Analysis of Extracranial Cerebrovascular Injuries: Clinical Predictors of Management and Outcomes.

BACKGROUND: Optimal management of traumatic extracranial cerebrovascular injuries (ECVIs) remains undefined. We sought to evaluate the factors that influence management and neurologic outcomes (stroke and brain death) following traumatic ECVI. METHODS: A retrospective review of a single level 1 trauma center's prospectively maintained data registry of patients older than 18 years of age with a diagnosis of ECVI was performed from 2013 to 2019. Injuries limited to the external carotid artery were excluded. Patient demographics, type of injury, timing of presentation, Biffl Classification of Cerebrovascular Injury Grade, Injury Severity Score (ISS), and Abbreviated Injury Scale were documented. Ultimate treatments (medical management and procedural interventions) and brain-related outcomes (stroke and brain death) were recorded. RESULTS: ECVIs were identified in 96 patients. The primary mechanism of injury was blunt trauma (89.5% vs. 10.5%, blunt versus penetrating), with 70 cases (66%) of vertebral artery injury and 37 cases of carotid artery injury. Treatments included vascular intervention (6.5%) and medical management (93.5%). Overall outcomes included ipsilateral ischemic stroke (29%) and brain death (6.5%). In the carotid group, vascular intervention was associated with higher Biffl grades (mean Biffl 3.17 vs. 2.23; P = 0.087) and decreased incidence of brain death (0% vs. 19%, P = 0.006), with no difference seen in ISS scores. Brain death was associated with higher ISS scores (40.29 vs. 24.17, P = 0.01), lower glascow coma score on arrival (3.57 vs. 10.63, P < 0.001), and increased rates of ischemic stroke (71% vs. 30%, P = 0.025). In the vertebral group, neither Biffl grade nor ISS were associated with treatment or outcomes. Regarding the timing of stroke in ECVI, there was no significant difference in the time from presentation to cerebral infarction between the carotid and vertebral artery groups (24.7 hr vs. 21.20 hr, P = 0.739). After this window, 98% of the ECVI cases demonstrated no further aneurysmal degeneration or new neurological deficits beyond the early time period (mean follow-up 9.7 months). CONCLUSIONS: Blunt cerebrovascular injuries should be viewed distinctly in the carotid and vertebral territories. In cases of injury to the carotid artery, Biffl grade and ISS score are associated with surgical intervention and neurologic events, respectively; vertebral artery injuries did not share this association. Neurologic deficits were detected in a similar time frame between the carotid artery and the vertebral artery injury groups and both groups had rare late neurologic events.

Pediatric Blunt Cerebrovascular Injuries: Approach and Management.

ABSTRACT: The low incidence of blunt cerebrovascular injury (BCVI) reported in pediatric studies (<1%) might be related to an underreporting due to both the absence of current screening guidelines and the use of inadequate imaging techniques. This research is a review of the literature limited to the last 5 years (2017-2022) about the approach and management of BCVI in pediatrics. The strongest predictors for BCVI were the presence of basal skull fracture, cervical spine fracture, intracranial hemorrhage, Glasgow Coma Scale score less than 8, mandible fracture, and injury severity score more than 15. Vertebral artery injuries had the highest associated stroke rate of any injury type at 27.6% (vs 20.1% in carotid injury). The sensitivity of the well-established screening guidelines of BCVI varies when applied to the pediatric population (Utah score - 36%, 17%, Eastern Association for the Surgery of Trauma (EAST) guideline - 17%, and Denver criteria - 2%). A recent metaanalysis of 8 studies comparing early computed tomographic angiogram (CTA) to digital subtraction angiography for BCVI detection in adult trauma patients demonstrated high variability in the sensitivity and specificity of CTA across centers. Overall, CTA was found to have a high specificity but low sensitivity for BCVI. The role of antithrombotic as well as the type and duration of therapy remain controversial. Studies suggest that systemic heparinization and antiplatelet therapy are equally effective.

Major Internal Carotid Artery Injury During Endoscopic Skull Base Surgery: Case Report.

Major vascular structures are always at risk during complex skull base surgery, particularly with use of the endoscopic endonasal approach, and intraoperative damage of the internal carotid artery (ICA) can be a devastating complication. Herein, we report a case of a young patient who had a major injury of the left ICA during endoscopic resection of a recurrent petrous bone chordoma. Massive bleeding was controlled by a Foley balloon inserted and kept in the resection area. Urgent angiography revealed a persistent leak from the petrous segment of the left ICA, and the vessel was sacrificed with coiling, since a balloon occlusion test showed good collateral blood flow. The patient woke up from anesthesia without a neurological deficit. Salvage resection of recurrent skull base neoplasms deserves specific attention because of the possibility of major vascular damage. In cases of intraoperative ICA injury, its management requires immediate decisions, and the available possibilities for endovascular therapy should always be considered.

A rare complication after an interventional procedure using the common carotid: carotid pseudoaneurysm in an infant.

The carotid artery is a valuable vascular access that can be used in patients who have undergone repetitive interventional and surgical procedures and premature babies. In the past, cut-down was used but nowadays, mostly the procedure is performed under ultrasonographic guidance. Complications such as bleeding, haematoma, and pseudoaneurysm may occur when the carotid artery is used as a vascular access for the procedures such as aortic balloon valvuloplasty, coarctation balloon angioplasty, or after interventional or surgical treatments to the carotid artery. Although pseudoaneurysm is very rare, prompt diagnosis and accurate treatment planning are life-saving. In this article, the diagnosis and treatment of pseudoaneurysm in the left common carotid after transcatheter coarctation balloon angioplasty in a 6-month-old infant will be presented.

Carotid Endarterectomy with Stent Graft Removal and End to End Bypass in the Treatment of In-Stent Occlusion after Endovascular Therapy of Carotid Gunshot Injury.

Carotid jugular fistula and pseudoaneurysm are easy to form after gunshot injury of carotid artery. Endovascular therapy, such as stent graft implantation, can successfully block the fistula and pseudoaneurysm cavity. However, the possibility of in-stent restenosis or occlusion will lead to treatment failure. The authors describe the case of a 30-year-old man with carotid jugular fistula and pseudoaneurysm after gunshot injury of left carotid artery who had received stent graft placement. However, two years after stent graft, the stenosis of proximal carotid artery near stent was found and gradually aggravated. During the follow-up, transient amaurosis of his left eye occurred intermittently and in-stent occlusion and severe stenosis of proximal carotid artery were found by computed tomography angiography (CTA) in our center. Carotid endarterectomy (CEA)with stent graft removal and end to end bypass using vascular graft was performed to reconstruct the blood flow of left carotid artery. To the extent of the authors' knowledge, this case illustrates a rare CEA and vascular graft bypass in the treatment of in-stent occlusion following the gunshot injury to the carotid artery. The successful treatment of this rare case provides an option to deal with this kind of tricky problem.

Utility of Routine Computed Tomography Angiogram Screening for Blunt Carotid Injury in Isolated Mandible Fractures.

PURPOSE: Determine the incidence of blunt carotid injury (BCAI) in the blunt trauma induced isolated mandible fracture population and determine the utility of computed tomographic angiography (CTA) screening for BCAI in this population. METHODS: A retrospective data review was performed on patients presenting to Boston Medical Center from January 2008 to January 2019 with a diagnosis of mandible fracture. Population selected utilizing ICD-9 and ICD-10 diagnosis codes for mandible fracture and BCAI. Excluded populations were pediatric (less than 18 years) and penetrating carotid injuries. RESULTS: A total of 1,508 mandible fractures were identified, with 73% (n = 1,103) being isolated injuries. Five BCAIs were identified, and of these, 1 was associated with an isolated mandible fracture (incidence <0.01%). One of 110 isolated mandible fractures screened for BCAI with the use of CTA was positive (incidence 0.9%). CONCLUSIONS: BCAI is a rare finding in isolated mandible fractures. The inclusion of this population as an independent risk factor for BCAI should be questioned. Routine screening with CTA is not warranted.

Endovascular Treatment of Carotid Blowout Syndrome.

BACKGROUND: Carotid blowout syndrome (CBS) is a life-threatening disease characterized by compromise of the carotid artery by head and neck cancer (HNC). MATERIALS AND METHODS: We reviewed the characteristics and outcomes of all patients with carotid blowout syndrome who were treated between April 2010 and December 2019. Twelve patients with a history of HNC and radiation therapy were investigated. The balloon occlusion test (BOT) was performed in all patients to confirm collateral circulation. We placed a stent in patients who were intolerant to the BOT. RESULTS: The patients' ages ranged from 50 to 81 years (mean: 68.1 years). Therapeutic occlusion of the affected internal carotid artery was performed in nine patients, while stenting was performed in three patients. Immediate hemostasis was achieved in all patients. Patients treated using stents were administered perioperative DAPT. One patient experienced rebleeding after surgery. Two patients had procedure-related cerebral infarctions. One patient died, but the others survived without major neurological deficits. One patient had persistent aneurysm after surgery that resolved over time. CONCLUSION: Endovascular treatment via occlusion or stent-based reconstruction of the internal carotid artery resulted in immediate hemostasis. Carotid occlusion and covered stent application are safe and efficient techniques to treat CBS secondary to HNC. Surgeons may obtain better outcomes if they perform BOT before occlusion and design treatment accordingly.

Traumatic pseudoaneurysms of external carotid artery branch: Case series and treatment considerations.

PURPOSE: To explore the diagnosis and treatment of traumatic external carotid branch pseudoaneurysms. METHODS: Eleven cases of traumatic external carotid artery branch pseudoaneurysms were admitted in our hospital. Digital subtraction angiography was performed in all patients. It revealed that the pseudoaneurysms originated from the internal maxillary artery in 5 cases, superficial temporal artery in 5 cases and occipital artery in 1 case. Five cases of internal maxillary artery pseudoaneurysms and 2 cases of superficial temporal artery pseudoaneurysms were treated by embolization; the other 3 cases were surgically resected. RESULTS: Complete cessation of nasal bleeding was achieved in all the 5 pseudoaneurysms of internal maxillary artery after the endovascular therapies. Scalp bleeding stopped and scalp defect healed up in 2 patients with superficial temporal artery pseudoaneurysms treated by interventional therapy. All patients were followed up for 0.5-2.0 years without recurrence of nosebleed and scalp lump. CONCLUSION: For patients with repeated severe epistaxis after craniocerebral injury, digital subtraction angiography should be performed as soon as possible to confirm traumatic pseudoaneurysm. Endovascular therapy is an effective method for traumatic internal maxillary artery pseudoaneurysms. For patients with scalp injuries and pulsatile lumps, further examinations including digital subtraction angiography should be performed to confirm the diagnosis. Surgical treatment or endovascular therapy for scalp traumatic pseudoaneurysm is effective.

Evaluation of Nonfatal Strangulation in Alert Adults.

STUDY OBJECTIVE: There is a paucity of evidence to guide the diagnostic evaluation of emergency department (ED) patients presenting after nonfatal strangulation (manual strangulation or near hanging). We seek to define the rate of serious injuries in alert strangled patients and determine which symptoms and examination findings, if any, predict such injuries. METHODS: Using prospectively populated databases and electronic medical record review, we performed a retrospective analysis of alert strangled patients treated in the ED of an academic Level I trauma center. Exclusions were Glasgow Coma Scale (GCS) score less than 13, younger than 16 years, and interhospital transfers. Trained researchers used structured forms to abstract demographics, symptoms, examination findings, radiology and operative findings, and final diagnoses. Injuries requiring greater than 24 hours' observation or specific treatment (surgery, procedure, specific medication) were considered clinically important. The electronic medical record was searched for 30 days after presentation to identify missed injuries. RESULTS: Advanced imaging (computed tomography or magnetic resonance maging) was obtained in 60%. Injuries were identified in 6 patients (1.7%, 95% CI, 0.7% to 3.6%). Two injuries were clinically important (0.6%, 95% CI, 0.1% to 2.0%). Both were cervical artery dissections with no neurologic deficits, treated with aspirin. No additional injuries were identified within 30 days or at next medical contact. Of 343 uninjured patients, 291 (85%) had documented medical follow up confirming the absence of any new diagnosis of injury or stroke. The small number of injuries precluded analyses of associations. CONCLUSION: Alert, strangled patients had a low rate of injuries. All patients with neck injuries had concerning findings besides neck pain; specifically, GCS score less than 15 or dysphagia. Our findings suggest, but do not prove, that a selective imaging strategy is safe in alert patients after strangulation findings besides neck pain.

Endovascular Repair of a Common Carotid Artery Perforation during Pacemaker Insertion.

BACKGROUND: We report the percutaneous endovascular management of an iatrogenic perforation of the left common carotid artery (LCCA) during an attempted trans-subclavian pacemaker (PM) placement. METHODS: An 87-year-old woman was urgently transferred after an attempted left subclavian vein PM implantation. Computed tomography angiography scan showed the accidental cannulation of LCCA in its most proximal segment. Owing to the significant surgical risks, the mortality rate, and the distal position of the vessel from the skin, we opted for an endovascular strategy with a balloon-expandable stent graft. The Advanta 8 × 38 mm V12 was inserted via a 7 French Flexor Introducer sheath through the right common femoral artery. RESULTS: The patient was discharged on postoperative day 2 without complications. A 6-month follow-up computed tomography angiography demonstrated stent graft and LCCA patency and the patient was in a good stable condition. CONCLUSIONS: This case highlights the effectiveness of a minimal invasive endovascular approach to treat this uncommon but potentially lethal injury.

Penetrating Injury to the Carotid Artery: Characterizing Presentation and Outcomes from the National Trauma Data Bank.

BACKGROUND: Penetrating injury to the neck can be devastating because of the multiple vital structures in close proximity. In the event of injury to the carotid artery, there is a significantly increased likelihood of morbidity or mortality. The purpose of this study was to assess presenting characteristics associated with penetrating injury to the carotid artery and directly compare approaches to surgical management. METHODS: Data from the National Trauma Data Bank from 2002-2016 were accessed to evaluate adult patients sustaining penetrating injury to the common or internal carotid artery. Management (operative versus nonoperative) and surgical approach (open versus endovascular) were evaluated based on presentation characteristics, and outcomes were compared after propensity score matching. RESULTS: Three thousand three hundred ninety-one patients fitting inclusion criteria and surviving past the emergency department were included in analyses (nonoperative: 1,976 [58.3%] patients and operative: 1,415 [41.7%] patients). The operative group was further classified by intervention as open = 1,192 patients and endovascular: 154 patients. On presentation, the nonoperative group demonstrated significantly higher prevalence of coma (Glasgow Coma Scale ≤8: nonoperative = 49.3% versus operative = 40.8%, P < 0.001), severe overall injury burden (Injury Severity Score ≥25: nonoperative = 42.3% versus operative = 33.3%, P < 0.001), and severe head injury (Abbreviated Injury Score ≥ 3: nonoperative = 44.9% versus operative = 22.0%, P < 0.001). After propensity score matching, the nonoperative group demonstrated higher mortality (nonoperative = 28.9% versus operative = 18.5%, P < 0.001), and lower rates of stroke (nonoperative = 6.6% versus operative - = 10.5%, P < 0.001). There were no differences in outcomes relating to surgical approach. CONCLUSIONS: These results indicate that nonoperative patients often present with a more severe overall injury burden, particularly injury to the head, and not surprisingly, have higher rates of mortality. The lack of significant differences in outcomes relating to surgical approach indicates open versus endovascular invention should be individualized to the patient-for example, based on presenting characteristics and the location of the injury.

Multistep and Multidisciplinary Management for Post-irradiated Carotid Blowout Syndrome in a Young Patient With Oropharyngeal Carcinoma: A Case Report.

BACKGROUND: Carotid blowout syndrome is a severe complication of head and neck cancer, associated with high mortality and morbidity. METHODS: We present a case of acute hemorrhage from the carotid artery of a 59-year-old man with a history of chemoradiotherapy for lingual base and oropharyngeal squamous cell carcinoma. The case was managed by a staged multidisciplinary approach of open arterial reconstruction, after initial endovascular hemorrhage control using stent graft. RESULTS: The patient was discharged to home with patent carotid artery, no sign of infection or bleeding, and autonomous ambulation. A CT/PET scan performed 6 months later confirmed healing and absence of tumor recurrence. CONCLUSIONS: A multidisciplinary approach involving vascular surgeons, ENT surgeons, plastic and maxillofacial surgeons is particularly appropriate in the management of carotid blowout syndrome to warrant a durable and effective repair of all the anatomical structures involved.

Off-label use of Proglide percutaneous closure device in iatrogenic arterial catheterizations: Our experience.

INTRODUCTION: Incidental arterial puncture is one of the main complications associated with central venous catheter placement. Manual compression to achieve hemostasis in subclavian and carotid artery punctures is often ineffective because of the anatomical arterial position. Accidental cannulation has traditionally been treated with open surgery or endovascular treatment, but such procedures are not exempt from complications. OBJECTIVES: Report our experience with ultrasound-guided off-label use of Perclose ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA) in patients with iatrogenic arterial cannulation. METHODS: Six unstable patients with accidental arterial catheterization during placement of a central venous catheter: five of them in the subclavian artery and one in the right common carotid artery. Ultrasound-guided percutaneous closure was performed at bedside using a Perclose ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA). RESULTS: All patients underwent duplex ultrasound 6, 12, 24, and 48 h postprocedure, and no complications associated with percutaneous closure (embolism, ischemia, stenosis, or arterial occlusion, bleeding, pseudoaneurysm, etc.) were described. CONCLUSIONS: Accidental artery puncture during central venous catheterization is an uncommon situation but can be effectively managed by using percutaneous vascular closure device. It is a reliable alternative that should be considered as a first-line approach before endovascular or open surgery, specially in patients with unstable conditions in which it is possible to be performed without transfer to an operation room.

Bilateral Traumatic Internal Carotid Artery Dissection after CrossFit Training.

Bilateral traumatic internal carotid artery (ICA) dissection after CrossFit training is an extremely rare and life-threatening condition associated with high risk of cerebral ischemia. Several imaging modalities are involved in its clinical evaluation and clinical decision-making. Anticoagulation and antiplatelet management, endovascular therapy, and open surgical intervention are the available options for ICA dissection treatment. This report details a bilateral traumatic ICA dissection after CrossFit training treated with antiplatelet and anticoagulation therapy.

Carotid Artery Entrapment by the Hyoid Bone-A Rare Cause of Recurrent Strokes in a Young Patient.

The search for etiology of stroke in a young patient may present a diagnostic challenge. In rare cases, chronic trauma to the carotid artery may be the cause of cerebral thromboembolic events. The hyoid bone lies in close proximity to the carotid artery bifurcation, and anatomic variants have been implicated in carotid compression, stenosis, dissection, and pseudoaneurysm. We report a case of recurrent strokes in a 32-year-old woman due to an elongated hyoid bone causing thrombus formation in her right internal carotid artery (ICA), resulting in recurrent embolic strokes confirmed on diffusion-weighted magnetic resonance imaging. Computed tomography angiography of the neck and head demonstrated the right hyoid bone was located between the ICA and external carotid artery (ECA), just above the carotid bifurcation, with residual nonocclusive thrombus in the right ICA. Carotid duplex ultrasonography confirmed that with the neck in neutral position, the hyoid was located between the ICA and ECA; however, with neck rotation, the hyoid slipped across the ICA and out of the bifurcation. There was no evidence of carotid stenosis. After an initial course of anticoagulation and antiplatelet therapy, resection of the greater cornu of the hyoid bone with release of the right ICA was performed. One year postoperatively, the patient had complete return of neurologic function and had no further neurologic events. Hyoid bone entrapment of the carotid artery is a rare etiology of thromboembolic stroke caused by repetitive local trauma. The diagnosis can be confirmed by carotid duplex with provocative maneuvers. Partial hyoid resection is a safe and effective treatment to relieve recurrent symptoms. Hyoid bone entrapment may be an important and under-recognized cause of stroke in young adults.

Noninvasive in vivo Assessment of the Re-endothelialization Process Using Ultrasound Biomicroscopy in the Rat Carotid Artery Balloon Injury Model.

OBJECTIVES: Ultrasound biomicroscopy (UBM), or ultra high-frequency ultrasound, is a technique used to assess the anatomy of small research animals. In this study, UBM was used to assess differences in intimal hyperplasia thickness as a surrogate measurement of the re-endothelialization process after carotid artery balloon injury in rats. METHODS: Ultrasound biomicroscopic data from 3 different experiments and rat strains (Sprague Dawley, Wistar, and diabetic Goto-Kakizaki) were analyzed. All animals were subjected to carotid artery balloon injury and examined with UBM (30-70 MHz) 2 and 4 weeks after injury. Re-endothelialization on UBM was defined as the length from the carotid bifurcation to the most distal visible edge of the intimal hyperplasia. En face staining with Evans blue dye was performed at euthanasia 4 weeks after injury, followed by tissue harvesting for histochemical and immunohistochemical evaluations. RESULTS: A significant correlation (Spearman r = 0.63; P < .0001) was identified when comparing all measurements of re-endothelialization obtained from UBM and en face staining. The findings revealed a similar pattern for all rat strains: Sprague Dawley (Spearman r = 0.70; P < .0001), Wistar (Spearman r = 0.36; P < .081), and Goto-Kakizaki (Spearman r = 0.70; P < .05). A Bland-Altman test showed agreement between en face staining and UBM. Immunohistochemical staining confirmed the presence of the endothelium in the areas detected as re-endothelialized by the UBM assessment. CONCLUSIONS: Ultrasound biomicroscopy can be used for repeated in vivo assessment of re-endothelialization after carotid artery balloon injury in rats.

Limited Clinical Relevance of Vertebral Artery Injury in Blunt Trauma.

BACKGROUND: Blunt cerebrovascular injury (BCVI), although rare, is more common than previously thought and carries a substantial stroke and mortality risk. The purpose of our study was to evaluate the differences between blunt carotid artery (CA) and vertebral artery (VA) injuries, assess the stroke and death rates related to these injuries, and identify the relationship of Injury Severity Score (ISS) with stroke and mortality in BCVI. METHODS: Using a retrospective review of the trauma registry at a level I trauma center, we identified patients with BCVI. The study period began in January 2003 and ended in July 2014. Demographics, injuries reported, investigative studies performed, and outcomes data were obtained and analyzed. Radiographic images of both blunt CA and VA injuries were reviewed and graded by an independent radiologist, according to the current classification of blunt CA injuries. RESULTS: BCVI involving 114 vessels was identified in 103 patients. This population consisted of 65 males and 38 females with an average age of 45 years (15-92, range). The average ISS was 22 (4-75, range). Cervical spine fracture occurred in 80% of VA injuries (64 total patients). Injuries involved the CA in 33, the VA in 59, and both in 11. The CA group had a higher incidence of traumatic brain injury (61% vs. 46%), ISS (27 vs. 18), and stroke (24% vs. 3%), compared to the VA group. Mortality in the CA group was 30% compared to 3% in the VA group. Patients with high ISS (≥25) had increased stroke rates compared to those with lower (<25) ISS (19% vs. 6.7%). All mortalities occurred with ISS >25. Logistic regression revealed that vessel injured, ISS, and Glasgow Coma Scale (GCS) were significant risk factors for mortality. Multivariate analysis demonstrated carotid injury, and lowest GCS were independently associated with mortality. CONCLUSIONS: In this comparison of CA and VA injuries in BCVI, VA injuries were more common and more frequently found with cervical spine fractures than CA injuries. However, VA injuries had a lower incidence of CVA and mortality. A high ISS was associated with stroke and mortality while carotid injury and lowest GCS were independently associated with increased mortality.

Sonographic Evaluation of Complications of Extracranial Carotid Artery Interventions.

Carotid endarterectomy and carotid artery stenting are among the most common peripheral vascular procedures performed worldwide. Sonography is the initial and often only imaging modality used in the evaluation of iatrogenic carotid arterial injuries. This pictorial essay provides an overview of the clinical and sonographic findings of complications after interventions in the extracranial carotid arteries, including dissection, fluid collections, pseudoaneurysm, thrombosis, thromboembolism, restenosis, and stent deformation. Grayscale, color, and pulsed Doppler imaging findings are reviewed, and correlations with computed tomography, magnetic resonance imaging, and angiography are provided.

Management of an Internal Carotid Artery Injury Caused by a Displaced Titanium Plate With a Combination of Interventional Vascular Radiology and Surgery.

Treatment of pseudoaneurysms in the internal carotid artery (ICA) is associated with a high risk of cerebral infarction; therefore, vessel ligation for hemostasis must be avoided. A 66-year-old man had intraoral hemorrhaging. At the time of the initial examination, computed tomography angiography showed jaw plate displacement near the ICA. A more detailed image was obtained using digital-subtraction angiography. After evaluation of the image, a pseudoaneurysm was diagnosed. Six days later, there were concerns about aspiration and airway obstruction; therefore, tracheostomy was performed. Interventional vascular radiology (IVR) and surgery were planned to facilitate complete recovery, removal of the jaw plate, and repair of the pseudoaneurysm. Before surgery, it was confirmed that it would be possible to block blood flow for approximately 20 minutes. Surgery was performed with the patient under general anesthesia. Before plate removal, cardiovascular surgeons exposed the left large saphenous vein and prepared it so that it could be used to patch the vascular wall defect. A balloon type of embolic protection device was placed so that it could be inflated at any time after plate removal via oral surgery. The pseudoaneurysm was found directly under the plate; however, it had adhered to the scar tissue. As removal progressed, hemorrhaging occurred. To achieve hemostasis, the balloon embolic protection device was inflated. The pseudoaneurysm was removed, and a red thrombus was aspirated. On postoperative day 41, bleeding reoccurred. Two days later, embolization using a platinum coil and stent placement were performed through IVR monotherapy. Postoperative progress was favorable, and the patient was discharged 83 days after treatment without neurologic sequelae. ICA pseudoaneurysms located near the skull base are risky and challenging to repair. However, for traumatic aneurysms such as the one in this case, a combination of IVR therapy and surgery is useful for controlling intraoperative hemorrhage.

Ultrasound-Enabled Noninvasive Management of Inadvertent Carotid Cannulation.

INTRODUCTION: Despite ultrasound use, accidental carotid cannulation is possible during placement of a central venous catheter (CVC), requiring operative repair of the carotid artery and removal of the catheter. CASE PRESENTATION: We report 2 cases-a 59-year-old Hispanic man and an 86-year-old white man-of inadvertent placement of a CVC into the left common carotid artery, removed via a pull-and-pressure technique under real-time ultrasound guidance. No complications occurred and follow-up imaging was negative for fistula creation, hematoma, or cerebral infarcts. DISCUSSION: Prior cases have reported accidental carotid cannulations that required operative repair. Our discussion focuses on the complications of removal of CVCs from the common carotid, and the utility, feasibility, and safety of using real-time ultrasound guidance in the removal. CONCLUSION: While operative removal of CVCs accidentally placed in the carotid is recommended, an ultrasound-enabled pull-and-pressure technique may prevent complications and avoid need for surgical repair in critically ill patients.