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J Vasc Surg Cases Innov Tech
J Vasc Surg Cases Innov Tech
Journal of Vascular Surgery Cases, Innovations and Techniques
2468-4287
Elsevier

S2468-4287(24)00175-8
10.1016/j.jvscit.2024.101591
101591
Case report
A rare case of spontaneous carotid sheath abscess presenting as a painful neck mass
Tabatabaeishoorijeh Ahmad BS ab
Benfor Bright MD a
Montelongo Simon J. DO a
Peden Eric K. MD ekpeden@houstonmethodist.org
a∗
a Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX
b School of Engineering Medicine, Texas A&M University, Houston, TX
∗ Correspondence: Eric K. Peden, MD, Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin St, Houston, TX 77030 ekpeden@houstonmethodist.org
02 8 2024
12 2024
02 8 2024
10 6 10159122 4 2024
12 7 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Infections of the carotid arteries and sheath without any underlying etiology are extremely uncommon. In this article, we report the successful open repair of a right carotid sheath abscess in a 71-year-old woman with multiple comorbidities. The repair consisted of excision of the affected carotid segment and reconstruction by interposition of a reversed great saphenous vein graft. Postoperative Doppler ultrasound examination showed patent right carotid artery, and the patient demonstrated no recurrence postoperatively. This case suggests that, although rare, spontaneous carotid sheath remains a possible cause of neck mass, warranting high suspicion index for optimal treatment in a timely manner to avoid further complications.

Keywords

Carotid artery
Carotid sheath
Abscess
Carotid artery repair
Neck mass
Carotid artery infection
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pmcCarotid artery infections (CAIs) are extremely rare, with <100 cases documented in the literature as of 2024, representing only a minute fraction of all vascular infections.1 Even more infrequent are carotid sheath infections (CSIs), which may arise as a complication of CAI or spontaneously owing to secondary pathologies, with only a handful of cases reported.2 These conditions, which often present as a neck mass, require the exclusion of other potential etiologies of neck masses, and a high index of suspicion is imperative for prompt diagnosis and intervention.3 We report a successful open emergent repair of a carotid sheath abscess at the level of the bifurcation of the carotid artery with restoration of flow using a reversed great saphenous vein (GSV) graft interposition. Written informed consent was obtained from the patient for the report of her case and accompanying imaging details.

Case report

A 71-year-old woman with a past medical history of end-stage renal disease presented to our institution with a 5-day history of right neck pain and swelling. She had recently undergone a tunneled dialysis catheter placement in the left internal jugular vein, which was complicated by methicillin-susceptible Staphylococcus aureus and Enterobacter bacteremia that was successfully treated with tunneled dialysis catheter removal and intravenous levofloxacin 2 weeks before admission, but denied any previous right-sided cannulation. Upon admission, the patient was afebrile despite a mild leukocytosis with a white blood cell count of 11.6 × 109/L; vital signs were stable, and blood cultures did not show any growth. Physical examination revealed swelling and tenderness to palpation of the right neck associated with poor dentition and hoarse voice. A computed tomography (CT) scan revealed a rim-enhancing lesion encasing a calcified right carotid bifurcation. It measured 1.7 × 1.3 cm and was surrounded by extensive edema (Fig 1). Upon high suspicion of carotid sheath abscess, the patient was brought into the operating room for surgical exploration.Fig 1 Axial (A) and coronal (B) views of preoperative computed tomography angiography (CTA) showing a hypodense mass with contrast-enhanced rim surrounding a calcified right carotid artery bifurcation, indicating a carotid sheath abscess.

The procedure was performed under general anesthesia. The carotid sheath was exposed through an oblique incision across the anterior border of the sternocleidomastoid muscle. Purulent discharge was encountered upon opening the sheath (Fig 2), and intraoperative cultures were obtained, which subsequently showed no growth. The inflammatory rind was identified and completely dissected off the vessels to obtain control of the bifurcation. The wall of the internal carotid artery was clearly compromised and seemed to be weakened. Upon opening the sheath, the artery was in direct contact with pus, heightening concerns about its involvement and the risk of rupture if left untreated. Thus, the decision was made to replace the affected portion of the carotid artery with a GSV graft that was harvested from the right thigh. Next, proximal and distal clamps were applied, and the infected carotid bifurcation was excised (Fig 2) and reconstructed with the reversed saphenous vein interposed between the common and internal carotid arteries (Fig 3). Both proximal and distal anastomoses were made using running sutures of 6-0 Prolene and, at the end of the procedure, satisfactory Doppler signals were obtained and the wound was closed with a sternocleidomastoid flap over a Jackson-Pratt drain. Surgical pathology confirmed an acute on chronic focal abscess formation with negative stains for fungus and acid-fast bacilli (Fig 4). Despite negative intraoperative and surgical pathology cultures, the patient was placed on broad-spectrum intravenous vancomycin and meropenem postoperatively per infectious disease staff owing to multiple comorbidities and a history of prior bacteremia. However, the patient continued to experience neck pain and discomfort, leukocytosis with whit blood cell counts peaking at 12.6 × 109/L, and a low-grade fever. These symptoms prompted a return to the operating room on postoperative day 10 for reexploration. CT angiography (CTA) performed before reexploration revealed a fluid collection in the anterior carotid space, measuring up to 2.4 × 1.5 cm in diameter, with no rim enhancement. Exploration revealed the absence of purulence or abscess. The rest of the postoperative course was uneventful, with a CTA revealing a patent carotid artery with no sign of infection (Fig 4). The patient was then discharged home 5 days later with a 2-week course of oral doxycycline. At the 30-day follow up, she was doing well, with stable vital signs and complete wound healing. At both the 6-month and 12-month follow-ups, the laboratory results were unremarkable, the patient reported no neck pain, showed no signs of infection or leukocytosis, and was able to swallow, eat, and drink normally.Fig 2 Gross images of the excised carotid bifurcation demonstrating presence of pus in the subintimal layer (yellow arrow).

Fig 3 Intraoperative image showing a reconstruction of the carotid bifurcation with a great saphenous vein (GSV) graft.

Fig 4 Postoperative computed tomography angiography (CTA) showing patent arterial reconstruction with no surrounding mass (A). Pathology was positive for carotid sheath abscess (B).

Discussion

CAIs are rare and are often associated with bacteremia secondary to head and neck infections, infective endocarditis, or recent surgical and catheter-related operations. These infections involve the arterial wall itself, often leading to severe complications such as mycotic aneurysms or arterial rupture.1,4, 5, 6 CSIs, in contrast, are defined as an infected fascia of the head and neck region and are considered a subtype of deep neck infections, rather than a mere vascular pathology. They are often associated with trauma, microbial infections, malignancies, various cysts, oral cavity infections and poor dentition, and they present as neck masses (Table). Unlike CAIs, CSIs primarily involve the connective tissue structures and potentially adjacent lymph nodes rather than the arterial wall.2,3 On histopathological comparison, CAIs are typically marked by inflammatory infiltrates within the arterial wall, often accompanied by necrosis and bacterial colonization, whereas CSIs exhibit inflammation of the surrounding fascia, potential abscess formation, and lesser direct involvement of the vascular structures when compared with CAIs. When approaching patients with neck masses, it is important to rule out the most common etiologies in adults, such as infectious lymphadenitis, thyroid nodules, salivary gland disorders, cystic lesions (like branchial cleft cysts or thyroglossal duct cysts), and malignancies, including lymphoma and metastatic carcinomas.3 The characteristics of the mass upon physical examination, a thorough history, and nonspecific symptoms such as cough and dysphagia, should further direct the differential diagnosis and guide investigations.3 Our 71-year-old patient presented with poor dentition, which is a known risk factor for CSI. Additionally, she had a recent history of contralateral central venous catheter-related bacteremia that had been treated appropriately; however, the possibility of a hematogenous seeding of infection cannot be ruled out with certainty. Owing to its rarity, a carotid sheath abscess may not be easily thought of as the possible etiology of a neck mass. However, like other reports in the literature, this case highlights the importance of a high index of suspicion for timely intervention to avoid further rupture and systemic or neurological complications. Surgical intervention is required and often involves the drainage of the abscess, debridement of necrotic tissue, excision, and reconstruction of the affected vascular segment to control the infection and restore bloodflow.4,17,18 In this case, given the evident involvement of the carotid artery wall, we determined that arterial replacement was necessary, despite the majority of reported cases in the literature not requiring arterial replacement (Table). It should be noted that, although most cases of carotid sheath abscess in the literature have been managed conservatively with debridement and muscle flaps, there remains no standardized management algorithm for these infections owing to the paucity of literature; however, we are biased toward a more radical approach when arterial involvement is suspected because we deem the consequences of a ruptured infect arterial wall to far outweigh the risk of excision and replacement. More studies are warranted to elucidate the optimal treatment strategy for CSIs.Table Reported cases of carotid sheath abscess and infections identified in a PubMed search

Case	Etiology	Presentation	Treatment	Outcome	
Badami et al. (1981)7	Branchial cyst (secondary)	Swelling, pain, fever	Surgical management (no vascular reconstruction)	N/A	
Yamaoka et al. (1990)8	Necrotizing fasciitis 2/2 Streptococcus and Bacteroides (secondary)	Dysphagia, drowsiness, swelling	Surgical management (no vascular reconstruction)	Return to baseline 22 months postoperatively	
Kono et al. (2001)9	Descending necrotizing mediastinitis (secondary)	Fever, neck swelling, leukocytosis, elevated CRP	Surgical management (no vascular reconstruction)	Return to baseline w/o serious complications	
Agada et al. (2006)10	Cutaneous tuberculosis (secondary)	Left-sided otitis externa, right-sided Bell's palsy, dysphagia	Medical management	Death (disseminated tuberculosis)	
Lin et al. (2007)11	Descending necrotizing mediastinitis (secondary)	Fever, SOB, epigastric pain, tachycardic, tachypneic	Surgical management (no vascular reconstruction)	Return to baseline 4 weeks postoperatively	
Antonopoulos et al. (2009)12	Cavernous hemangioma (secondary)	Mild neck discomfort	Surgical management (no vascular reconstruction)	Return to baseline 7 days postoperatively	
McKay-Davies et al. (2011)13	Hematoma abscess (secondary)	Fever, neck stiffness, elevated CRP and ESR	Surgical Management (No Vascular Reconstruction)	Return to baseline 7 days postoperatively	
Tuncturk et al. (2015)2	Tooth decay infection (secondary)	Neck abscess, nausea, headache, dysphagia, leukocytosis	Surgical management (no vascular reconstruction)	Return to baseline 8 days postoperatively	
Rahhal et al. (2015)14	Uvular SCC and abscess (secondary)	Dyspnea, cough, fever, purulent sputum, tachypneic	Medical management	Death (respiratory insufficiency)	
Sanchez et al. (2018)15	CA-MRSA pericarditis (secondary)	Neck abscess, fever, tachycardia, tachypnea, leukocytosis	Surgical management (no vascular reconstruction)	Return to baseline 7 days postoperatively	
Tabatabaeishoorijeh et al. (present case)16	Spontaneous abscess (primary)	Neck abscess, pain, swelling, leukocytosis	Surgical management (with vascular reconstruction)	Return to baseline 30 days postoperatively	

Autologous grafts are preferred over prosthetic grafts as they are more resistant to reinfection.1,16,17 In this case, we opted for a reversed GSV graft, which was of adequate caliber to accommodate the size of the native artery. In the absence of a suitable GSV, other autologous conduits such as deep veins of the lower extremity or upper arm or, less commonly, upper arm veins may be used.19, 20, 21 Furthermore, given the proximity of the carotid sheath to other neck structures, the approach to carotid sheath abscess should be multidisciplinary, with collaboration between vascular surgeons, otolaryngologists, and plastics surgeons to ensure adequate surgical exposure, arterial reconstruction, and appropriate wound closure with muscle flaps. Postoperative management in this case was complicated by persistent neck pain and low-grade fever, necessitating a second surgical exploration. This case underscores the complexity of postoperative care for carotid sheath abscesses and further highlights the unpredictable nature of the recovery process which extends beyond surgical intervention to include meticulous monitoring for complications and prompt intervention.22

Conclusions

Although rare, this case demonstrates that spontaneous carotid abscess is a possible cause of neck mass, warranting a high index of suspicion for timely intervention. Surgical resection and reconstruction ensures complete eradication of the infection while maintaining arterial flow.

Disclosures

None.

E.K.P. is a consultant for Voyager Medical, Venostent and Humacyte Inc. All fees are retained by Houston Methodist.

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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References

1 Dansey K. Stratton L. Park B.D. Staphylococcus hominis carotid artery infection with septic embolization J Vasc Surg Cases 1 2015 81 83 31724579
2 Tuncturk F.R. Uzun L. Kalcioglu M.T. Egilmez O.K. Timurlenk E. Erguven M. Carotid sheath abscess caused by a tooth decay infection on the opposite side Case Rep Otolaryngol 2015 2015 739630
3 Pynnonen M.A. Gillespie M.B. Roman B. Clinical practice guideline: evaluation of the neck mass in adults Otolaryngol--Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg 157 suppl 2017 S1 S30
4 Knouse M.C. Madeira R.G. Celani V.J. Pseudomonas aeruginosa causing a right carotid artery mycotic aneurysm after a dental extraction procedure Mayo Clin Proc 77 2002 1125 1130 12374256
5 Saleh H.M. Tawfik M.M. Abouellail H. Prospective, randomized study of long-term hemodialysis catheter removal versus guidewire exchange to treat catheter-related bloodstream infection J Vasc Surg 66 2017 1427 1431.e1 28822660
6 Diandra J.C. Lo Z.J. Ang W.W. A review of arteriovenous fistulae creation in octogenarians Ann Vasc Surg 46 2018 331 336 28743653
7 Badami J.P. Athey P.A. Sonography in the diagnosis of branchial cysts AJR Am J Roentgenol 137 1981 1245 1248 6976100
8 Yamaoka M. Furusawa K. Kiga M. Iguchi K. Hirose I. Necrotizing buccal and cervical fasciitis J Cranio-Maxillo-Fac Surg 18 1990 223 224
9 Kono T. Kohno A. Kuwashima S. CT findings of descending necrotising mediastinitis via the carotid space ('Lincoln Highway') Pediatr Radiol 31 2001 84 86 11214691
10 Agada F.O. Sharma R. Makura Z.G. Atypical presentation of cutaneous tuberculosis and a retropharyngeal neck abscess Ear Nose Throat J 85 2006 60 62 16509249
11 Lin Y.Y. Hsu C.W. Chu S.J. Chen S.C. Tsai S.H. Rapidly propagating descending necrotizing mediastinitis as a consequence of intravenous drug use Am J Med Sci 334 2007 499 502 18091375
12 Antonopoulos C. Karagianni M. Zolindaki C. Anagnostou E. Vagianos C. Cavernous hemangioma of infrahyoid carotid sheath and review of the literature on carotid sheath tumors Head Neck 31 2009 1381 1386 19260115
13 McKay-Davies I. Tweedie D. Pitkin L. The perils of paint-balling BMJ Case Rep 2011 2011 bcr0920103314
14 Rahhal H. de Campos F.P. Ferreira C.R. Felipe-Silva A. Lemierre's syndrome due to intratumoral abscess of the uvula Autops Case Rep 5 2015 11 20
15 Sanchez J. Schneider A. Tretter J.T. Community-acquired MRSA pericarditis and mediastinitis in a previously healthy infant J Pediatr Intensive Care 7 2018 97 101 31073479
16 Tabatabaeishoorijeh A. Haddad P. Chauhan Y. Atkins M.D. Rahimi M. Open repair of a proximal left subclavian artery mycotic aneurysm with median claviculectomy J Vasc Surg Cases Innov Tech 10 2024 101374
17 O’Connell J.B. Darcy S. Reil T. Extracranial internal carotid artery mycotic aneurysm: case report and review Vasc Endovasc Surg 43 2009 410 415
18 Bush R.L. Lin P.H. Dodson T.F. Dion J.E. Lumsden A.B. Endoluminal stent placement and coil embolization for the management of carotid artery pseudoaneurysms J Endovasc Ther 8 2001 53 61 11220470
19 Tabiei A. Cifuentes S. Colglazier J.J. Cryopreserved arterial allografts vs autologous vein for arterial reconstruction in infected fields J Vasc Surg 79 2024 941 947 38101708
20 Forsyth A. Haqqani M.H. Alfson D.B. Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma J Vasc Surg 79 2024 1339 1346 38301809
21 Aspalter M. Bako T. Hitzl W. Long-Term results of autologous bifurcated carotid artery reconstructions Ann Vasc Surg 92 2023 93 103 36639097
22 Grossi R.J. Onofrey D. Tvetenstrand C. Blumenthal J. Mycotic carotid aneurysm J Vasc Surg 6 1987 81 83 3298700
