Extracranial internal carotid artery (ICA) aneurysms are rare, accounting for less than 1% of all arterial aneurysms and their treatment accounts for less than 2% of all extracranial carotid procedures. There are currently no guidelines for their management due to a lack of data. As with intracranial aneurysms, endovascular techniques are challenging open surgery. We report here the case of a symptomatic extracranial carotid aneurysm with excessive tortuosity treated by open resection.

A 61-year-old female smoker presented with a left upper cervical pain in the parotid region after a failed conservative antalgic treatment without clinical or biological signs of infection. An ultrasound showed a partially thrombosed left ICA aneurysm. Completion of the medical history revealed a possible amaurosis fugax of the left eye. An extensive biological and radiological work-up, including CT angiography and MRI, ruled out intracerebral microembolic scarring, inflammatory or infectious process, traumatic aetiology or any signs of fibromuscular dysplasia. The 16mm saccular aneurysm of the mid ICA (Attigah I) was incidentally associated with a distal occlusion of the contralateral distal ICA with a Moya Moya network and a 3 mm ipsilateral saccular aneurysm of the left anterior communicating artery (ACA) as well as hypoplasic posterior communicating arteries of the circle of Willis. Apart from an excessively tortuous ICA, no aetiology could be identified.

Despite the unfavourable intracranial anatomy for carotid clamping, we performed an open aneurysm resection with end-to-end reconstruction due to a highly tortuous and elongated ICA, under general anaesthesia. Shunting was not possible due to excessive carotid spasm during exploration precluding shunt insertion. Uneventful recovery allowed hospital discharge on day 4 on Aspirin 100mg daily with no postoperative neurological deficit except for left ear hypoesthesia. Histopathology revealed a degenerative atherosclerotic aneurysm.

This case illustrates an open surgical repair of an ICA aneurysm. The anatomy allowed us to perform an end-to-end anastomosis, sparing an interposition graft or patch angioplasty. This strategy allowed us to confirm the aetiology of the disease and avoid potential embolic complications of an endovascular approach in a tortuous anatomy.