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Endovascular management of a rare pseudoaneurysm of the external carotid artery secondary to tonsillectomy
(Portuguese PDF version)

Leonard Hermann Roelke¹, José Maria Gómez Perez², Frederico Christo Torezane³, Fanilda Souto Barros⁴, Sandra Pontes⁵

1. Physician, specialist in Angiology and Peripheral Vascular Surgery, Brazilian Society of Angiology and Vascular Surgery. Assistant professor of Clinical Surgery (Peripheral Vascular Surgery), Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil.
2. Physician. Associate professor of Clinical Surgery, Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil.
3. Vascular surgeon, Hospital Meridional, Cariacica, ES, Brazil.
4. Vascular sonographist, Clínica Angiolab, Vitória, ES, Brazil.
5. Vascular sonographist, Clínica Angiolab, Vitória, ES, Brazil.

Correspondence:
Leonard Hermann Roelke
Av. Construtor David Teixeira, 155/601
CEP 29065-320 - Vitória, ES, Brazil
Phone/Fax: +55 (27) 3227.8427
E-mail: leonardhr@terra.com.br

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ABSTRACT

A 21-year-old, female patient underwent elective tonsillectomy. Postoperatively, two episodes of local hemorrhage occurred, requiring suture at tonsillar fossa under general anesthesia. It progressed to submandibular swelling and odynophagia. She underwent puncture-aspiration of the swollen area, evidencing blood in its interior. Color Doppler ultrasound revealed presence of a pseudoaneurysm. Digital angiography confirmed the presence of a pseudoaneurysm of the external carotid artery. The patient underwent embolization of the aneurysmal sac with gelfoam particles and occlusion of the feeding artery with Gianturco coil. Monitoring with color Doppler ultrasound confirmed thrombosis of the aneurysmal sac. During a five-year follow-up, the patient remained asymptomatic.

Key-words: tonsillectomy, pseudoaneurysm, external carotid artery, therapeutic embolization.
Palavras-chave: amigdalectomia, pseudoaneurisma, artéria carótida externa, embolização terapêutica.

J Vasc Br 2004;3(2):172-5

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Pseudoaneurysm of the external carotid artery secondary to tonsillectomy is a rare complication due to the position of this artery in the tonsillar fossa, which protects it from an occasional intraoperative trauma. There are few such cases reported in medical literature.^1-4 When it occurs, the pseudoaneurysm must be treated due to potential further complications, such as hemorrhage and embolization. Surgical ligation of the feeding vessel is an option. The authors report a case of endovascular management with a successful outcome.

CASE REPORT

A Caucasian, 21-year-old female student, weighing 56 kg, underwent elective tonsillectomy. There was no perioperative complication. The patient presented with local hemorrhage in the left tonsillar fossa on the sixth postoperative day, which required an overnight hospital stay and suture under general anesthesia. On the eighth postoperative day, another hemorrhage occurred and another suture at tonsillar fossa was performed under general anesthesia. Erythrocyte transfusion was needed due to acute anemia. The patient progressed satisfactorily until the thirty fifth postoperative day, when a left submandibular swelling recurred along with odynophagia. Puncture-aspiration of the swollen area (through the oropharynx) was performed, evidencing blood in its interior. Color Doppler ultrasound confirmed the presence of a pseudoaneurysm. The patient underwent a digital subtraction angiography, which revealed a pseudoaneurysm of the external carotid artery (ECA) (Figure 1). Then, during the same procedure, a selective catheterization of the ECA and of the pseudoaneurysm was performed, as well as the embolization of the aneurysmal sac with gelfoam particles, a Gianturco coil of 2 mm was placed in the branch of the ECA feeding the pseudoaneurysm (lingual artery). Aneurysmal thrombosis occurred, as shown in angiography studies performed on the same occasion (Figure 2).

Figure 1 -Pseudoaneurysm of the external carotid artery.

Figure 2 - Thrombosis of the pseudoaneurysm of the external carotid artery.

One month later, the color Doppler ultrasound evidenced the thrombosis of the pseudoaneurysm (Figure 3). The patient was followed for the last five years and remains asymptomatic; the swollen area reduced and there were no more hemorrhagic events.

Figure 3 - Thrombosis of the pseudoaneurysm of the external carotid artery evidenced by color Doppler ultrasound.

DISCUSSION

Tonsillectomy is a surgical procedure frequently performed in our milieu. The most common complications associated with this procedure are dehydration and respiratory compromise. Vascular complications are reported in medical literature and are associated trauma of the carotid artery during tonsillectomy. Hemorrhagic episodes may occur, requiring emergent care, usually with ligation of the internal carotid artery.⁵ Trauma may also lead to dissection of the internal carotid artery, with or without neurological symptoms.⁶ Infection of soft parts may also lead to pseudoaneurysm formation.⁷ Desimpelaere at al. reported a mycotic aneurysm of the carotid artery in immunosuppressed patients.⁸ Ilum & Haahar even reported a case of pseudoaneurysm of the external carotid artery associated with blunt trauma due to seat belt injury.⁹

Despite the fact that pseudoaneurysm secondary to tonsillectomy is a rare condition, cases of pseudoaneurysm in the internal carotid artery (ICA) have been reported in medical literature,^5-10 given that it is a potential complication of such type of procedure.¹¹ Pseudoaneurysms of the ECA are less common due to the position of this artery. After the bifurcation, the ECA initially lies anteromedial to the ICA. As it ascends, it courses laterally and becomes superficial, while the ICA lies medial to the posterior belly of the digastric muscle. It is at this point that the ICA becomes more vulnerable to traumas during tonsillectomy. ECA, considering its usual position, is not considered to be at risk of injury during tonsillectomy. Perhaps an unusual anatomical positioning, such as a failure on lateralization, may make it vulnerable to such risk.

Deutsch et al. studied the anatomical relation between the ICA and the tonsillar fossa.¹² The measurement of the distance between such structures in 100 children through magnetic resonance imaging studies evidenced a variation ranging from 6 mm to 28.6 mm, depending on the age and weight of the child.

Clinical manifestation of pseudoaneurysms in the neck includes swelling under mandibular angle, which may cause pain and even be mistaken for an abscess. Bruits and thrills or cranial nerve neuropathies may occur. Differential diagnosis includes tortuosity of the artery, branchial cyst, lymphatic malformation, abscess, glomus tumor, lymphadenitis and malignancy.

Diagnosis may be confirmed through color Doppler ultrasound, computed tomography scanning, magnetic resonance imaging and angiography.

Pseudoaneurysms must be treated because of the complications inherent to it. The usual treatment to such injuries is surgery, with dissection and ligation of the afferent artery and, if possible, resection of the aneurysmal sac. Such maneuver may increase the risk of injury to surrounding structures involved in the pseudoaneurysm. A bibliographical review at Medline made four years ago found four reports of such case. Three of them, in which patients presented with a swollen area that could be mistaken for an abscess, were treated through surgery and had a successful outcome.^1-3 Karas et al.² reported difficulty during the surgery due to the fact that the pseudoaneurysm involved the hypoglossal nerve. In this case, the aneurysmal sac was opened, the distal vessels were ligated inside the sac and it was left in situ in order to avoid damaging surrounding structures. Mitchell et al.⁴ reported the case of a female patient with profuse acute hemorrhage. She underwent angiography, revealing a pseudoaneurysm in the lingual artery, which was embolized with several coils, and the bleeding was halted. In our case, the patient presented two episodes of hemorrhage, which were controlled with a suture of the tonsillar fossa. Before the treatment, the patient presented with submandibular swelling without hemorrhage. The endovascular treatment was effective and resulted in reduced morbidity to the patient. Superselective catheterization of the lingual artery and the use of embolizing material resulted in the aneurysmal thrombosis and the cure of the condition.

CONCLUSION

Pseudoaneurysm of the external carotid artery secondary to tonsillectomy is an extremely rare complication due to the usual position of such artery, which protects it from an occasional trauma. Color Doppler ultrasound, computed tomography scanning, magnetic resonance imaging studies and arteriography may confirm the diagnosis. The authors' choice for embolization was effective, because it treated the lesion, and resulted in reduced morbidity to the patient when compared with the traditional surgical approach.

REFERENCES

1. Laage G, BeuthnerD. Carotid aneurysm following tonsillectomy and its plastic treatment. HNO 1972;5:152-3.

2. Karas D, Sawin R, Sie K. Pseudoaneurysm of the external carotid artery after tonsillectomy. Arch Otolaryngol Head Neck Surg 1997;123:345-7.

3. Menauer F, Suckfull M, Stabler A, Grevers G. Pseudoaneurysm of the lingual artery after tonsillectomy. A rare complication. Laryngorhinootologie 1999;78(7):405-7.

4. Mitchel RB, Pereira KD, Lazar RH, Long TE, Fournier NF. Pseudoaneurysm of the right lingual artery: an unusual cause of severe hemorrhage during tonsillectomy. Ear Nose Throat J 1997;76(8):575-6.

5. Tovi F, Leibermann A, Hertzanu Y, Golcman L. Pseudoaneurysm of the internal carotid artery secondary to tonsillectomy. Int J Pediatr Otorhinolaryngol 1987;13:69-75.

6. Wraige E, Ganesan V, Pohl KR. Arterial dissection complicating tonsillectomy. Dev Med Child Neurol 2003;45(9):638-9.

7. Maurizi M, Almadori G, Paludetti G, Ottaviani F, Loschi A. Pseudo aneurysm of the external carotid artery: report of a case. Int J Pediatr Otorhinolaryngol 1985;8(3):263-9.

8. Desimpelaere J, Seynaeve P, Kockx M, Appel B, Gyselinck J, Mortelmans L. Mycotic pseudo-aneurysm of the extracranial carotid artery. J Radiol.Belge 1997;80(4):170-1.

9. Ilum L, Haahar PE. Extracranial pseudo-aneurysm of the carotid artery following seat belt injury. Ugeskr Laeger 1987;149(48):3268-9.

10. Hertzanu Y, Hirsch M, Tovi F. Pseudoaneurysm of internal carotid artery secondary to tonsillectomy: combined radiologic and surgical treatment. Cardiovasc Intervent Radiol 1987;10(3):147-9.

11. April MM, Naclerio RM, Eisele D. Complications of tonsillectomy and adenoidectomy. St Louis, MO: Mosby-Year Book Inc; 199. p. 262-266.

12. Deutsch M, Kriss VM, Willging JP. Distance between the tonsillar fossa and internal carotid artery in children. Arch Otolaryngol Head Neck Surg 1995;121:1410-12.