G. Caddeo, L. Pascalis, C. Politi
Jun 1, 2007
The Neuroradiology Journal
Background: 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 carotid angioplasty and stenting (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. We report a case of perforation of ECA and describe the management of this potentially life-threatening complication. Case Report: A 74-year-old woman, symptomatic for TIA’s was found to have a severe (90%) left ICA stenosis by CT-Angiography. The patient received 5000 units of heparin. A Right coronary Judkins4 6F catheter was inserted in CCA. A stiff exchange wire 0.035” was then placed in the ECA, and the diagnostic catheter was replaced with a 6 Fr 90 cm Shuttle introducer sheath. An Accunet 6.5 FilterWire was used to cross the lesion and the filter deployed. Then we placed an Acculink 7-10, 3cm. The post-procedural angiogram revealed no evident sign of extravasation in the territory of the ECA. The patient immediately had difficulty clearing her throat , difficulty talking and, on examination, she had left side of neck and left hemi-tongue swelling. The anaesthesiologist emergently evaluated the patient, and it was determined that she had a significant subglottic haematoma. The patient was electively intubated. Left carotid angiography documented a distortion of normal anatomy due to haematoma mass effect, an extravasation of contrast from a proximal branch (probably the tonsillar artery) of the facial artery that had been wired during the catheter exchange. At this point, a Tracker 14 microcatheter on a Dasher 14 microwire were used to pass through the stent and selectively catheterize the parent vessel in front of the ruptured branch. Angiography performed via the microcatheter documented good positioning of the microcatheter with extravasation distal to the catheter tip. N-butyl-2-cyanoacrylate glue was used to occlude the vessel. Post-embolisation angiography documented occlusion of the vessel and the absence of any further contrast extravasations. Then the patient underwent in surgical suite and the surgeon decided to place only a draining device in the left parapharingeal space. After 48 hours, the haematoma had decreased in size enough to allow us to extubate the patient. The patient experienced no other symptoms and she recovered fully.