Introduction
Carotid artery stenting (CAS) is an endovascular procedure for symptomatic or high-grade stenosis in high-risk patients, and is generally safe.1 We describe a man with a rapidly expanding neck hematoma after CAS - an exceedingly rare complication documented in only two case series of 4 in 1,000 cases2 and 1 in 132 cases.3 This emergency requires securement of the airway, perioperative management of a high-risk patient, and is typically seen with open carotid surgery.
Case Description
An 81 year old man with non-ischemic cardiomyopathy (EF 19%), hypertension and moderate COPD experienced amaurosis fugax. 70-80% ipsilateral left carotid artery stenosis was identified, and he underwent CAS under monitored anesthesia care. The patient tolerated the procedure well with no contrast blushing, stable cerebral oximetry, and controlled blood pressure.
Prior to leaving the operating room, the patient – with clear voice – noted new onset of moderate nasal and facial pain on the procedural side. Underneath a warming blanket on the patients left neck was a new, roughly 5x5x3 cm firm mass. The vascular surgery attending and nursing team were immediately called back. The patient’s voice became hoarse and he complained of dysphonia without neurological deficits. By the time the attending surgeon arrived, the patient would not speak due to pain, and his thyroid cartilage deviated rightwards with hematoma expansion. The Anesthesia team discussed the need for intubation and exploration as the Vascular team considered stat CTA. General anesthesia was induced; direct laryngoscopy showed marked laryngeal swelling with rightward displacement. The airway was secured with 6.0 mm endotracheal tube. During open surgical exploration, dexamethasone was administered, epinephrine infusion was required to support the LV, and despite evacuation of 100cc of blood, no perforation was identified. The patient was left intubated, transferred to the intensive care unit, extubated POD#4, and discharged home POD#7.
In debriefing with the Vascular team, possible contributing factors included pre-operative loading dose of clopidogrel, no intravenous protamine reversal, and challenging anatomy (type III aortic arch with L common carotid artery originating from the innominate artery) prompting utilization of a “caterpillar” technique – sheath-over-dilator-over-straight wire (as opposed to coiled tip), requiring deep seating of the wire into the ECA.
Discussion
Despite a successful MAC with tight blood pressure control, this patient experienced the very rarely reported complication of rapidly expanding neck hematoma in the setting of CAS. Only 5 cases have been described in the literature. Vigilance and rapid action rescued the airway prior to obstruction, and preparation for a back-up GA allowed for immediate emergency anesthetic management. Retrospective debrief with OR team identified potential risk factors and systems issues for future patients. Prospective advice for the ICU allowed for a smooth transition of care while anticipating airway and hemodynamic management in a high-risk patient.
References
- Brott TG, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. NEJM;2010;363(1):11–23.
- Taha MM, et al. Access site complications with carotid angioplasty and stenting. SurgNeurol;2007;Oct;68(4):431-7.
- Ecker RD, et al. Perforation of external carotid artery branch arteries during endoluminal carotid revascularization procedures. JInvasiveCardiol;2005;Jun;17(6):292-5.
