Eur J Cardiothorac Surg 1999;16:582-583
© 1999 Elsevier Science NL
Spontaneous rupture of the common carotid artery presenting as a widened mediastinum
Sakhawat H. Rahman,
Muzhar-Ur -Rehman,
James A.C. Thorpe
Yorkshire Heart Centre, Jubilee Building, Leeds General Infirmary, Leeds, UK
Corresponding author. 2 Crescent Court, The Crescent, Alwoodley, Leeds LS17 7LY, UK. Tel.: +44-113-261-1974
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Abstract
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Spontaneous rupture of the common carotid artery is an extremely rare disorder. Presentation in an elderly gentleman as a widened mediastinum with cardiac compromise has not been previously reported. Emergency surgical exploration to decompress the airway revealed a 5-mm tear just proximal to the left common carotid artery bifurcation and a large para-oesophageal haematoma. The case is reviewed and the possible causes discussed.
Key Words: Carotid • Para-oesophageal • Haematoma • Rupture
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1. Introduction
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An 88-year-old man presented to the emergency department with an expanding left sided neck mass causing respiratory compromise. Laryngoscopic findings prior to intubation showed an oedematous larynx and pharynx. His carotid pulses were palpable and equal and grey-scale ultrasonography demonstrated normal carotid arteries.
Chest X-ray showed a widened mediastinum and contrast CT scan demonstrated a large soft tissue mass extending from the pharynx to the gastro-oesophageal junction, compressing and displacing the larynx to the right (Fig. 1). Trans thoracic echocardiography demonstrated an extracardial mass pressing on the left atrium demonstrated as a haematoma on CT (Fig. 2).
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Fig. 1. Computerised tomography demonstrating a large haematoma compressing and displacing the trachea to the right.
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Fig. 2. Computerised tomography demonstrating a large para-oesophageal mass compressing the atrium. The mass is extra-pericardial and most likely a haematoma.
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Oesophagoscopic findings were of oedema and haematoma extending from the soft palate to the lower posterior wall of the oesophagus, with no intra-luminal pathology. The possibility of a posterior oesophageal haemorrhage from a malignancy or an oesophageal dissection was thus entertained. Further respiratory compromise lead to emergency evacuation of the haematoma through an incision anterior to the left sternocleidomastoid muscle. A large haematoma was contained beneath the carotid sheath extending down into the para-oesophageal space and posterior mediastinum. Surgical exploration revealed a 5-mm tear in the left common carotid artery, 2-cm proximal to the bifurcation. The lesion was successfully managed with polypropylene sutures during temporary partial arterial occlusion of the carotid artery using a small arterial side-biting clamp. The procedure took no more than a few minutes. Further careful dissection revealed no obvious pathology and the degree of carotid atheroscerosis was minimal. He was successfully extubated after 72 h but later died following a cerebral ischaemic event affecting the contralateral hemisphere on the sixth post-operative day. Salient features of his past medical history include recurrent transient ischaemic attacks, and reflux oesophagitis diagnosed by histology 10 years previously.
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2. Discussion
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Spontaneous rupture of the common carotid artery is a very rare, life threatening complication. Rupture is usually secondary to underlying pathology, aneurysmal disease, tumour invasion, heavy radiation or existence of infected oro-cutaneous fistula. However, after a careful and thorough examination of the carotid vessel minimal disease had been detected. It is unlikely that the patients ischaemic event on the sixth post-operative day was related to the surgical intervention, and may have been due to intra-cerebral pathology.
Occlusive and ulcerative atherosclerotic lesions of the cervical carotid arteries are extremely common. Aneurysms of these vessels are rare, particularly in comparison with the frequency of aneurysms involving the intracranial carotid arteries. The largest series reported by McCollum and associates at Baylor University, consisted of only 37 aneurysms over a 21-year period during which approximately 8500 operations for arterial aneurysms of all types were performed in the same institution [1]. The common carotid artery is the commonest site, particularly for atherosclerotic aneurysmal disease, and rarely is the external carotid the diseased vessel [2]. Syphilitic arteritis was the most common cause prior to World War II, the change in the incidence of syphilitic disease has decreased the prevalence, however, other causes of mycotic aneurysms still occur. Organisms responsible are Staphylococci, Eschericha coli, Klebsiella, Corynebacterium species. Miscellaneous causes include cystic medial necrosis, Marfan's syndrome, Ehler–Danlos syndrome type IV, and fibromuscular dysplasia [3].
Mogi et al. reported spontaneous rupture of the common carotid artery at a similar site to our patient [4]. The possibility of a small aneurysmal defect cannot be excluded as Lane and Weisman reported aneurysms between 6 and 8 mm [5]. Rupture usually results in pseudo-aneurysm formation and subsequent pressure symptoms. Pre-operative investigation in the stable patient should involve an arteriogram to define the anatomy and confirm this rare diagnosis [6]. Although our patient presented with a widened mediastinum, an arch aortogram was deemed inappropriate due to the strange presentation and morbidity of the patient. Treatment of such a surgical emergency depends on the underlying cause and a search for the pathology.
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References
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Rhodes E.L., Stanley J.C., Hoffman G.L., Cronenwette J.L., Fry W.J. Aneurysms of extracranial carotid arteries. Arch Surg 1976;111(4):339-343.[Abstract/Free Full Text]
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Miyauchi M., Shionoya S. Aneurysm of the extracranial internal carotid artery caused by fibromuscular dysplasia. Eur J Vasc Surg 1991;5:587-591.[Medline]
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Mogi G., Kado K. Spontaneous rupture of the common carotid artery. Arch Otolaryngol 1982;108:525-527.[Abstract/Free Full Text]
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Lane R.J., Weisman R.A. Carotid artery aneurysm: an otolaryngolic perspective. Laryngoscope 1980;80:879-911.
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Kim K.H., Sung M.W., Oh S.H. Spontaneous rupture of the common carotid artery: a case report. Head Neck 1992;14(6):496-501.[Medline]
Received February 8, 1999;
received in revised form August 23, 1999;
accepted September 1, 1999.
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Abstract
1. Introduction
