CAR 1. Acute Bleeding Caused by Infected Carotid Pseudoaneurysm and Carotid Patch-Cutaneous Fistula 12 Years After Endarterectomy

We report a case in which 12 years after a successful left carotid endarterectomy, a carotid-cutaneous fistula resulted in pulsatile bleeding from the neck that necessitated urgent intervention and surgical reconstruction. The patient is an 87-year-old man with history of left internal carotid artery endarterectomy with Dacron patch closure performed 12 years ago for right hemiplegia caused by high-grade stenosis of the left internal carotid artery. The patient was discharged after 72 hours and was asymptomatic at 1 month, 3 months, and 6 months of follow-up; he was then reported lost to follow-up. After this, the patient reported to the emergency department with sudden onset of pulsatile bleeding from an area of skin ulceration on the left side of the neck. The patient's hemodynamic status remained stable, which allowed time for evaluation. Computed tomography angiography revealed occlusion of the left internal carotid artery and a pseudoaneurysm without active extravasation of contrast material in the common carotid artery. Following this diagnosis, the patient’s apixaban therapy was immediately discontinued. In this case, endovascular treatment with a covered stent was performed to prevent a new bleeding episode. However, because of the high risk of infected pseudoaneurysm, open surgery was performed after discontinuation of apixaban for 48 hours. During the operation, it was discovered that the pseudoaneurysm had eroded to the skin surface, causing a carotid patch-cutaneous fistula. The dissection was difficult as tissue planes were fibrosed. After control of left carotid vessels, resection of the Dacron patch and arteriotomy primary closure with polypropylene were carried out. There were no systemic signs of infection; however, culture specimens obtained from the Dacron patch were positive for Escherichia coli, and appropriate antibiotic therapy was initiated. The patient was discharged asymptomatic after 72 hours. Open surgical repair, including carotid patch resection and arterial reconstruction, remains the standard treatment of common carotid artery pseudoaneurysm. However, in recent years, endovascular intervention has been used as an effective alternative in the treatment of pseudoaneurysm. In this case, endovascular treatment was not an option because of localized infection of the Dacron carotid patch, which led to mycotic degeneration, pseudoaneurysm formation, and erosion of the skin surface.