|Year : 2020 | Volume
| Issue : 4 | Page : 432-434
Internal carotid to external carotid transposition for symptomatic carotid stenosis with associated coil
Nicolas Ramly1, Animesh Singla2, Eric Farmer2
1 Depertment of Vascular Surgery, Liverpool Hospital; University of New South Wales, Sydney, Australia
2 Depertment of Vascular Surgery, Liverpool Hospital, Sydney, Australia
|Date of Submission||13-Apr-2020|
|Date of Acceptance||12-May-2020|
|Date of Web Publication||24-Dec-2020|
Depertment of Vascular Surgery, Liverpool Hospital; University of New South Wales, Sydney
Source of Support: None, Conflict of Interest: None
The significance of dolichoarteriopathies of the internal carotid artery (ICA) both in isolation and in the context of the proximal stenosis is a topic of contention. The majority of asymptomatic cases are treated conservatively, however symptomatic cases which can present as transient ischemic attacks or stroke, often require surgical intervention. Herein, we discuss unique surgical management of a patient with a symptomatic high-grade left internal carotid artery (ICA) stenosis and concurrent ICA coiling in which an end-to-side anastomosis onto the external carotid artery was performed.
Keywords: Anastomosis, coiling, endarterectomy
|How to cite this article:|
Ramly N, Singla A, Farmer E. Internal carotid to external carotid transposition for symptomatic carotid stenosis with associated coil. Indian J Vasc Endovasc Surg 2020;7:432-4
|How to cite this URL:|
Ramly N, Singla A, Farmer E. Internal carotid to external carotid transposition for symptomatic carotid stenosis with associated coil. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Mar 9];7:432-4. Available from: https://www.indjvascsurg.org/text.asp?2020/7/4/432/304632
| Introduction|| |
The significance of dolichoarteriopathies of the internal carotid artery (ICA) both in isolation and in the context of proximal stenosis is a topic of contention. While most asymptomatic cases are treated conservatively, when symptomatic they can result in transient ischemic attacks or stroke, requiring surgical intervention. Herein, we discuss unique surgical management of a patient with a symptomatic high-grade left internal carotid (ICA) stenosis and concurrent ICA coiling.
| Case Report|| |
An 85-year-old male presented to a peripheral hospital with dysarthria right-sided facial droop, and right arm weakness. His medical history included previous cerebrovascular accident, atrial fibrillation on anticoagulation, and chronic renal insufficiency. He had a known 50%–60% left ICA stenosis from imaging 2 years prior. He was a lifelong nonsmoker. He was independent of activities of daily living. Magnetic resonance imaging demonstrated acute embolic infarcts in his left frontoparietal territory. He was referred for urgent investigation with a carotid artery duplex, which demonstrated an 80%–99% diameter stenosis of the left ICA, involving the proximal 2.5 cm of the vessel origin with concurrent 50% of external carotid artery (ECA) stenosis. The more cephalad portion of the ICA was also noted to be very tortuous, forming a complete loop (type II dolichoartheriopathy) [Figure 1].
|Figure 1: Computed tomography reconstruction demonstrating the tortuous path of the left internal carotid artery|
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The patient underwent urgent carotid endarterectomy. The procedure was performed under general anesthetic, with nasotracheal intubation and intraoperative shunting. Cerebral oximetry was used as a surrogate for ipsilateral hemispheric perfusion. Intraoperatively, findings showed a hemorrhagic plaque with in situ thrombosis. Distally, as suspected, there was significant tortuosity and kinking of the distal ICA. Due to the severity of the kink, the patient could not undergo standard patch plasty without risking significant stenosis of the graft. Following resection of the endarterectomised portion of the ICA, the remaining length of distal ICA was transposed onto the proximal ECA origin (which had undergone eversion endarterectomy) with an end-to-side anastomosis using 6-0 prolene. The proximal end of the ICA stump was oversewn with 6-0 prolene. Intraoperative photographs demonstrating the patient's anatomy pre- and post-intervention are included in this study [Figure 2] and [Figure 3].
|Figure 2: Intra-operative photograph demonstrating the patient's anatomy prior to any operative intervention|
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|Figure 3: Intra-operative photograph demonstrating the end to side anastomosis of the internal carotid artery onto the external carotid artery|
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The patient recovered well postoperatively and was discharged on day 2 postoperatively.
| Discussion|| |
Dolichoarteriopathies of the ICA result from its elongation between its two points of fixation – the bifurcation of the common carotid artery and the carotid canal – and involve tortuosity, coiling, or kinking of the artery in isolation or in combination. Tortuosity is defined as exaggerated C or S-shaped curving. Coiling is defined as a circular configuration of the ICA. Kinking is defined as a sharp angulation of the ICA.,,
The pathogenesis of dolichoarteriopathies remains unclear. Initially, they were thought to be related to increased age, as well as cardiac risk factors. However, a carotid duplex Doppler study involving 885 participants ranging from age one to ninety, demonstrated no increase in prevalence with age, and no relationship between incidence and cardiac risk factors. Focus is now being placed on congenital factors that may play a role in disease development.
The indication for the management of dolichoarteriopathies is also a topic of contention. The European Society for Vascular and Endovascular Surgery does not recommend the surgical management of isolated lesions when asymptomatic. When symptomatic – associated with a transient ischemic attack or with stroke symptoms – a multidisciplinary team review to rule out alternate causes is recommended before the performance of corrective surgery.
The significance of coils associated with carotid artery bifurcation stenosis is unclear. There is a hypothetical risk that they increase the risk of postendarterectomy complications through the altered hemodynamics they cause; however, data to support this are lacking. Regardless, these are often removed intraoperatively in the hope of decreasing postoperative thrombosis and restenosis.
Although evident on multiplanar reconstruction images of computed tomography scan, the use of ultrasound as an imaging modality allowed us to visualize this extensive tortuosity in advance. The visualization of the loop and also the visualization of the distal extent of the plaque sonographically gave us the confidence we could access this lesion surgically.
Management options are numerous and include posterior transverse plication, resection of the tortuous portion with an end-to-end anastomosis of the ICA to the proximal ICA stump, or the carotid artery, or to the ECA. Bypass grafting can also be considered, either with a synthetic or autologous graft; however, this method is less preferred and utilized when other methods are not appropriate.,,
| Conclusion|| |
The significance of dolicoarthropathies, both in isolation and in association with carotid bifurcation disease, remains unclear. Management recommendations at this stage are based on either consensus opinion (asymptomatic isolated lesions) and the results of a single randomized controlled trial (symptomatic isolated lesions). No formal recommendations are available regarding lesions associated with carotid bifurcation stenosis. Further research into this area is needed before definitive guidelines can be established. However, as it is common practice for many vascular surgeons to remove the lesions when encountered in carotid endarterectomies, it is important to have a thorough understanding of the management options.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]