What is the best treatment for a common carotid artery aneurysm with occlusion of the distal iliac or femoral artery and 70% thrombosis?

From the Guidelines

The definitive best treatment for a common carotid aneurysm with distal arterial occlusion (iliac or femoral) showing 70% thrombosis is carotid angioplasty (option D). This interventional procedure directly addresses both the aneurysm and the significant thrombosis by mechanically restoring blood flow through the affected vessels. Carotid angioplasty involves inserting a balloon-tipped catheter to widen the narrowed artery and often includes stent placement to maintain vessel patency. According to the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1, antiplatelet therapy and sequential imaging are generally recommended even for asymptomatic patients. However, in the case of a 70% thrombosis, immediate revascularization is necessary to prevent further complications.

The use of antiplatelet agents like aspirin and clopidogrel is important for preventing clot formation, but they cannot effectively address an existing 70% thrombosis or the structural issue of the aneurysm. Following angioplasty, patients would typically be placed on dual antiplatelet therapy (aspirin plus clopidogrel) for a period to prevent stent thrombosis, but this would be adjunctive to the primary interventional treatment. The ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease also support the use of endovascular procedures like angioplasty for the treatment of iliac and femoral artery occlusive disease 1.

Key points to consider in the treatment of common carotid aneurysm with distal arterial occlusion include:

• The need for immediate revascularization in high-grade stenosis situations
• The importance of addressing both the aneurysm and the thrombosis
• The role of antiplatelet therapy in preventing clot formation and stent thrombosis
• The selection of patients for endovascular therapy based on TASC anatomic classifications and severity of symptoms.

In terms of morbidity, mortality, and quality of life, carotid angioplasty has been shown to be an effective and safe procedure for the treatment of carotid artery disease, with low rates of complications and high rates of patency and clinical success 1. Overall, carotid angioplasty is the most appropriate treatment option for a common carotid aneurysm with distal arterial occlusion showing 70% thrombosis, as it provides immediate revascularization and addresses both the aneurysm and the thrombosis.

From the Research

Treatment Options for Common Carotid Aneurysm and Occlusion

• The treatment for common carotid aneurysm and occlusion of distal iliac or femoral artery with 70% thrombosis depends on various factors, including the location and morphology of the aneurysm, as well as the patient's overall health.
• According to a study published in 2016 2, the etiology, location, and morphology of an extra-cranial carotid artery aneurysm (ECCA) determine the selection of appropriate therapy.
• For large or tortuous aneurysms, as well as aneurysms involving the common carotid or proximal internal carotid artery, open surgical therapy is often indicated 2.
• Endovascular techniques, such as stent-graft repair, may be used to treat aneurysms that involve the distal internal carotid artery or false anastomotic aneurysms 2, 3.
• A review of the literature on the management of common carotid artery occlusion (CCAO) found that open surgical management is a safe, durable, and effective therapeutic strategy with low perioperative cerebrovascular morbidity 4.
• The use of antiplatelet therapy, such as aspirin and clopidogrel, is also important in the management of patients with symptomatic peripheral arterial disease and stenosis of the carotid arteries 5.
• A study published in 2022 found that perioperative dual antiplatelet therapy with aspirin and ticagrelor may be a reasonable alternative to aspirin and clopidogrel for patients undergoing carotid artery stenting, particularly when protamine is used 6.

Medical Therapy

• Aspirin and clopidogrel are commonly used antiplatelet agents in the management of patients with symptomatic peripheral arterial disease and stenosis of the carotid arteries 5.
• The use of ticagrelor, a more potent antiplatelet agent, may be considered in certain cases, particularly when protamine is used 6.
• However, the choice of medical therapy should be individualized based on the patient's specific needs and medical history.

Interventional Therapy

• Carotid angioplasty and stenting are minimally invasive procedures that may be used to treat carotid artery stenosis and aneurysms 6, 2.
• Stent-graft repair is a type of endovascular therapy that may be used to treat aorto-iliac occlusive disease coexisting with common femoral artery disease 3.
• The choice of interventional therapy should be based on the patient's specific anatomy and medical history, as well as the availability of experienced operators and facilities.