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Surgical correction of the kinked carotid artery
Surgical Correction of the Kinked Carotid Artery
David Rosenthal, MD, Atlanta, Georgia Paul E. Stanton, Jr., MD, FACS, Atlanta, Georgia Pano A. Lamis, MD, FACS, Atlanta, Georgia David McClusky, MD, Atlanta, Georgia
The association between kinking of the internal carotid artery and cerebrovascular insufficiency was first described by Riser et al [I]. Since that initial report, no conclusive evidence has been presented to demonstrate the hemodynamic significance of a kinked internal carotid artery. Stanton et al [2] recently correlated positional oculoplethysmography with intraoperative electromagnetic flow measurements and demonstrated the benefit of correcting the symptomatic carotid artery kink. Previously, our technique for resecting an internal carotid artery kink involved ligating the external carotid artery and reducing the kink by excising a portion of the common carotid artery [2]. We currently prefer a reimplantation technique whereby preservation of the external carotid artery is maintained, resection of the internal carotid artery is avoided and, when necessary, endarterectomy may be safely performed.
cephalographic monitoring is employed to evaluate the adequacy of cerebral blood flow during carotid occlusion. After positional electromagnetic flowmeter studies are completed, the patient is heparinized and trial clamping of the internal carotid artery is performed. If no electroencephalographic evidence of cerebral ischemia is demonstrated, the internal carotid artery is divided obliquely at the carotid bifurcation (Figure 1). If concomitant carotid atherosclerotic occlusive disease is present, eversion endarterectomy of the internal carotid artery is performed and the endarterectomy continued until the plaque tapers to its end (Figure 2). The site of the anastomosis is determined by approximating the cut end of the internal carotid artery to the side
Surgical Technique Ten operations were performed usinggeneral anesthesia. The carotid bifurcation was exposed by standard technique. If necessary, the internal carotid artery was mobilized to the base of the skull and all fibrous bands were severed. Meticulous dissection is necessary around the kinked area, as the internal carotid artery is often extremely thin in this region. If adequate mobilization of the internal carotid artery is not complete, accentuation of a kink may occur after resection and reanastomosis of the proximal internal carotid artery. Twelve-lead electroenFrom the Department of Surgery, Georgia Baptist Medical Center, Atlanta, Georgia 30312. Requests for reprints should be addressed to David Rosenthal, MD, Suite 412. 315 Boulevard N.E., Atlanta, Georgia 30312.
Volume 141, February 1991
F&e 1, lelt. Internal carotid artery divkfed hquely at the carotid bliurcatlon. Figure 2, rlght. Eve&on endarterectomy of a kinked Internal carot/d artery.
295
Rosenthal et al
Figure 3, left. SHe of Internal carotid artery anastomosis determIn?d by approxlmatlng the end of the internal carotid artery to the side of the common carotid artery. Figure 4, right. End-to-side anastomosis completed. The original internal carol/d arierectomy site is closed.
of the common carotid artery (Figure 3). The common carotid is incised at this level, or the arteriotomy may be extended from the original internal carotid arterectomy site. If atherosclerotic plaque is encountered at the reimplantation site, a limited endarterectomy may be performed. After endarterectomy, an end-to-end anastomosis is fashioned and the defect in the common carotid artery is closed (Figure 4). Cerebral ischemia manifested by electroencephalographic changes necessitates the use of a temporary shunt. The internal carotid artery is incised as in Figure 1 and a shunt is rapidly inserted (Figure 5). If extensive endarterectomy is necessary, the shunt may be inserted through a separate common carotid arteriotomy, proximal to the anastomotic site. Routinely, however, this is cumbersome and adds an additional arteriotomy closure. With electroencephalographic monitoring, we were forced to use a shunt in only one patient in this series. Before completion of operation, positional electromagnetic flow studies are repeated. Cerebrovascular insufficiency symptoms may occur in the kinked carotid artery despite the absence of atherosclerotic occlusive disease. Metz et al [3] reported that 15 percent of the population has kinking of the carotid artery, and therefore the importance of its diagnosis and surgical treatment in selected patients cannot be overemphasized.
Summary The hemodynamic significance of the kinked internal carotid artery and cerebrovascular insufficiency are demonstrated. Several procedures have been devised to correct a carotid kink, but these involve resection or excision of the internal, external or common carotid artery. We currently prefer a reimplantation technique whereby preservation of the external carotid is maintained, resection of the internal carotid artery is avoided and, when necessary, endarterectomy may be safely employed. References
: Figure 5. Wth electroencephalographlc evidence of ischemla, a temproary shuti is necessary. the shunt may also be Inserted through a separate common carotid arterrOtomy, proximal to the anastomotlc Me.
296
1. Riser MM, Gerard J, Ducodray J. Dolico-Internal carotid with vertiginous syndrome. Rev Neurol 1951;85:10. 2. Stanton PE. McClusky D, Lamis P. Hemodynamic assessment and surgical correction of kinking of the internal carotid artery. Surgery 1978;84:793-802. 3. Metz M, Murray-Leslie RM, Bannister RB. Kinking of the internal carotid artery in relation to cerebrovascular disease. Lancet 1981;1:424.
The American Journal of Surgery
David Rosenthal, MD, Atlanta, Georgia Paul E. Stanton, Jr., MD, FACS, Atlanta, Georgia Pano A. Lamis, MD, FACS, Atlanta, Georgia David McClusky, MD, Atlanta, Georgia
The association between kinking of the internal carotid artery and cerebrovascular insufficiency was first described by Riser et al [I]. Since that initial report, no conclusive evidence has been presented to demonstrate the hemodynamic significance of a kinked internal carotid artery. Stanton et al [2] recently correlated positional oculoplethysmography with intraoperative electromagnetic flow measurements and demonstrated the benefit of correcting the symptomatic carotid artery kink. Previously, our technique for resecting an internal carotid artery kink involved ligating the external carotid artery and reducing the kink by excising a portion of the common carotid artery [2]. We currently prefer a reimplantation technique whereby preservation of the external carotid artery is maintained, resection of the internal carotid artery is avoided and, when necessary, endarterectomy may be safely performed.
cephalographic monitoring is employed to evaluate the adequacy of cerebral blood flow during carotid occlusion. After positional electromagnetic flowmeter studies are completed, the patient is heparinized and trial clamping of the internal carotid artery is performed. If no electroencephalographic evidence of cerebral ischemia is demonstrated, the internal carotid artery is divided obliquely at the carotid bifurcation (Figure 1). If concomitant carotid atherosclerotic occlusive disease is present, eversion endarterectomy of the internal carotid artery is performed and the endarterectomy continued until the plaque tapers to its end (Figure 2). The site of the anastomosis is determined by approximating the cut end of the internal carotid artery to the side
Surgical Technique Ten operations were performed usinggeneral anesthesia. The carotid bifurcation was exposed by standard technique. If necessary, the internal carotid artery was mobilized to the base of the skull and all fibrous bands were severed. Meticulous dissection is necessary around the kinked area, as the internal carotid artery is often extremely thin in this region. If adequate mobilization of the internal carotid artery is not complete, accentuation of a kink may occur after resection and reanastomosis of the proximal internal carotid artery. Twelve-lead electroenFrom the Department of Surgery, Georgia Baptist Medical Center, Atlanta, Georgia 30312. Requests for reprints should be addressed to David Rosenthal, MD, Suite 412. 315 Boulevard N.E., Atlanta, Georgia 30312.
Volume 141, February 1991
F&e 1, lelt. Internal carotid artery divkfed hquely at the carotid bliurcatlon. Figure 2, rlght. Eve&on endarterectomy of a kinked Internal carot/d artery.
295
Rosenthal et al
Figure 3, left. SHe of Internal carotid artery anastomosis determIn?d by approxlmatlng the end of the internal carotid artery to the side of the common carotid artery. Figure 4, right. End-to-side anastomosis completed. The original internal carol/d arierectomy site is closed.
of the common carotid artery (Figure 3). The common carotid is incised at this level, or the arteriotomy may be extended from the original internal carotid arterectomy site. If atherosclerotic plaque is encountered at the reimplantation site, a limited endarterectomy may be performed. After endarterectomy, an end-to-end anastomosis is fashioned and the defect in the common carotid artery is closed (Figure 4). Cerebral ischemia manifested by electroencephalographic changes necessitates the use of a temporary shunt. The internal carotid artery is incised as in Figure 1 and a shunt is rapidly inserted (Figure 5). If extensive endarterectomy is necessary, the shunt may be inserted through a separate common carotid arteriotomy, proximal to the anastomotic site. Routinely, however, this is cumbersome and adds an additional arteriotomy closure. With electroencephalographic monitoring, we were forced to use a shunt in only one patient in this series. Before completion of operation, positional electromagnetic flow studies are repeated. Cerebrovascular insufficiency symptoms may occur in the kinked carotid artery despite the absence of atherosclerotic occlusive disease. Metz et al [3] reported that 15 percent of the population has kinking of the carotid artery, and therefore the importance of its diagnosis and surgical treatment in selected patients cannot be overemphasized.
Summary The hemodynamic significance of the kinked internal carotid artery and cerebrovascular insufficiency are demonstrated. Several procedures have been devised to correct a carotid kink, but these involve resection or excision of the internal, external or common carotid artery. We currently prefer a reimplantation technique whereby preservation of the external carotid is maintained, resection of the internal carotid artery is avoided and, when necessary, endarterectomy may be safely employed. References
: Figure 5. Wth electroencephalographlc evidence of ischemla, a temproary shuti is necessary. the shunt may also be Inserted through a separate common carotid arterrOtomy, proximal to the anastomotlc Me.
296
1. Riser MM, Gerard J, Ducodray J. Dolico-Internal carotid with vertiginous syndrome. Rev Neurol 1951;85:10. 2. Stanton PE. McClusky D, Lamis P. Hemodynamic assessment and surgical correction of kinking of the internal carotid artery. Surgery 1978;84:793-802. 3. Metz M, Murray-Leslie RM, Bannister RB. Kinking of the internal carotid artery in relation to cerebrovascular disease. Lancet 1981;1:424.
The American Journal of Surgery