{'fraction_non_alphanumeric': 0.023688288687181758, 'fraction_numerical': 0.004870489262785035, 'mean_word_length': 5.605263157894737, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Hath David once again slayed Goliath?

The most common and disabling neurologic condition, stroke, occurs in over one-half million elderly people annually [1]. The etiology of upward to 1/3 of these strokes is referable to carotid artery occlusive disease. Carotid endarterectomy (CEA) has traditionally been maintained as the standard of care in the treatment of patients with significant extracranial obstructive carotid artery stenosis [2]. During the previous decade, two landmark trials, North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS), conclusively demonstrated that carotid endarterectomy reduce the risk for strokes and death in both symptomatic and asymptomatic patients with carotid artery obstruction as compared to conservative medical therapy [3, 4]. As is true with any vascular procedure, surgical or endovascular, there always exists the potential risk to incur complications and resultant morbidity despite their proven safe track records. In the case of CEA, a procedure that was originally pioneered by Eascott and DeBakey [2] in the 1950s, even in experienced operators the complication rates have been reportedly acceptably low, notably the specific complication of a postsurgical pseudoaneurysm (PSA), although rare, with the incidence estimated to be approximately 0.3%. The formation of a carotid pseudoaneurysm post-CEA, while more commonly seen in cases where prosthetic patches were employed, further raises the possibility that the etiology of the PSA is due to an occult infection, which similarly is seen in the context of prosthetic graft conduit. With the advent of nonsurgical revascularization procedures and rapidly evolving technologic advances in endovascular devices (e.g., thrombin injection, stents, covered stent grafts, and coils for embolization), the traditional surgical repair following vascular injury may someday be replaced by alternative, less invasive therapeutic options in selected cases [6–11]. In the accompanying article, Gupta, et al. [5], present a case report of a very large pseudoaneurysm that was successfully repaired endovascularly with a covered stent graft. The patient had undergone a previous right CEA with a Dacron patch and 2 years post-CEA had developed what eventually was diagnosed as a pseudoaneurysm involving the common carotid artery. The patient did not seek medical attention, therefore delaying appropriate evaluation and definitive diagnosis until symptoms progressed over the ensuing 2 years, at which time a carotid duplex ultrasound confirmed the appearance of a giant (6 cm 4 cm) PSA. Further complicating the scenario was occlusion of the surgically revascularized internal carotid artery and a concomitant severe stenosis involving the proximal external carotid artery (ECA). In light of the patient’s extensive comorbid disease, she was deemed to be at very high risk for surgical reintervention, therefore a less invasive endovascular repair employing a covered stent graft was successfully deployed. Unique to this case, the interventionalist elected to perform adjunctive balloon angioplasty of the stenotic ECA, thus preserving its patency potentially to ensure collateral flow to the ipsilateral intracranial circulation. Acute technical and clinical success were achieved without neurologic or associated complications, and at 6-month follow-up the duplex ultrasonography documented absence of flow within the PSA and a significant reduction in its size. A number of features unique to this case allow us to glean important lessons in the evaluation and management of these patients, albeit rare. The massive size of the pseudoaneurysm (“giant” as described by the authors) in and of itself imposes any management strategy a challenging feat. The etiology of its formation, although not conclusive, temporally was related to a violent coughing episode, which has been implicated in spontaneous carotid and vertebral artery dissections, which one might implicate as the provocative event in this woman. Her prolonged delay in seeking medical attention undoubtedly contributed to the tremendous size termed “giant,” elusive as this definition may be. Other compelling features are the anatomic considerations, located in the common carotid artery with occlusion of the internal carotid artery and a hemodynamically significant stenosis of the ECA. The operators describe in detail the technical aspects of the endovascular stent graft procedure, includ-