Open and endovascular surgery recommended over ligation in ruptured extracranial carotid aneurysms

Maarit Venermo

Both open and endovascular surgical approaches are likely to produce improved outcomes compared to ligation in the treatment of ruptured extracranial carotid artery aneurysms. This was the salient point delivered by Maarit Venermo (Helsinki University Hospital, Helsinki, Finland) at the recent Charing Cross (CX) Symposium (25–27 April, London, UK).

The speaker described ruptured extracranial carotid artery aneurysms as “very rare” but “potentially life-threatening” entities at the outset of her talk—a point that was backed up by the fact that, when asked by Venermo if they had encountered such cases in their own practice, very few audience members raised their hand.

Two cases encountered by Venermo’s Helsinki-based team led them to wonder what other centres had experienced and, subsequently, to conduct a literature review that is now published in the Journal of Vascular Surgery. This review consisted mostly of case reports, Venermo stated, with 56 papers being included in the final analysis. In combination with the aforementioned two from their own centre, the authors found a total of 74 cases (mean age, 50 years; male-to-female ratio, 2.2:1).

Venermo and her colleagues found that open surgical reconstruction was the most common treatment approach, having been selected in 32% of these patients, followed by ligation (23%) and endovascular procedures (14%). The speaker also noted that two patients underwent conservative management, and one received no treatment, while therapeutic approaches were not detailed in the remaining case reports (27%).

“If open surgical intervention was [selected], interposition graft was the most common treatment, and these aneurysms were mainly located in Zone 2,” Venermo continued. “Almost all patients who underwent endovascular treatments had a covered stent—and these aneurysms were a little bit more distal, [as] 60% were in Zone 3.”

Shifting focus to adverse events observed in their review, Venermo noted that a total of nine deaths occurred throughout the follow-up period, adding that six of these were related to the patient’s aneurysm. Both of the conservatively treated patients died, as did three who received ligation and one who received open repair, but no deaths occurred in those who underwent endovascular treatments. She further detailed that there was a total of five strokes, all of which occurred after ligation, with three being fatal.

“So, in conclusion, the most common aetiology of ruptured extracranial [carotid] artery aneurysms was infection [26%], followed by connective tissue disorder [18%]—unlike in elective cases, where it is atherosclerotic disease,” Venermo said. “Ligation carried a high risk of stroke and death, and is not recommended, [while] endovascular treatment showed promising results although, in elective cases, [it is controversial] and we may consider use of a long, covered stent.”

The speaker concluded by reiterating that reconstructive surgery was found to be the most common approach, demonstrating improved safety compared to ligation regarding stroke and death, but that three ‘blowout’ cases were observed during follow-up and, as such, graft selection and anastomosis technique are “important”.


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