- Email: [email protected]
Stenting of a Retropharyngeal Internal Carotid Artery
Accepted Manuscript Stenting of a Retropharyngeal Internal Carotid Artery Gordon H. Martin, MD, FACS, Naveed U. Saqib, MD, FACS, Hazim J. Safi, MD, FACS PII:
S0890-5096(16)30225-4
DOI:
10.1016/j.avsg.2016.01.019
Reference:
AVSG 2765
To appear in:
Annals of Vascular Surgery
Received Date: 5 January 2016 Accepted Date: 8 January 2016
Please cite this article as: Martin GH, Saqib NU, Safi HJ, Stenting of a Retropharyngeal Internal Carotid Artery, Annals of Vascular Surgery (2016), doi: 10.1016/j.avsg.2016.01.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Stenting of a Retropharyngeal Internal Carotid Artery
2
4
RI PT
3
Gordon H. Martin, MD, FACS; Naveed U. Saqib, MD, FACS; Hazim J. Safi, MD, FACS
5
Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at
7
Houston, Houston, Texas
SC
6
M AN U
8 9 10 11 12
14 15
Corresponding author:
17
Hazim J. Safi, MD
18
6400 Fannin St. Suite 2850
19
Houston, TX 77030
20
Tel: 713 486 5100
21
Fax: 713 512 7200
22
[email protected]
23 24
AC C
EP
16
TE D
13
ACCEPTED MANUSCRIPT
Abstract
26
A retropharyngeal course of the carotid artery is an uncommon variant. Recognition of this
27
anatomic anomaly is important in avoiding severe hemorrhage with endotracheal intubation and
28
oropharyngeal procedures and for planning carotid interventions. We present a rare case of
29
stenting for an asymptomatic, high-grade stenosis in a retropharyngeal internal carotid artery.
RI PT
25
AC C
EP
TE D
M AN U
SC
30
ACCEPTED MANUSCRIPT
Introduction
32
Anatomic abnormalities of the carotid vessels, including aplasia, hypoplasia, and aberrant
33
positioning, are uncommon. In particular, a retropharyngeal course of the carotid artery is very
34
rare, with only a few cases reported.1-7 Significant carotid bifurcation atherosclerotic lesions
35
associated with this anatomic variant have been observed with even less frequency. Recognition
36
of this rare anatomic variant is important, as adverse events have been reported with
37
endotracheal intubation and oropharyngeal surgery.8-9 There are no reports of surgical
38
intervention for a retropharyngeal carotid plaque. Stenting has been widely reported for the
39
treatment of carotid disease in patients at high risk for perioperative complications and for
40
patients with challenging anatomy, including recurrent stenosis, irradiated necks, and high
41
cervical lesions. We report only the second case in the literature of stenting for a
42
retropharyngeal, carotid bifurcation atherosclerotic lesion.7 The patient consented to publication
43
of this report.
TE D
44
M AN U
SC
RI PT
31
Case Report
46
A 69-year-old female presented to the clinic for evaluation of an asymptomatic internal carotid
47
artery stenosis. Three years earlier she was diagnosed with occlusion of the left subclavian
48
artery, presenting with mild arm claudication symptoms. She had not experienced symptoms of
49
posterior circulation cerebral ischemia. She denied any dysphagia, dysphonia or other
50
oropharyngeal symptoms. Her medical history was significant for smoking, hypertension,
51
hypercholesterolemia, and coronary artery disease, with a prior percutaneous coronary
52
intervention. On examination, the carotid pulses were palpable in the usual anterolateral position.
53
A carotid duplex ultrasound scan demonstrated 80-99% stenosis of the left internal carotid artery
AC C
EP
45
ACCEPTED MANUSCRIPT
without evidence of an abnormal course of the vessels. Computed tomography angiography
55
(CTA) revealed a tortuous, retropharyngeal course of the left carotid artery with a focal 70-80%
56
stenosis of the proximal internal carotid artery. There was significant medial displacement of the
57
left carotid vessels. The carotid bifurcation lesion was positioned at the midline of the C3
58
vertebral body with partial compression of the posterior esophageal wall (Figure 1). The
59
proximal and intracranial vessels were unremarkable, without any other anomalies. The patient
60
was counseled on the treatment options of medical therapy and surgical or endovascular
61
intervention. There was concern regarding adequate surgical exposure of the carotid vessels, and
62
an increased risk of stroke and cranial nerve injury associated with a more extensive surgical
63
dissection.
SC
M AN U
64
RI PT
54
Additionally, the patient was apprehensive about treatment with medical therapy only. The decision was made to proceed with an endovascular intervention to obviate the exposure
66
concerns and definitively treat the lesion. The patient received preoperative Statin, ACE
67
inhibitor, and dual antiplatelet therapy. Conventional digital subtraction angiography confirmed a
68
high-grade internal carotid artery stenosis as well as occlusion of the left subclavian artery and
69
retrograde flow in the left vertebral artery (Figure 2). With utilization of distal embolic
70
protection (Emboshield NAV6, Abbott Vascular, Redwood City, Calif.) the carotid lesion was
71
treated with a tapered 6-8 mm x 40 mm Nitinol Xact stent (Abbott Vascular, Redwood City,
72
Calif.) without any complications. (Figure 3)
EP
AC C
73
TE D
65
74
Discussion
75
The common and internal carotid arteries develop from the third and fourth aortic arches.
76
Generally, the common and internal carotid arteries have a straight course through the neck,
ACCEPTED MANUSCRIPT
running lateral to the esophagus and trachea. Anatomic deviations from this course are quite
78
common, with 10-40% of patients having curvatures, elbowing or notching (10). However, the
79
incidence of an aberrant carotid artery is less common, estimated at less than 0.2%.1-2 A
80
retropharyngeal course of the carotid arteries is one of these rare anomalies and has been
81
described by Munoz1 as “kissing carotids,” due to the deviation of the carotid vessels medially
82
toward each other. Some investigators have implicated atherosclerosis, aging, hypertension and
83
fibromuscular dysplasia as inciting factors for these anatomic anomalies of the carotid vessels.10-
84
11
86 87
SC
Others12 indicate that embryology is likely the primary factor, citing the incidence of
M AN U
85
RI PT
77
carotid vessel tortuosity and kinking does not change as we age.
Most retropharyngeal carotid arteries are asymptomatic. However, some patients have presented with a pulsating mass in the posterior wall of the pharynx, dysphagia, or hoarseness.1
89
Others have presented with glossopharyngeal neuralgia,13 sleep apnea, or cerebrovascular
90
insufficiency.14
91
TE D
88
It is important for both the anesthesiologist and surgeon to be aware of this arterial variant with proximity of the carotid artery to the oropharyngeal wall. If the retropharyngeal
93
course of the carotid vessel is not noted, life-threatening hemorrhage may occur with laceration
94
of the oropharyngeal mucosa during endotracheal intubation or oropharyngeal surgery.8-9
AC C
95
EP
92
Tillman proposed the term “dangerous loop” for an aberrant cervical internal carotid
96
artery associated with a pharyngeal pseudomass, as it poses a risk during oropharyngeal
97
surgery.15 If a displaced carotid pulse is appreciated on physical examination or if oropharyngeal
98
symptoms are elicited, further imaging with CTA or magnetic resonance angiogram (MRA)
99
should be considered to evaluate for an aberrant course of the carotid vessels. Some have also
ACCEPTED MANUSCRIPT
100
advocated imaging intra-cranially to evaluate for aneurysms and other pathology which may be
101
more prevalent in these patients.16
102
Our patient’s carotid lesion was asymptomatic and may have been managed medically or surgically. While there are reports of medical management of retropharyngeal carotid arteries
104
associated with non-hemodynamically significant atherosclerotic lesions,4-6 there are no reports
105
of medical therapy for high-grade stenoses. Additionally, there are no reported cases of an
106
endarterectomy for the treatment of a retropharyngeal carotid lesion. It is unlikely that an open
107
surgical intervention for a retropharyngeal carotid lesion could be performed with the same low-
108
risk profile associated with an anatomically uncomplicated procedure. There was also concern
109
regarding the possibility of inducing dysphagia or esophageal erosion with an open repair and
110
patch angioplasty of the vessel. Additionally, our patient was adverse to medical management
111
only and the results of carotid stenting for asymptomatic lesions are acceptable, as seen in the
112
recent CREST trial.17 We are aware of only one previous case of stenting, performed for a
113
symptomatic retropharyngeal carotid lesion, with a good outcome.7
114
TE D
M AN U
SC
RI PT
103
Conclusion
116
There are significant clinical consequences associated with a retropharyngeal carotid artery and
117
this anomaly should be recognized prior to endotracheal intubation or oropharyngeal procedures
118
to avoid a hemorrhagic catastrophe. This anomaly should be noted also in planning for carotid
119
arterial intervention. Stenting has been widely adopted for the treatment of anatomically high-
120
risk lesions, including recurrent stenosis, high-cervical lesions and previously irradiated necks. A
121
retropharyngeal position of the carotid plaque may represent another anatomic indication for an
AC C
EP
115
ACCEPTED MANUSCRIPT
122
endovascular approach. Stenting of a retropharyngeal carotid lesion may be an acceptable
123
alternative to medical or surgical intervention.
AC C
EP
TE D
M AN U
SC
RI PT
124
ACCEPTED MANUSCRIPT
125
References
126
1. Munoz A, De Vergas J, Crespo J. Imaging and clinical findings in patients with aberrant
131 132 133 134 135 136 137 138 139
RI PT
130
case report. Int J Anat Var 2011;4: 174-8.
3. Chen SS, Shao KN, Chiang JH, et al. Aberrant cervical carotid artery. Zhonghua Yi Xue ZA Zhi (Taipei) 2000;63:653-7.
SC
129
2. Agrawal R, Agrawal SK. Dangerous anatomic variation of internal carotid artery – a rare
4. Mousa AY, AbuRahma AF. Retropharyngeal internal carotid artery: a rare presentation with significant clinical implications. Ann Vasc Surg 2013:27; 1189.el-1189.e4.
M AN U
128
course of the cervical internal carotid arteries Open Neuroimag J 2010;4:174-81.
5. Virvilis D, Koullias G, Labropoulos N. Bilateral retroesophageal course of the carotid arteries. J Vasc Surg 2013;57:1395-7.
6. Figueiredo RR, Aparecida de Azevedo A. Retropharyngeal Internal Carotid Artery: Case Report. Intl Arch Otorhinolaryngol 2009, vol.13, no. 1, Jan./Mar.
TE D
127
7. Jeyabalan G. Advances in Management of Carotid Artery Stenosis. Vascular Rounds (Univ. of Pittsburgh Med. Ctr.) Fall 2014 [09/14].
8. Palacios E, Kirsch D, Rojas R. Anomalous course of the carotid arteries in the
141
retropharyngeal space poses a surgical risk. Ear Nose Throat J 2005;84:336-7.
143
9. Postma GN, Buenting JE, Jones KR. Oropharyngeal perforation after traumatic intubation.
AC C
142
EP
140
Otolaryngol Head Neck Surg 1995;113:290-2.
144
10. Paulsen F, Tillman B, Christofides C, et al. Curving and looping of the internal carotid artery
145
in relation to the pharynx: frequency, embryology and clinical implications. J. Anat 2000,
146
197:373-81.
ACCEPTED MANUSCRIPT
148 149 150
11. Lam RC, Lin SC, DeRubertis B, et al. The Impact of Increasing Age on Anatomic Factors Affecting Carotid Angioplasty and Stenting. J Vasc Surg Vol. 45, No.5, 2007, pp. 875-880. 12. Beigelman R, Izaguirre AM, Robles M, et al. Are kinking and coiling of carotid artery congenital or acquired? Angiology 2010;61:107-12.
RI PT
147
151
13. Iwasaki S, Fujishiro Y, Abbey K. Glossopharyngeal neuralgia associated with aberrant
152
internal carotid artery in the oropharynx. Ann OtolRhinol Laryngol 2002;111:193-5.
155 156 157
SC
154
14. Marcucci C, Thomas P, Sewell DA. Retropharyngeal carotid artery: an important anatomic variation for the anesthesiologist. Anesthesiology 2009;111:454-5.
15. Tillman B, Christofides C. The Dangerous Loop of the Internal Carotid Artery. An Anatomic
M AN U
153
Study. HNO, Vol. 43, No. 10, 1995, pp. 601-4.
16. Siddiqui AA, Sobani ZA. Bilateral hypoplasia of the internal carotid artery presenting as a subarachnoid hemorrhage secondary to intracranial aneurysm formation: a case report. J Med
159
Case Rep 2012;6:45.
162
Carotid Artery Stenosis. N Engl J Med 2010;363:11-23.
EP
161
17. Brott TG, Hobson RW, Howard G, et al. Stenting versus Endarterectomy for Treatment of
AC C
160
TE D
158
ACCEPTED MANUSCRIPT
163
Figure Legend
164 165
Figure 1: CTA image of carotid bifurcation compression of the posterior esophageal wall.
RI PT
166 167
Figure 2: Digital subtraction angiogram demonstrating high-grade, left internal carotid artery
168
stenosis.
170
SC
169
Figure 3: Angiographic image after deployment of Nitinol stent.
AC C
EP
TE D
M AN U
171
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0890-5096(16)30225-4
DOI:
10.1016/j.avsg.2016.01.019
Reference:
AVSG 2765
To appear in:
Annals of Vascular Surgery
Received Date: 5 January 2016 Accepted Date: 8 January 2016
Please cite this article as: Martin GH, Saqib NU, Safi HJ, Stenting of a Retropharyngeal Internal Carotid Artery, Annals of Vascular Surgery (2016), doi: 10.1016/j.avsg.2016.01.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Stenting of a Retropharyngeal Internal Carotid Artery
2
4
RI PT
3
Gordon H. Martin, MD, FACS; Naveed U. Saqib, MD, FACS; Hazim J. Safi, MD, FACS
5
Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at
7
Houston, Houston, Texas
SC
6
M AN U
8 9 10 11 12
14 15
Corresponding author:
17
Hazim J. Safi, MD
18
6400 Fannin St. Suite 2850
19
Houston, TX 77030
20
Tel: 713 486 5100
21
Fax: 713 512 7200
22
[email protected]
23 24
AC C
EP
16
TE D
13
ACCEPTED MANUSCRIPT
Abstract
26
A retropharyngeal course of the carotid artery is an uncommon variant. Recognition of this
27
anatomic anomaly is important in avoiding severe hemorrhage with endotracheal intubation and
28
oropharyngeal procedures and for planning carotid interventions. We present a rare case of
29
stenting for an asymptomatic, high-grade stenosis in a retropharyngeal internal carotid artery.
RI PT
25
AC C
EP
TE D
M AN U
SC
30
ACCEPTED MANUSCRIPT
Introduction
32
Anatomic abnormalities of the carotid vessels, including aplasia, hypoplasia, and aberrant
33
positioning, are uncommon. In particular, a retropharyngeal course of the carotid artery is very
34
rare, with only a few cases reported.1-7 Significant carotid bifurcation atherosclerotic lesions
35
associated with this anatomic variant have been observed with even less frequency. Recognition
36
of this rare anatomic variant is important, as adverse events have been reported with
37
endotracheal intubation and oropharyngeal surgery.8-9 There are no reports of surgical
38
intervention for a retropharyngeal carotid plaque. Stenting has been widely reported for the
39
treatment of carotid disease in patients at high risk for perioperative complications and for
40
patients with challenging anatomy, including recurrent stenosis, irradiated necks, and high
41
cervical lesions. We report only the second case in the literature of stenting for a
42
retropharyngeal, carotid bifurcation atherosclerotic lesion.7 The patient consented to publication
43
of this report.
TE D
44
M AN U
SC
RI PT
31
Case Report
46
A 69-year-old female presented to the clinic for evaluation of an asymptomatic internal carotid
47
artery stenosis. Three years earlier she was diagnosed with occlusion of the left subclavian
48
artery, presenting with mild arm claudication symptoms. She had not experienced symptoms of
49
posterior circulation cerebral ischemia. She denied any dysphagia, dysphonia or other
50
oropharyngeal symptoms. Her medical history was significant for smoking, hypertension,
51
hypercholesterolemia, and coronary artery disease, with a prior percutaneous coronary
52
intervention. On examination, the carotid pulses were palpable in the usual anterolateral position.
53
A carotid duplex ultrasound scan demonstrated 80-99% stenosis of the left internal carotid artery
AC C
EP
45
ACCEPTED MANUSCRIPT
without evidence of an abnormal course of the vessels. Computed tomography angiography
55
(CTA) revealed a tortuous, retropharyngeal course of the left carotid artery with a focal 70-80%
56
stenosis of the proximal internal carotid artery. There was significant medial displacement of the
57
left carotid vessels. The carotid bifurcation lesion was positioned at the midline of the C3
58
vertebral body with partial compression of the posterior esophageal wall (Figure 1). The
59
proximal and intracranial vessels were unremarkable, without any other anomalies. The patient
60
was counseled on the treatment options of medical therapy and surgical or endovascular
61
intervention. There was concern regarding adequate surgical exposure of the carotid vessels, and
62
an increased risk of stroke and cranial nerve injury associated with a more extensive surgical
63
dissection.
SC
M AN U
64
RI PT
54
Additionally, the patient was apprehensive about treatment with medical therapy only. The decision was made to proceed with an endovascular intervention to obviate the exposure
66
concerns and definitively treat the lesion. The patient received preoperative Statin, ACE
67
inhibitor, and dual antiplatelet therapy. Conventional digital subtraction angiography confirmed a
68
high-grade internal carotid artery stenosis as well as occlusion of the left subclavian artery and
69
retrograde flow in the left vertebral artery (Figure 2). With utilization of distal embolic
70
protection (Emboshield NAV6, Abbott Vascular, Redwood City, Calif.) the carotid lesion was
71
treated with a tapered 6-8 mm x 40 mm Nitinol Xact stent (Abbott Vascular, Redwood City,
72
Calif.) without any complications. (Figure 3)
EP
AC C
73
TE D
65
74
Discussion
75
The common and internal carotid arteries develop from the third and fourth aortic arches.
76
Generally, the common and internal carotid arteries have a straight course through the neck,
ACCEPTED MANUSCRIPT
running lateral to the esophagus and trachea. Anatomic deviations from this course are quite
78
common, with 10-40% of patients having curvatures, elbowing or notching (10). However, the
79
incidence of an aberrant carotid artery is less common, estimated at less than 0.2%.1-2 A
80
retropharyngeal course of the carotid arteries is one of these rare anomalies and has been
81
described by Munoz1 as “kissing carotids,” due to the deviation of the carotid vessels medially
82
toward each other. Some investigators have implicated atherosclerosis, aging, hypertension and
83
fibromuscular dysplasia as inciting factors for these anatomic anomalies of the carotid vessels.10-
84
11
86 87
SC
Others12 indicate that embryology is likely the primary factor, citing the incidence of
M AN U
85
RI PT
77
carotid vessel tortuosity and kinking does not change as we age.
Most retropharyngeal carotid arteries are asymptomatic. However, some patients have presented with a pulsating mass in the posterior wall of the pharynx, dysphagia, or hoarseness.1
89
Others have presented with glossopharyngeal neuralgia,13 sleep apnea, or cerebrovascular
90
insufficiency.14
91
TE D
88
It is important for both the anesthesiologist and surgeon to be aware of this arterial variant with proximity of the carotid artery to the oropharyngeal wall. If the retropharyngeal
93
course of the carotid vessel is not noted, life-threatening hemorrhage may occur with laceration
94
of the oropharyngeal mucosa during endotracheal intubation or oropharyngeal surgery.8-9
AC C
95
EP
92
Tillman proposed the term “dangerous loop” for an aberrant cervical internal carotid
96
artery associated with a pharyngeal pseudomass, as it poses a risk during oropharyngeal
97
surgery.15 If a displaced carotid pulse is appreciated on physical examination or if oropharyngeal
98
symptoms are elicited, further imaging with CTA or magnetic resonance angiogram (MRA)
99
should be considered to evaluate for an aberrant course of the carotid vessels. Some have also
ACCEPTED MANUSCRIPT
100
advocated imaging intra-cranially to evaluate for aneurysms and other pathology which may be
101
more prevalent in these patients.16
102
Our patient’s carotid lesion was asymptomatic and may have been managed medically or surgically. While there are reports of medical management of retropharyngeal carotid arteries
104
associated with non-hemodynamically significant atherosclerotic lesions,4-6 there are no reports
105
of medical therapy for high-grade stenoses. Additionally, there are no reported cases of an
106
endarterectomy for the treatment of a retropharyngeal carotid lesion. It is unlikely that an open
107
surgical intervention for a retropharyngeal carotid lesion could be performed with the same low-
108
risk profile associated with an anatomically uncomplicated procedure. There was also concern
109
regarding the possibility of inducing dysphagia or esophageal erosion with an open repair and
110
patch angioplasty of the vessel. Additionally, our patient was adverse to medical management
111
only and the results of carotid stenting for asymptomatic lesions are acceptable, as seen in the
112
recent CREST trial.17 We are aware of only one previous case of stenting, performed for a
113
symptomatic retropharyngeal carotid lesion, with a good outcome.7
114
TE D
M AN U
SC
RI PT
103
Conclusion
116
There are significant clinical consequences associated with a retropharyngeal carotid artery and
117
this anomaly should be recognized prior to endotracheal intubation or oropharyngeal procedures
118
to avoid a hemorrhagic catastrophe. This anomaly should be noted also in planning for carotid
119
arterial intervention. Stenting has been widely adopted for the treatment of anatomically high-
120
risk lesions, including recurrent stenosis, high-cervical lesions and previously irradiated necks. A
121
retropharyngeal position of the carotid plaque may represent another anatomic indication for an
AC C
EP
115
ACCEPTED MANUSCRIPT
122
endovascular approach. Stenting of a retropharyngeal carotid lesion may be an acceptable
123
alternative to medical or surgical intervention.
AC C
EP
TE D
M AN U
SC
RI PT
124
ACCEPTED MANUSCRIPT
125
References
126
1. Munoz A, De Vergas J, Crespo J. Imaging and clinical findings in patients with aberrant
131 132 133 134 135 136 137 138 139
RI PT
130
case report. Int J Anat Var 2011;4: 174-8.
3. Chen SS, Shao KN, Chiang JH, et al. Aberrant cervical carotid artery. Zhonghua Yi Xue ZA Zhi (Taipei) 2000;63:653-7.
SC
129
2. Agrawal R, Agrawal SK. Dangerous anatomic variation of internal carotid artery – a rare
4. Mousa AY, AbuRahma AF. Retropharyngeal internal carotid artery: a rare presentation with significant clinical implications. Ann Vasc Surg 2013:27; 1189.el-1189.e4.
M AN U
128
course of the cervical internal carotid arteries Open Neuroimag J 2010;4:174-81.
5. Virvilis D, Koullias G, Labropoulos N. Bilateral retroesophageal course of the carotid arteries. J Vasc Surg 2013;57:1395-7.
6. Figueiredo RR, Aparecida de Azevedo A. Retropharyngeal Internal Carotid Artery: Case Report. Intl Arch Otorhinolaryngol 2009, vol.13, no. 1, Jan./Mar.
TE D
127
7. Jeyabalan G. Advances in Management of Carotid Artery Stenosis. Vascular Rounds (Univ. of Pittsburgh Med. Ctr.) Fall 2014 [09/14].
8. Palacios E, Kirsch D, Rojas R. Anomalous course of the carotid arteries in the
141
retropharyngeal space poses a surgical risk. Ear Nose Throat J 2005;84:336-7.
143
9. Postma GN, Buenting JE, Jones KR. Oropharyngeal perforation after traumatic intubation.
AC C
142
EP
140
Otolaryngol Head Neck Surg 1995;113:290-2.
144
10. Paulsen F, Tillman B, Christofides C, et al. Curving and looping of the internal carotid artery
145
in relation to the pharynx: frequency, embryology and clinical implications. J. Anat 2000,
146
197:373-81.
ACCEPTED MANUSCRIPT
148 149 150
11. Lam RC, Lin SC, DeRubertis B, et al. The Impact of Increasing Age on Anatomic Factors Affecting Carotid Angioplasty and Stenting. J Vasc Surg Vol. 45, No.5, 2007, pp. 875-880. 12. Beigelman R, Izaguirre AM, Robles M, et al. Are kinking and coiling of carotid artery congenital or acquired? Angiology 2010;61:107-12.
RI PT
147
151
13. Iwasaki S, Fujishiro Y, Abbey K. Glossopharyngeal neuralgia associated with aberrant
152
internal carotid artery in the oropharynx. Ann OtolRhinol Laryngol 2002;111:193-5.
155 156 157
SC
154
14. Marcucci C, Thomas P, Sewell DA. Retropharyngeal carotid artery: an important anatomic variation for the anesthesiologist. Anesthesiology 2009;111:454-5.
15. Tillman B, Christofides C. The Dangerous Loop of the Internal Carotid Artery. An Anatomic
M AN U
153
Study. HNO, Vol. 43, No. 10, 1995, pp. 601-4.
16. Siddiqui AA, Sobani ZA. Bilateral hypoplasia of the internal carotid artery presenting as a subarachnoid hemorrhage secondary to intracranial aneurysm formation: a case report. J Med
159
Case Rep 2012;6:45.
162
Carotid Artery Stenosis. N Engl J Med 2010;363:11-23.
EP
161
17. Brott TG, Hobson RW, Howard G, et al. Stenting versus Endarterectomy for Treatment of
AC C
160
TE D
158
ACCEPTED MANUSCRIPT
163
Figure Legend
164 165
Figure 1: CTA image of carotid bifurcation compression of the posterior esophageal wall.
RI PT
166 167
Figure 2: Digital subtraction angiogram demonstrating high-grade, left internal carotid artery
168
stenosis.
170
SC
169
Figure 3: Angiographic image after deployment of Nitinol stent.
AC C
EP
TE D
M AN U
171
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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EP
TE D
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ACCEPTED MANUSCRIPT