Introduction Traumatic pseudoaneurysm of the carotid artery is a dangerous complication of penetrating trauma. Stent grafting is an accepted treatment; however the youngest reported patient so treated at the time was 11 years old. We report the successful use of stent grafting in the case of a 4-year-old female with carotid pseudoaneurysm from penetrating neck injury.
Clinical Materials and Methods An otherwise healthy 4-year-old girl presented to an outside ED after accidentally stabbing herself in the neck with a toy fishing pole while using a slide. Physical examination demonstrated a small puncture wound to the right neck and no neurologic deficit. Initial CT examination demonstrated complete occlusion of the right internal carotid artery (RICA). After transfer to our institution, catheter angiography showed a patent RICA with focal 35% stenosis and double wall pseudoaneurysms at the level of C2. Vascular surgery and pediatric neurosurgical consultations indicated that surgical repair was not optimal due to the uncertainty of distal control and the likely need to disarticulate the right TMJ for exposure; stent grafting was requested and preferred to RICA sacrifice. After informed consent for possible off-label stent grafting vs RICA sacrifice, the patient was placed under general anesthesia. After access of both common femoral arteries and heparinization (800 units IV), an angiographic RICA balloon test occlusion showed probably adequate collateral supply to the right anterior circulation. DSA showed interval growth of the anterior and posterior wall RICA pseudoaneurysms and increased stenosis (50%). The decision was taken to stent graft the RICA. A 7F sheath was positioned in the RCCA and a Viabahn 5 mm × 25 mm self-expanding stent graft (Gore) was deployed across the lesion. A minor endoleak from the anterior pseudoaneurysm nearly resolved after balloon dilation of the stent. Hemostasis was obtained manually. Patient was loaded with aspirin and clopidogrel (16 mg) after the procedure for a 1-month course.
Results The patient was neurologically intact after the procedure with preservation of her right pedal pulses. Baseline postprocedure duplex and MRA showed wide patency of the stent graft without visible endoleak. Repeat duplex at 8 weeks redemonstrated wide patency of the graft and occlusion of the pseudoaneurysms. On a clinic visit at 10 weeks, the neurological examination was normal, no neck bruit was audible, and the right pedal pulses were 2+.
Conclusion Carotid stent graft is a viable treatment option for traumatic pseudoaneurysm in children as young as 4 years of age.
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