CASE CAROTID ARTERY DISEASE...right internal carotid artery (ICA), and
Resection of a large carotid
3
CASE REPORTS Resection of a large carotid artery aneurysm under cervical epidural anaesthesia Saeid JAHANBAKHSH 1 , Hassan RAVARI 2 , Patricia KHASHAYAR 3 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 Aneurysm of the carotid artery is one of the rare arterial aneurysms. McCollum et al. have reported the majority of the cases of this aneurysm; in their report, only 37 cases of the carotid artery aneurysm had undergone an operation in a period of 21 ∞years, whilst 8500 cases of other types of aneurysms were diagnosed and repaired during the same period 1 . Although aneurysm of the carotid artery is rare, it should be considered in differential diagnoses of cervical and posterior pharyngeal masses because of its variant manifestations. The resection of an aneurysm and its replacement with the saphenous vein is the surgical procedure of choice in many cases 2 . Endovascular treatment has been developed in recent years; however, it has not yet resulted in an optimal outcome com- pared with the resection of the aneurysm. Case history The patient was a 22-year-old woman, suffering from a painless mass in the right side of her neck. The mass had grown considerably during the past 4 ∞years and had resulted in difficulties in swallowing solid food within recent months. She did not complain about any neurological symptoms or speech disorders. Medical examinations revealed a 5*10 ∞cm pulsatile mass that was easily moved laterally with an audible bruit on auscultation. Angiography showed a 5*9 ∞cm aneurysm at the bifurcation of the carotid artery with two smaller aneurysms in the internal carotid artery (figure 1). It was impossible to perform cervical block- ade, as the aneurysm was located on the spot where the cervical plexus was not accessible. Moreover, insert- ing a shunt before clamping the carotid artery would require an intracranial approach due to the extension of the aneurysm to the base of the skull, which would be accompanied by a high risk of neurological damage. Considering the fact that general anaesthesia was not possible due to the absence of neurological monitor- ing facilities in our centre, cervical epidural anaesthe- sia appeared to be the preferable procedure. After obtaining written informed consent, the patient was placed in the seated position with an ECG monitoring and a pulse oximeter attached. After applying local 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- ade was carried out for ensuring the anaesthesia in the region. Twelve cc of the local anaesthetic solution containing 10 cc lidocaine 2% and 2 ∞mcg/kg fentanyl Address of correspondence: Patricia Khashayar, M.D., Sina Hospital, 11367-46911 Tehran, Iran. E-mail: [email protected] Received 20 July 2007; revision accepted for publication 5 September 2007. Acta Cardiol 2008; 63(1): 81-83 doi: 10.2143/AC.63.1.2025336 81
-
Upload
patricia-khashayar -
Category
Health & Medicine
-
view
616 -
download
0
description
Transcript of Resection of a large carotid
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 differentialdiagnosis of cervical and posterior pharyngeal masses. The purpose of the present article was toreport a carotid artery aneurysm in a patient in whom cervical blockade, the common anaestheticmethod, was not possible due to the location of the aneurysm. In this case, the surgeon decided toresect 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 todiagnose 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 arteryaneurysm by an experienced anaesthetist is safe and acceptable.
Keywords: carotid aneurysm – cervical epidural anaesthesia – cervical mass.
Introduction
Aneurysm of the carotid artery is one of the rarearterial aneurysms. McCollum et al. have reported themajority of the cases of this aneurysm; in their report,only 37 cases of the carotid artery aneurysm hadundergone an operation in a period of 21∞∞years, whilst8500 cases of other types of aneurysms were diagnosedand repaired during the same period1. Althoughaneurysm of the carotid artery is rare, it should beconsidered in differential diagnoses of cervical andposterior pharyngeal masses because of its variantmanifestations. The resection of an aneurysm and itsreplacement with the saphenous vein is the surgicalprocedure of choice in many cases2. Endovasculartreatment has been developed in recent years; however,it has not yet resulted in an optimal outcome com-pared with the resection of the aneurysm.
Case history
The patient was a 22-year-old woman, sufferingfrom a painless mass in the right side of her neck. The
mass had grown considerably during the past 4∞∞yearsand had resulted in difficulties in swallowing solid foodwithin recent months. She did not complain about anyneurological symptoms or speech disorders.
Medical examinations revealed a 5*10∞∞cm pulsatilemass that was easily moved laterally with an audiblebruit on auscultation. Angiography showed a 5*9∞∞cmaneurysm at the bifurcation of the carotid artery withtwo smaller aneurysms in the internal carotid artery(figure 1). It was impossible to perform cervical block-ade, as the aneurysm was located on the spot wherethe cervical plexus was not accessible. Moreover, insert-ing a shunt before clamping the carotid artery wouldrequire an intracranial approach due to the extensionof the aneurysm to the base of the skull, which wouldbe accompanied by a high risk of neurological damage.Considering the fact that general anaesthesia was notpossible due to the absence of neurological monitor-ing facilities in our centre, cervical epidural anaesthe-sia appeared to be the preferable procedure. Afterobtaining written informed consent, the patient wasplaced in the seated position with an ECG monitoringand a pulse oximeter attached. After applying localanaesthesia, C6-C7 epidural space was determined byTouhy needle number 18 with a hanging drop and lossof resistance technique. Seven segments (C2-T1) block-ade was carried out for ensuring the anaesthesia in theregion. Twelve cc of the local anaesthetic solution containing 10 cc lidocaine 2% and 2∞∞mcg/kg fentanyl
Address of correspondence: Patricia Khashayar, M.D., Sina Hospital,11367-46911 Tehran, Iran. E-mail: [email protected]
Received 20 July 2007; revision accepted for publication 5 September2007.
Acta Cardiol 2008; 63(1): 81-83 doi: 10.2143/AC.63.1.2025336 81
0964-08_ActaCardio_63-1_13_07-3028 29-01-2008 14:14 Pagina 81
was injected. The epidural catheter was then insertedand fixed. At the end of the procedure the patient wasplaced 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. Alarge 15*8∞∞cm aneurysm causing the lateral displace-ment of the internal jugular vein was revealed.
The omohyoid muscle and the facial vein were lig-ated and cut. The incision was then enlarged to theposterior region of the right ear. The aneurysm hadinvolved the bifurcation of the carotid artery, and twosmaller aneurysms were also found in about one cen-timetre from the original aneurysm. The aneurysmswere extended to the base of the skull on the rightinternal carotid artery (figure 2).
In order to maintain the anaesthesia, 7 cc of lido-caine and epinephrine with a concentration of1/200,000 was infused hourly through the epiduralcatheter. No haemodynamic or respiratory problemrequiring intervention occurred during the operation.
The patient’s consciousness, speech, and the mus-cular power of the left hand were assessed incessantlywhile the carotid artery was clamped. After beingassured of the sufficient collateral circulation, thecarotid clamp was fixed and the resection was accom-plished.
As the operation took more than two hours andthe patient had become tired, general anaesthesia wasdetermined for the remaining time. The patient becamehypotensive after the induction phase; dopamine wasinfused at this time in order to prevent cerebral perfu-sion decrement.
Subsequently, the effects of muscular relaxants werereversed and the patient was extubated. In the recov-ery room, the patient underwent a complete neuro-logical assessment which did not reveal any neurologicdefect. The patient was then transferred to the ICU
and was discharged three days later in a good generalcondition.
Discussion
Carotid artery surgery is often performed by apply-ing general anaesthesia or blocking the deep and super-ficial cervical plexus3. The careful monitoring of theneurological function is essential for preventing post-operative neurological sequels; it is also necessary todiagnose brain ischaemia as soon as possible. This maybe achieved via several methods all of which lack effi-cient sensitivity and also require expensive facilitiesand high experience4.
On the contrary, the continuous evaluation of theneurological status of the patient is possible with themethod used in this operation, as the patient is awake.In addition, this method is more sensitive in revealingthe insufficient perfusion or the brain dysfunction. Theother stated advantages include no need for expensivefacilities to monitor the cerebral function, a decreasedneed for shunt and vasoactive agents, more stablehaemodynamic status and reduced hospital charges5.
It can be concluded that the cervical plexus block-ade is the anaesthetic technique of choice in carotidartery operations such as carotid endarterectomy; how-ever, it could not be used to resect the aneurysm of thecarotid artery. It seems that cervical epidural anaes-thesia performed by an experienced anaesthetist wouldbe a safe and an acceptable method in these cases.
References
1. McCollum CH, Wheeler WG, Noon GP, DeBakey ME.Aneurysms of the extracranial carotid artery. Twenty-oneyears’ experience. Am J Surg 1997; 137: 196-200.
82 S. Jahanbakhsh et al.
Fig.∞∞2 - After the incision was performed on the SCM, alarge 15*8∞∞cm aneurysm causing the lateral displacement of theinternal jugular vein was revealed.
Fig.∞∞1 - Angiography of the mass showed a 5*9∞∞cm aneurysmat the bifurcation of the carotid artery with two smalleraneurysms in the internal carotid artery.
0964-08_ActaCardio_63-1_13_07-3028 29-01-2008 14:14 Pagina 82
2. Rockman CB, Riles TS, Gold M, Lamparello PJ, GiangolaG, Adelman MA, Landis R, Imparato AM. A comparisonof regional and general anesthesia in patients undergoingcarotid endarterectomy. J Vasc Surg 1996; 24: 946-53.
3. Corson JD, Chang BB, Shah DM, Leather RP, DeLeo BM,Karmody AM. The influence of anesthetic choice on carotidendarterectomy outcome. Arch Surg 1987; 122: 807-12.
4. Forssell C, Takolander R, Bergqvist D, Johansson A, Pers-son NH. Local versus general anaesthesia in carotid surgery.A prospective, randomised study. Eur J Vasc Surg 1989; 3:503-9.
5. Gabelman CG, Gann DS, Ashworth CJ Jr., Carney WI Jr.One hundred consecutive carotid reconstructions: local ver-sus regional anesthesia. Am J Surg 1983; 145: 477-82.
Large aneurysm of the carotid artery 83
0964-08_ActaCardio_63-1_13_07-3028 29-01-2008 14:14 Pagina 83
