Surgical carotid pseudoaneurysm repair following percutaneous catheterization: a case report

Background: Patients with cyanotic congenital heart disease (CHD), including pulmonary atresia with intact ventricular septum (PA-IVS), often require systemic-to-pulmonary-artery-shunts, such as the modified Blalock-Taussig-Thomas (mBTT) shunt. Approximately 7% of patients with mBTT shunts experience shunt malfunction (e.g., thrombotic occlusions). Transcatheter stenting can reopen an occluded mBTT shunt. Percutaneous carotid approaches (PCA) for transcatheter interventions in infants with CHD are becoming more common. Here, we describe a rare case of late pseudoaneurysm formation, identified 29 days after PCA catheterization for mBTT shunt stenting in an infant. The pseudoaneurysm was successfully managed surgically. Case Description: A male infant with prenatally diagnosed PA-IVS was born at 34 weeks, weighing 1.8 kg. He was maintained on prostaglandins. At 55 days old, 3.3 kg, the patient underwent surgical repair that included right ventricular (RV) outflow tract patch plasty, RV muscle bundle resection, right atrial reduction, and mBTT shunt placement. The patient was placed on a post-operative heparin drip to prevent shunt thrombosis. On post-operative-day (POD) 10, day-of-life 65, the patient’s oxygen saturation dropped, and echocardiogram revealed mBTT shunt thrombosis. The baby was taken to the catheterization lab and an mBTT stent was placed utilizing right PCA with a size 4-French sheath. Hemostasis was achieved by manual pressure. Post-intervention the patient was maintained on heparin and then transitioned to aspirin, enoxaparin, and clopidogrel. Twenty-nine days following the PCA intervention, day-of-life 94, a non-tender nodule was identified on the patient’s right neck. Ultrasound revealed a medial right common carotid artery pseudoaneurysm. Computed tomography angiogram with contrast confirmed the presence of a 1.8 cm × 1.7 cm × 2.1 cm pseudoaneurysm. As interventional treatment was not feasible, the patient underwent surgical repair of the pseudoaneurysm on day-of-life 103, POD-48. The pseudoaneurysm was excised and the carotid artery opening closed with 5-0 Prolene sutures. The patient was discharged home 14 days later on day-of-life 117. At the most recent follow-up, 2 years post-operation, the patient was growing well and meeting his development milestones. Conclusions: We describe a rare late-developing carotid pseudoaneurysm following PCA interventions in an infant with significant exposure to anticoagulation and antiplatelet therapy. The pseudoaneurysm was surgically repaired.