Reversible Rapid Neck Swelling Following Carotid Artery Stenting: A Case Report

A 63-year-old man, who was on follow-up for squamous cell carcinoma of thebase of the tongue status postradiation therapy 3 years prior, presented for color Doppler examination of the neck vessels. He was asymptomatic for neurologic deficits and was being treated for radiation-induced hypothyroidism and xerostomia. Clinical examination revealed no neck masses or nodes. Chest radiograph revealed fibrosis in both lung apices. Duplex study of the neck vessels (Toshiba Medical Systems Corporation, Xario, Japan) demonstrated diffuse long segment wall thickening of bilateral common carotid arteries with 80% stenosis. Laboratory work-up was negative for inflammatory markers. Hewas started on 75 mgof oral acetyl salicylic acid per day, and a repeat examination performed 3 months later revealed progression of the stenosis to 90% bilaterally. We planned for bilateral carotid artery stenting in a staged manner. The left common carotid artery was treated first. He was given a loading dose of clopidogrel 300 mg orally, 2 hours prior to the procedure. The procedure was performed under local anesthesia. A digital subtraction angiography of the left common carotid artery demonstrated multiple segments of narrowing (►Fig. 1) involving the common carotid artery, with the narrowest portion measuring 90%, just below the carotid artery bifurcation. The distal most segments of the common carotid artery and the internal carotid artery were normal. The external carotid artery branches were uniformly narrowed. The contrast iohexol (Omnipaque, Nycomed Imaging AS, Oslo, Norway) was injected with hand, each injection approximately 2 to 4 mL during the procedure. Subsequently, a 7-F, 45-cm long sheath (Arrow International, Reading, Pennsylvania, United States) was placed within the left common carotid artery. A bolus intravenous injection of heparin 5,000 U was given. An 8 mm 8 cm self-expanding stent Protégé GPS EV3 (EV3, Plymouth, Minnesota, United States) was placed across the abnormal segments of left common carotid artery over a 0.035-inch glidewire (Terumo Corporation, Somerset, New Jersey). A distal protection device was not used. Angioplasty was performed using a 7 mm 6 cm balloon (Cook Medical Inc., Bloomington, Indiana, United States). There was adequate restoration of the lumen (►Fig. 2) on postangioplasty angiography. There were no intracranial emboli on postprocedure cerebral angiography. Approximately 1 hour after the procedure, patient developed left neck swelling (►Fig. 3). His blood pressure was 90/60 mm Hg. A color Doppler examination of the neck vessels revealed a patent left common carotid artery and the stent. There was no hematoma around the left common carotid artery. The left parotid gland showed diffuse swelling with edema. He also complained of mild head ache. A reperfusion injurywas considered as the possiblemechanism Keyword ► carotid artery stenting Abstract We report a case of rapid neck swelling from diffuse enlargement of the parotid gland that developed following stenting of the common carotid artery for significant stenosis in a postradiation scenario. Hyperperfusion was considered as the possible mechanism. The pathology and differential diagnoses are discussed. It was conservatively managed and there was significant reduction in the swelling within three days.