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| CASE REPORT |
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| Year : 2022 | Volume
: 1
| Issue : 2 | Page : 86-88 |
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Anesthetic management of carotid artery pseudoaneurysm repair in a healthy weight lifter: A rare case report
Sahil Garg, Lekshmi V Nair, Jasveer Singh, K Indumathi
Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| Date of Submission | 01-Sep-2022 |
| Date of Decision | 26-Oct-2022 |
| Date of Acceptance | 29-Oct-2022 |
| Date of Web Publication | 02-Dec-2022 |
Correspondence Address:
Dr. Sahil Garg
Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh - 160 030
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jica.jica_27_22
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 May 30];1:86-8. Available from: https://www.jicajournal.in//text.asp?2022/1/2/86/362613 |
| Introduction | |  |
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 | | |
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
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| Discussion | | |
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 | | |
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.
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| 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. |
| 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. |
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[Figure 1], [Figure 2]
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