

His workup included a computed tomogram (CT) scan of his head that showed an acute stroke in the distribution of the left middle cerebral artery. A carotid duplex ultrasound examination revealed no significant bilateral carotid artery stenosis but did show a 1.5 cm aneurysm with a small amount of mural thrombus in the proximal left internal carotid artery (ICA) (Figure 27-1). A magnetic resonance angiogram (MRA) of the neck confirmed the presence of the proximal left ICA aneurysm, but there was also a question of stenosis at the proximal and distal extent of the aneurysm (Figure 27-2).

###### FIGURE 27-1

Transverse arterial ultrasound image, highlighting the diameter of 1.5 cm (cursor + signs).

###### FIGURE 27-2

Magnetic resonance angiogram (MRA) image showing proximal left internal carotid aneurysm (red arrow) and relatively normal con-tralateral carotid artery. There is a possible high-grade stenosis at the proximal extent of the aneurysm (blue arrow).

A catheter-directed angiogram was therefore performed to rule out any other intimal defects given the discrepancy between the MRA and the duplex. No significant stenosis was identified, and no other luminal irregularities were seen (Figure 27-3).

###### FIGURE 27-3

Carotid angiogram highlighting the aneurysm.

After he functionally recovered from his stroke, he was offered left carotid aneurysm repair with a vein interposition graft (Figures 27-4 and 27-5).

###### FIGURE 27-4

Intraoperative photo of carotid shunt in place with reversed saphenous vein graft (blue arrow) assembled over the shunt (green arrow) in preparation for anastomosis.

###### FIGURE 27-5

Photograph of completed interposition saphenous vein graft (blue arrow) and exclusion of the aneurysm.

This was accomplished and he recovered uneventfully. Further workup revealed no other aneurysmal disease.

### EPIDEMIOLOGY

• Rare pathologic finding. Several series exist that are small and often span decades.1,2,3,4, and 5 One study reported the incidence of pro-cedures performed for carotid artery aneurysm to be less than 1% of the total carotid procedures over a 20-year period.1

• Men are much more commonly afflicted than women, as would be expected since the most common etiology of carotid aneurysms is a degenerative, atherosclerotic pathology.

• No association with the occurrence of other aneurysms has been shown.

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