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Simultaneous Revascularization of the Internal Carotid and Vertebral Arteries in their Distal Cervical Segments
Technical notes
Simultaneous Revascularization of the Internal Carotid and Vertebral Arteries in their Distal Cervical Segments Alain Branchereau MD, Michel Ferdani, MD, Louis Scotti, MD, Marseille, France
Flbrodysplaslc lesions or tortuosity, involving both ipsilateral carotid and distal vertebral arteries may be treated by a one stage combined procedure of external and internal carotid artery transposition and possibly dilatation of the internal carotid artery. Indications for this technique are uncommon. Only 4 of 969 cerebrovascular reconstructions performed between January 1980 and June 1986 utlllzed this method. Goad results were obtained in all cases. This technique is a satisfactory and simple solution for certain situations requiring vascular reconstruction. (Ann Vasc S U ~1986, , 1, 267-270). KEY-WORDS :Carotid flbromuscular dysplasia.
Fibromuscular dysplasia (FMD) or tortuosity of the carotid or vertebral arteries can cause focal ischemia or more commonly non-hemispheric symptoms. While the goal of surgery is to relieve the patient of sym toms, it is important to improve cerebral blood f row and restore both carotid and vertebra1 arterial flow. These lesions are usually located high in the subparotid space for the internal carotid artery (ICA) and at the suboccipital level for the vertebral artery (VA). The technique described allows a one stage combined reconstruction for ipsilateral carotid and vertebral lesions [l].
From the Service de Chirurgie Vasculaire, H6pital de la Timone, Marseille, France. Reprint re uests :A . Branchereau, MD, Service de Chirurgie Vascu?aire, HSpital de la Timone, 13385 Marseille cedex 04 France.
- Distal vertebral bypass.
TECHNIQUE An incision anterior to the sternocleidomastoid is extended upward to the mastoid process. The ICA is exposed distally, the digastric muscle is sectioned and the hypoglossal nerve mobilized. If necessary the styloid process is gently broken off and the ICA may be seen to within 1 to 2 cm of the skull. The VA is approached in the Cl-C2 interspace. If additional exposure of the VA is needed the C1 bony canal may be unroofed [2, 31. The external carotid artery (ECA) is mobilized by ligating its branches up to and including the facial artery in order to obtain a segment with adequate length and diameter for revascularization of the ICA (Fig. 2). In the case of FMD gentle intraluminal dilatation may be necessary to treat an area of stenosis [4]. This is performed through an arteriotomy in the carotid bifurcation after systemic heparinization and cross clampin the common carotid artery. This maneuver may a so relieve a tortuous artery of its kink,
f
268
REVASCULARIZATION OF THE ICA A N D VERTEBRAL ARTERY
ANNALS OF VASCULAR SLJRFERY
Fig. 1. - Example of carotid fibromuscular dysplasia (double arrow) associated with abnormal penetration of the vertebral artery into the transverse canal (single arrow).
but may then produce excess length. Saline is injected to determine the diameter and precise length of the artery after dilatation. The ICA is then trimmed transversely and anastomosed end-to-end with the proximal prepared segment of the ECA (Fig. 3). The arteriotomy at the carotid bifurcation is then closed and arterial blood flow restored. The proximal ICA is then transposed, trimmed, and anastomosed with the distal VA either end-to-end or endto-side (Fig. 4). From January 1980 to June 1986 we performed this procedure four times without complication. In all cases postoperative arteriograms demonstrated patency.
Fig. 2. - Location of arterial transections for reconstruction (insert : intraluminal dllatatlon of the internal carotid artery).
DISCUSSION Combined ipsilateral carotid and vertebral artery reconstructions may be indicated for : - a symptomatic carotid lesion associated with non-hemispheric symptoms and an ipsilateral VA lesion,
- non-hemispheric symptoms associated with iPsilateral ICA and VA lesions which both have high grade stenoses, or - a symptomatic carotid lesion associated with a severely stenosed, dominant ipsilateral VA [l, 5 , 61.
VOLUME 1
NO 2 - 1986
REVASCULARIZATION OF THE ICA AND VERTEBRAL ARTERY
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269
Fig. 3. First Step of the reVaSCUlarlZatiOn : anastomosis between the mobilized external carotid artery and the distal segment of the internal carotid artery.
Fig. 4. - Second step of the revascularizatlon : after blood flow to the internal carotid artery is restored, anastomosis is performed between the proximal stump of the internal car+ tid artery and the distal vertebral artery.
In particular, external and internal carotid artery transposition, as described here, is indicated for coexisting FMD and/or tortuosity of the ICA and ipsilateral middle or distal VA. The surgeon may decide to proceed with this operation after intraluminal dilatation, if the internal carotid wall is suitable. Indications for this operation are infrequent. In our experience between January 1980 and June 1986, only 104 of 969 reconstructions involving cerebrovascular arteries involved combined carotid and
vertebral artery procedures and only four cases were done by the method described here. Alternative rnethods include : a),.double saphenous vein bypasses from the common carotid artery to both the distal ICA and the distal extracranial V A , and b) intraluminal dilatation and possibly a shortening procedure of the ICA with a vein bypass graft to the distal VA [2, 71. Neither is faster or easier and each involves the additional time and risk of saphenous vein harvesting. One disadvantage of our technique
REVASCLILARIZATION OF THE ICA AND VERTEBRAL ARTERY
270
ANNALS ot. VASCULAR SLJRGFRY
is the sacrifice of the ECA, precluding its possible later utilization for extracranial to intracranial bypass. Under the circumstances previously mentioned, the technique of external and internal carotid transposition is simple, time efficient, and probably the best solution. The functional and anatomic results obtained have always been satisfactory.
REFERENCES 1. KIEFFER E , RANCUREL G . Surgical management of
-
Fig. 5. Postoperative arteriogram demonstrating postoperative patency.
combined carotid and vertebral disease. In ; BERGUER R.. BAUER R.B. ed. Vertebrobasilar arterial occlusive di.wuse. New York, Raven Press 1984, 305-311. 2. KIEFFER E . Chirurgie de I’artbre vertebrale. Encycl M i d Chir (Paris, France), Techniques chirurgiales, Chirurgie vasculaire, 43130, 4.9.12 ; 34 p. 3. LAUKIAN C, GEORGE B. Abord de I’artere vertkbrale extracrbnienne. Etude anatomique, inter& chirurgical. Nouv Presse M i d , 1979 ;8 ;436. 4. MORRIS GC Jr, LECHTER A, DE BAKEY ME. Surgical treatment of fibromuscular disease of the carotid arteries. Arch Surg, 1968 ; y6 ;636-643. 5 , BERGUER R. Selections of patients choice of surgical technique, and results with vertebral artery reconstruction. In : BERGUER R., BAUER R.B., eds. Vertebrobasilar urferial occlusive disease. New York, Raven Press 1984 ; 297-303. 6. KIEFFER E, RANCUREL G , BRANCHEREAU A . L’insuffisance vertkbrobasilaire par lksion de l’artbre vertebrale. J . Mal. Vasc., 1985 : 10, Suppl. C, 235-309. 7. KIEFFER E . RANCUREL G . RICHARD T. Reconstruction of the distal vertebral artery. In :BERGUER R, BAUER R cds. Vertebrobasilar arterial occlusive disease. New York. Raven Press 1984 : 265-289.
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Simultaneous Revascularization of the Internal Carotid and Vertebral Arteries in their Distal Cervical Segments Alain Branchereau MD, Michel Ferdani, MD, Louis Scotti, MD, Marseille, France
Flbrodysplaslc lesions or tortuosity, involving both ipsilateral carotid and distal vertebral arteries may be treated by a one stage combined procedure of external and internal carotid artery transposition and possibly dilatation of the internal carotid artery. Indications for this technique are uncommon. Only 4 of 969 cerebrovascular reconstructions performed between January 1980 and June 1986 utlllzed this method. Goad results were obtained in all cases. This technique is a satisfactory and simple solution for certain situations requiring vascular reconstruction. (Ann Vasc S U ~1986, , 1, 267-270). KEY-WORDS :Carotid flbromuscular dysplasia.
Fibromuscular dysplasia (FMD) or tortuosity of the carotid or vertebral arteries can cause focal ischemia or more commonly non-hemispheric symptoms. While the goal of surgery is to relieve the patient of sym toms, it is important to improve cerebral blood f row and restore both carotid and vertebra1 arterial flow. These lesions are usually located high in the subparotid space for the internal carotid artery (ICA) and at the suboccipital level for the vertebral artery (VA). The technique described allows a one stage combined reconstruction for ipsilateral carotid and vertebral lesions [l].
From the Service de Chirurgie Vasculaire, H6pital de la Timone, Marseille, France. Reprint re uests :A . Branchereau, MD, Service de Chirurgie Vascu?aire, HSpital de la Timone, 13385 Marseille cedex 04 France.
- Distal vertebral bypass.
TECHNIQUE An incision anterior to the sternocleidomastoid is extended upward to the mastoid process. The ICA is exposed distally, the digastric muscle is sectioned and the hypoglossal nerve mobilized. If necessary the styloid process is gently broken off and the ICA may be seen to within 1 to 2 cm of the skull. The VA is approached in the Cl-C2 interspace. If additional exposure of the VA is needed the C1 bony canal may be unroofed [2, 31. The external carotid artery (ECA) is mobilized by ligating its branches up to and including the facial artery in order to obtain a segment with adequate length and diameter for revascularization of the ICA (Fig. 2). In the case of FMD gentle intraluminal dilatation may be necessary to treat an area of stenosis [4]. This is performed through an arteriotomy in the carotid bifurcation after systemic heparinization and cross clampin the common carotid artery. This maneuver may a so relieve a tortuous artery of its kink,
f
268
REVASCULARIZATION OF THE ICA A N D VERTEBRAL ARTERY
ANNALS OF VASCULAR SLJRFERY
Fig. 1. - Example of carotid fibromuscular dysplasia (double arrow) associated with abnormal penetration of the vertebral artery into the transverse canal (single arrow).
but may then produce excess length. Saline is injected to determine the diameter and precise length of the artery after dilatation. The ICA is then trimmed transversely and anastomosed end-to-end with the proximal prepared segment of the ECA (Fig. 3). The arteriotomy at the carotid bifurcation is then closed and arterial blood flow restored. The proximal ICA is then transposed, trimmed, and anastomosed with the distal VA either end-to-end or endto-side (Fig. 4). From January 1980 to June 1986 we performed this procedure four times without complication. In all cases postoperative arteriograms demonstrated patency.
Fig. 2. - Location of arterial transections for reconstruction (insert : intraluminal dllatatlon of the internal carotid artery).
DISCUSSION Combined ipsilateral carotid and vertebral artery reconstructions may be indicated for : - a symptomatic carotid lesion associated with non-hemispheric symptoms and an ipsilateral VA lesion,
- non-hemispheric symptoms associated with iPsilateral ICA and VA lesions which both have high grade stenoses, or - a symptomatic carotid lesion associated with a severely stenosed, dominant ipsilateral VA [l, 5 , 61.
VOLUME 1
NO 2 - 1986
REVASCULARIZATION OF THE ICA AND VERTEBRAL ARTERY
-
269
Fig. 3. First Step of the reVaSCUlarlZatiOn : anastomosis between the mobilized external carotid artery and the distal segment of the internal carotid artery.
Fig. 4. - Second step of the revascularizatlon : after blood flow to the internal carotid artery is restored, anastomosis is performed between the proximal stump of the internal car+ tid artery and the distal vertebral artery.
In particular, external and internal carotid artery transposition, as described here, is indicated for coexisting FMD and/or tortuosity of the ICA and ipsilateral middle or distal VA. The surgeon may decide to proceed with this operation after intraluminal dilatation, if the internal carotid wall is suitable. Indications for this operation are infrequent. In our experience between January 1980 and June 1986, only 104 of 969 reconstructions involving cerebrovascular arteries involved combined carotid and
vertebral artery procedures and only four cases were done by the method described here. Alternative rnethods include : a),.double saphenous vein bypasses from the common carotid artery to both the distal ICA and the distal extracranial V A , and b) intraluminal dilatation and possibly a shortening procedure of the ICA with a vein bypass graft to the distal VA [2, 71. Neither is faster or easier and each involves the additional time and risk of saphenous vein harvesting. One disadvantage of our technique
REVASCLILARIZATION OF THE ICA AND VERTEBRAL ARTERY
270
ANNALS ot. VASCULAR SLJRGFRY
is the sacrifice of the ECA, precluding its possible later utilization for extracranial to intracranial bypass. Under the circumstances previously mentioned, the technique of external and internal carotid transposition is simple, time efficient, and probably the best solution. The functional and anatomic results obtained have always been satisfactory.
REFERENCES 1. KIEFFER E , RANCUREL G . Surgical management of
-
Fig. 5. Postoperative arteriogram demonstrating postoperative patency.
combined carotid and vertebral disease. In ; BERGUER R.. BAUER R.B. ed. Vertebrobasilar arterial occlusive di.wuse. New York, Raven Press 1984, 305-311. 2. KIEFFER E . Chirurgie de I’artbre vertebrale. Encycl M i d Chir (Paris, France), Techniques chirurgiales, Chirurgie vasculaire, 43130, 4.9.12 ; 34 p. 3. LAUKIAN C, GEORGE B. Abord de I’artere vertkbrale extracrbnienne. Etude anatomique, inter& chirurgical. Nouv Presse M i d , 1979 ;8 ;436. 4. MORRIS GC Jr, LECHTER A, DE BAKEY ME. Surgical treatment of fibromuscular disease of the carotid arteries. Arch Surg, 1968 ; y6 ;636-643. 5 , BERGUER R. Selections of patients choice of surgical technique, and results with vertebral artery reconstruction. In : BERGUER R., BAUER R.B., eds. Vertebrobasilar urferial occlusive disease. New York, Raven Press 1984 ; 297-303. 6. KIEFFER E, RANCUREL G , BRANCHEREAU A . L’insuffisance vertkbrobasilaire par lksion de l’artbre vertebrale. J . Mal. Vasc., 1985 : 10, Suppl. C, 235-309. 7. KIEFFER E . RANCUREL G . RICHARD T. Reconstruction of the distal vertebral artery. In :BERGUER R, BAUER R cds. Vertebrobasilar arterial occlusive disease. New York. Raven Press 1984 : 265-289.
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