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Treatment of ruptured common carotid artery
- Operators: Seung-Whan Lee, MD
History and pre-intervention evaluation

A 63-year-old female was admitted for radiofrequency catheter ablation (RFCA) to treat chronic atrial fibrillation. Her past medical history was hypertension and cerebrovascular accident 1 year ago and her current medication were warfarin, amiodarone, angiotension receptor blocker. She was alert and oriented. Ausculation of the neck showed normal carotid upstrokes.

After successful RFCA, she started to complain of shortness of breath and painful swelling on anterior part of right neck. The computed tomogram (CT) of the neck revealed extensive hemorrhagic infiltration around the right CCA which expanded into the mediastinum (Figure 1). Her right common carotid artery (CCA) accidentally ruptured while unsuccessfully attempting at catheter placement in the right internal jugular vein. She was hemodynamically unstable (blood pressure 83/53 mmHg) and mechanically ventilated. The hematocrit had dropped from 37% to 26.8% in 4 hours. Although, we consulted with otolaryngologist about an emergent operation, they recommended elective operation the following morning because they believed intubation to keep her airway from obstruction. However, her symptoms and vital sign deteriorated rapidly during observation. We couldn’t help using with stent to control hemorrhage from right CCA.

Endovascular procedure

A 7 Fr. sheath was inserted into the right femoral artery. Heparinization was performed during the intervention with the active clotting time being kept at about 250 to 300 seconds. A 5Fr. Headhunter diagnostic catheter (Cook, Bloomington, IN, USA) was placed in the right CCA. Angiography showed bleeding from the proximal right CCA (Figure 2A). A 0.035-inch stiff Amplatz wire (Cook, Bloomington, IN, USA) was used to exchange a 7Fr. Shuttle guide sheath (Cook, Bloomington, IN, USA) into the right CCA. The Shuttle guide sheath was positioned proximal to the right common carotid bifurcation. A Jostent peripheral stent graft (5 x 28 mm; Abbott, Illinois, USA) was hand mounted onto the Ultrathin diamond balloon catheter (6 x 40 mm; Boston Scientific, MA, USA). The stent-graft and balloon were advanced to the injured segment of the CCA (Figure 2B). The loaded balloon catheter was positioned at the level of the injured CCA. After a control angiogram was obtained, the stent-graft was inflated upto 15 atm (Figure 2C). The balloon was deflated while negative pressure was applied and then, the balloon was removed. A final angiogram showed total closure of the ruptured portions of the CCA (Figure 2D). The patient had no neurologic changes after the procedure. Follow-up CT suggested decreased the extent of hematoma around CCA and in the mediastinum in 5 days after procedure (Figure 3). She was discharged from hospital without any symptoms and complications.

BRILLIANT!!!
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