Extracorporeal membrane oxygenation-assisted resection of a ruptured carotid artery pseudoaneurysm causing airway compromise: a novel surgical strategy.

Abstract

A 55-year-old man presented with sudden-onset right-sided neck swelling, fever, and stridor. Clinical examination revealed a firm, non-mobile mass near the angle of the mandible. Ultrasonography and contrast-enhanced computed tomography of the neck confirmed a pseudoaneurysm of the right common carotid artery just proximal to the bifurcation, measuring 37 × 28 × 33 mm, surrounded by a peripherally enhancing inflammatory mass extending into the parapharyngeal space and causing airway compromise. The internal jugular vein was thrombosed. Due to anterior tracheal compression, both intubation and tracheostomy were deemed unsafe. Elective extracorporeal membrane oxygenation (ECMO) was initiated via femoral artery and vein cannulation using a cardiopulmonary bypass machine. Spinal anaesthesia was administered, and systemic heparinization was performed to achieve an activated clotting time > 480 s. ECMO enabled safe general anaesthesia and surgical control. A longitudinal cervical incision exposed the pseudoaneurysm, which was excised along with the surrounding infected mass. The anterior carotid wall was necrotic, and the intima was calcified. A reversed saphenous vein graft was used to reconstruct the artery between the common and internal carotid segments. The external carotid artery and thrombosed internal jugular vein were ligated. Postoperatively, the patient was ventilated and supported with inotropes. He was extubated on postoperative day 3 and discharged on day 10 without neurological deficits. This case highlights the novel use of ECMO in managing carotid pseudoaneurysms with airway compromise, offering a safe alternative when conventional airway access is not feasible.