Endovascular stenting is option that must be considered in the patients with high predicted peri-operative mortality. Endovascular repair has been successfully used to treat postoperative carotid artery pseudoaneurysm in the past. Marin et al have described a case of known infected pseudoaneurysm treated with good outcome with no re-infection at 1 year follow up. (12) (13) While this will treat the immediate risk of pseudoaneurysm rupture and eliminate the risk of continued expansion, in the setting of an infected graft it is important to consider the risk of embolization and thrombosis peri-operatively and the risk of infection recurrence. A middle ground approach termed as the EndoVAC Hybrid repair has been described in detail. In this 3-stage treatment approach a stent is first deployed to treat the pseudoaneurysm. At a later point surgical debridement is done followed by VAC therapy in combination with long term antibiotics. In the study described by Wanhainen et al. there was no infection recurrence in their cohort of 16 patients at 5 years. (14)

In our patient, the CT scan had demonstrated that the pseudoaneurysm was very high in the neck. We had anticipated that there would be difficulty in gaining distal control and need for ligation if unsuccessful. But we felt that a completely conservative approach or endovascular approach may not be the best given her relatively good activity of daily living. We also wanted to avoid ligating the carotid artery as it measured 5mm on CT scan and would be associated with high risk of neurological deficit. After our vascular MDT discussion, we considered an endovascular balloon to gain control but eventually agreed that a stent placement will provide more durability and leave the artery patent during dissection. After stent placement, when we had dissected down to the carotid artery the bare metal stent was fully visible. We were then able to perform dissection taking care to avoid nerve injury and safely get distal control. To our knowledge, there is no reported case describing a transcervical stent assisted carotid pseudoaneurysm repair.

Interestingly, our patient had a recently diagnosed occluded left carotid artery on a CT scan as of September 2019. Her initial presentation with a pulsatile mass neck in clinic was very unusual but given her history of CEA we had considered pseudoaneurysm as likely. The pathophysiology is likely inflammation secondary to infection causing the vessel to re-canalize and evolve into a pseudoaneurysm. To our knowledge, there have been no case reports describing a previously occluded CEA site re-canalizing and developing into a pseudoaneurysm.