Management of ruptured common carotid pseudoaneurysm following trans-carotid arterial revascularization in a patient with type III aortic arch

Trans carotid artery revascularization (TCAR) has become a treatment option for patients with carotid bifurcation disease who are high risk for carotid endarterectomy. This new treatment option comes with improved neuroprotection compared to transfemoral carotid stenting with the avoidance of aortic arch manipulation and robust flow reversal prior to manipulating the lesion. However, with common carotid arterial access and sheath placement for flow reversal there is associated risk of access site complications. Complications such as cranial nerve injury and dissection have been described in the literature (Suh et al., 2021). The risk of pseudoaneurysm formation following arterial dissection is known. The management of the initial dissection during TCAR can include stenting, open repair, and medical management. We present the first known complication and management of ruptured common carotid artery pseudoaneurysm at the common carotid artery access site following TCAR. Repair of this dreaded complication can include and open, endovascular or hybrid approach (Choi et al., 2018). The traditional gold standard would be an open repair. In certain scenarios an endovascular approach can be a safe alternative especially in high-risk patients. In this case we present a transfemoral endovascular repair of a ruptured common carotid artery pseudoaneurysm with a challenging type III aortic arch anatomy.