Internal carotid artery stenting for blunt carotid artery injuries with an associated pseudoaneurysm

Background. Blunt carotid artery injuries (BCI) are being recognized and treated with increasing frequency because of improved screening protocols. Recent advances in endovascular techniques using microcoils, angioplasty, and stenting offer a new treatment strategy for those patients with traumatic pseudoaneurysms (PA) (BCI and PA). Experience with these techniques is limited because of the rarity of these injuries. Hypothesis. Early anticoagulation (AC) or antiplatelet (AP) therapy combined with carotid artery stenting is a safe alternative to AC alone for the treatment of grade III carotid artery injuries (BCI and PA). Design: Prospective cohort study. Setting: A rural, community Level I trauma center. Patients and Methods: All patients with a nonocclusive BCI and PA during a 5.5 year period from June 23, 2000 to December 31, 2005 were included in the study. Results. Eleven patients with grade BCI and PA underwent endovascular repair. Nine patients (81%) had associated traumatic intracranial hemorrhage. AC (heparin drip) or AP therapy (clopidogrel or aspirin or both) was initiated in all patients within 48 hours of diagnosis of BCI. Time from admission to AC or AP was 21 +/- 9.5 hours (mean +/- SD). Mortality rate was 18% (2 of 11). One death was attributed to severe brain injury. The other was attributed to a stroke from the carotid injury. No patient had radiologic progression of traumatic intracranial hemorrhage on head computed tomography despite AP or AC. One patient sustained a mild embolic cerebrovascular ischemic event before stenting. No other survivors developed a stroke or any other evidence of cerebral ischemic symptoms. Two recurrent PAs developed during hospitalization and were successfully managed with an additional stent. All survivors were discharged with a good neurologic outcome. Seven patients had follow-up from 6 months to 4 years: one developed asymptomatic 50% sterrosis at 6 months requiring successful angioplasty. All others showed complete healing without stenosis. Conclusions: Carotid artery stenting is safe and effective initial therapy for patients with nonocclusive BCI and PA. Initial intermediate-term follow-up also fails to demonstrate significant morbidity for up to 4 years.