• Users Online: 729
  • Print this page
  • Email this page

 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 1  |  Issue : 2  |  Page : 86-88

Anesthetic management of carotid artery pseudoaneurysm repair in a healthy weight lifter: A rare case report


Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India

Date of Submission01-Sep-2022
Date of Decision26-Oct-2022
Date of Acceptance29-Oct-2022
Date of Web Publication02-Dec-2022

Correspondence Address:
Dr. Sahil Garg
Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh - 160 030
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jica.jica_27_22

Rights and Permissions
  Abstract 

We report a 37-year-old healthy male who developed left-sided neck pain following rigorous weight training. The pain was followed by development of a neck lump which was diagnosed as a left carotid bulb pseudoaneurysm with a partial thrombus in the lumen. The patient successfully underwent rent repair of the left common carotid artery wall at the level of its bifurcation and removal of thrombus under general anesthesia with complete recovery.

Keywords: Carotid artery, pseudoaneurysm, weight lifting


How to cite this article:
Garg S, Nair LV, Singh J, Indumathi K. Anesthetic management of carotid artery pseudoaneurysm repair in a healthy weight lifter: A rare case report. J Ind Coll Anesth 2022;1:86-8

How to cite this URL:
Garg S, Nair LV, Singh J, Indumathi K. Anesthetic management of carotid artery pseudoaneurysm repair in a healthy weight lifter: A rare case report. J Ind Coll Anesth [serial online] 2022 [cited 2023 Feb 4];1:86-8. Available from: https://www.jicajournal.in//text.asp?2022/1/2/86/362613


  Introduction Top


Carotid artery aneurysm in healthy weight lifters is a rare condition. The incidence of cases reported in weight lifters is 0.2%–5% who underwent surgical corrections.[1] The condition is associated with high risk of thromboembolic events, rupture, and neurological deficits. The incidence of extracranial carotid artery aneurysm is <1%.[2] The most common site of extracranial carotid aneurysm is at the level of bifurcation of the common carotid artery, with the common causes being congenital defects, trauma, infections, and connective tissue disorders such as Marfan syndrome. Excessive weight lifting causes a sudden increase in blood pressure which may cause even arterial dissections.[3] Here, we present a case of left carotid artery pseudoaneurysm following weight lifting in a regular gym goer, which was successfully managed without any neurological deficit.


  Case Report Top


A 37-year-old male patient presented with complaints of pain over the left side of the neck for 1 month following heavy weight lifting in a gym. He continued his regular strength training with pain medications. Later, he noticed a lump over the same side of the neck along with difficulty and pain while swallowing food. One month later, he suddenly noticed an increase in the size of the visible lump along with aggravation of pain over the left side of the mid-neck. He then presented with the above mentioned complaints to the hospital emergency conscious, oriented, and with stable vitals. He did not have any comorbidities or a history of connective tissue disorders in the family. The pain was not associated with any trauma, fever, or hoarseness of voice. He did not give any history suggestive of anabolic steroid or hormone supplementation or any sudden increase or decrease in weight. On local examination, there was a nonpulsatile swelling of size 2–3 cm, soft in consistency with no local tenderness, and the overlying skin was normal. On auscultation, no bruit was heard over the swelling. The neck ultrasound showed a well-defined oval cystic lesion of 17.8 mm × 10 mm in the left parapharyngeal region along the medial wall of the left carotid bulb communicating with it showing flow on Doppler (“yinyang” sign) at the level of the upper border of thyroid cartilage suggestive of a pseudoaneurysm. A partial thrombus of maximum thickness of 4.5 mm was seen along the inferior wall of the pseudoaneurysm. For further evaluation, an emergency computed tomography angiography was done, which indicated an aneurysm arising just proximal to the carotid artery bulb with a long axis of 2.1 cm with its widest part of sac 9.2 mm [Figure 1]. The patient was taken for rent repair of the pseudoaneurysmal sac in the emergency operation theater (OT) after written informed consent. All routine investigations were within normal limits. Preoperative vitals were stable. Routine monitoring (heart rate, noninvasive blood pressure, SpO2, temperature, and EtCo2) was done throughout the perioperative period. On the OT table, intravenous (IV) access was achieved through two 16G and two 18G cannulas. General anesthesia was induced with midazolam 2 mg IV, glycopyrrolate 0.2 mg IV, morphine 0.15 mg/kg IV, propofol 2 mg/kg IV, and vecuronium 0.1 mg/kg IV given after confirming optimal bag and mask ventilation. Under direct laryngoscopy, an oral cuffed endotracheal tube of size 8.5 mm ID was inserted. Cormack and Lehane grading was 1 for this patient.[4] Anesthesia was maintained with O2, N2O, isoflurane, and injection vecuronium. The mean arterial pressure (MAP) was maintained between 75 and 80 mmHg with propofol infusion started initially at the rate of 50 mcg/kg/min and then titrated accordingly to maintain MAP between 75 and 80 mmHg. Arterial cannulation was done in the right radial artery after modified Allen's test for continuous blood pressure monitoring intraoperatively. Cerebral oximetry monitor was attached for assessing tissue oxygenation throughout the procedure. His baseline near-infrared spectroscopy was 91%, and throughout the procedure, it was maintained at 90% of the baseline. Once the proximal control of the artery was taken, the patient was heparinized with 100 units/kg and then clamping of the left internal carotid artery was done. Intraoperatively, goal-directed fluid therapy was given with urine output monitoring.[5] The rent repair was done with 6-0 Prolene suture [Figure 2]. Blood loss was insignificant, and hence, there was no requirement of blood transfusion intraoperatively. At the end of the procedure, Bailey's maneuver was done using ProSeal laryngeal mask airway of size 5 for smooth extubation to prevent rapid fluctuation of blood pressure,[6] and the patient was reversed with 0.05 mg/kg neostigmine IV and 10 mcg/kg glycopyrrolate IV. Postoperatively, adequate analgesia was provided with nonsteroidal anti-inflammatory drugs.
Figure 1: Images of CT angiogram and digital subtraction angiography. CT: Computed tomography

Click here to view
Figure 2: Image of left carotid artery rent repair

Click here to view



  Discussion Top


The spontaneous development of pseudoaneurysm in a patient following weight lifting is a very rare entity. Hatzaras et al. did a case series showing fatal vascular injuries following heavy weight lifting with almost 32% mortality in patients who developed acute aortic dissections.[7] The most common cause of extracranial carotid artery aneurysm is atherosclerosis, followed by trauma.[8] The common symptoms are pulsatile neck swelling with localized pain. Other symptoms such as difficulty in swallowing and hoarseness are observed in those patients who develop an aneurysm in the distal portion of the extracranial carotid artery. It occurs due to the compression of cranial nerves or postganglionic sympathetic fibers.[9] Similarly, in young patients, genetic disorders such as Marfan syndrome have to be ruled out. This can cause degenerative effects on the already immature vessel wall causing its rupture due to excessive strain.[10] Aghasadeghi and Aslani reported a case study on a 23-year-old bodybuilder. The patient developed spontaneous coronary artery dissection following weight lifting and developed the symptoms within 1 h and he became hemodynamically unstable. Such patients need continuous hemodynamic monitoring perioperatively. Postoperative complications which can arise in these cases can be postendarterectomy pseudoaneurysm, rupture, embolization, thrombosis, or airway and cranial nerve compression. The anesthetic management should be focused mainly on two aspects, i.e., high risk of massive bleeding and embolization of the thrombus during the repair and how to prevent it.[11] The prevention of massive bleeding can be done by maintaining MAP within normal range, and thromboembolism can be prevented by heparinization of blood as suggested by cardiovascular surgeons. All the emergency drugs and external defibrillators should be kept ready during the perioperative period. Postoperative management mainly targets on maintenance of mean arterial blood pressure and adequate analgesia.


  Conclusion Top


Hence, in patients, especially bodybuilders with known vascular pathologies or aortic dilatation, regular screening should be recommended to prevent sudden death. The anesthetic management should be focused mainly on two aspects, i.e., to anticipate, prevent, and manage massive bleeding and embolization of the thrombus during the repair. Early management and successful perioperative monitoring help in significant reduction of morbidity and mortality.

Informed consent

Written informed consent for publication was taken from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Painter TA, Hertzer NR, Beven EG, O'Hara PJ. Extracranial carotid aneurysms: Report of six cases and review of the literature. J Vasc Surg 1985;2:312-8.  Back to cited text no. 1
    
2.
Liapis CD, Gugulakis A, Misiakos E, Verikokos C, Dousaitou B, Sechas M. Surgical treatment of extracranial carotid aneurysms. Int Angiol 1994;13:290-5.  Back to cited text no. 2
    
3.
Berrouschot J, Bormann A, Routsi D, Stoll A. Sports-related carotid artery dissection. Fortschr Neurol Psychiatr 2009;77:528-31.  Back to cited text no. 3
    
4.
Koh LK, Kong CE, Ip-Yam PC. The modified Cormack-Lehane score for the grading of direct laryngoscopy: Evaluation in the Asian population. Anaesth Intensive Care 2002;30:48-51.  Back to cited text no. 4
    
5.
Kendrick JB, Kaye AD, Tong Y, Belani K, Urman RD, Hoffman C, et al. Goal-directed fluid therapy in the perioperative setting. J Anaesthesiol Clin Pharmacol 2019;35:S29-34.  Back to cited text no. 5
    
6.
Sorbello M, Cortese G, Gaçonnet C, Skinner M. A modified Bailey's manoeuvre for supraglottic airway continuum using LMA Protector™. Indian J Anaesth 2019;63:78-80.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Hatzaras I, Tranquilli M, Coady M, Barrett PM, Bible J, Elefteriades JA. Weight lifting and aortic dissection: More evidence for a connection. Cardiology 2007;107:103-6.  Back to cited text no. 7
    
8.
Garg K, Rockman CB, Lee V, Maldonado TS, Jacobowitz GR, Adelman MA, et al. Presentation and management of carotid artery aneurysms and pseudoaneurysms. J Vasc Surg 2012;55:1618-22.  Back to cited text no. 8
    
9.
McCollum CH, Wheeler WG, Noon GP, DeBakey ME. Aneurysms of the extracranial carotid artery. Twenty-one years' experience. Am J Surg 1979;137:196-200.  Back to cited text no. 9
    
10.
Mayerick C, Carré F, Elefteriades J. Aortic dissection and sport: Physiologic and clinical understanding provide an opportunity to save young lives. J Cardiovasc Surg (Torino) 2010;51:669-81.  Back to cited text no. 10
    
11.
Aghasadeghi K, Aslani A. Spontaneous coronary artery dissection in a professional body builder. Int J Cardiol. 2008;130:e119-20.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed288    
    Printed50    
    Emailed0    
    PDF Downloaded20    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]