Distal cervical internal carotid artery stenosis

This report describes a case of distal cervical internal carotid artery (ICA) occlusive lesion managed by saphenous interposition vein graft after exposure of the ICA up to the skull base. The skull base approach described herein emphasizes the mobilization of the mandible without mandibular osteotomy or disarticulation. Instead, the stylomandibular and stylosphenoidal ligaments are resected to allow mandibular mobilization. In addition, the distal ICA lesion represented a form of diffuse intimal thickening without any plaque formation. This required the resection of the thickened, stenotic segment and reconstruction of the distal cervical ICA with a saphenous interposition graft. The surgical management implications of diffuse intimal thickening are discussed.     

Common carotid trunk and right vertebral artery originating from the right common carotid artery in a patient with carotid stenosis

Truncus bicaroticus is a very rare vascular malformation. In this report, we present a very rare anomaly in a patient with left internal carotid artery stenosis together with truncus bicaroticus and right vertebral artery originating from the right common carotid artery.     

In-stent restenosis after carotid angioplasty-stenting: incidence and management

PURPOSE: Carotid angioplasty-stenting (CAS) has been advocated as an alternative to carotid endarterectomy (CEA) in patients with restenotic lesions after prior CEA, primary stenoses with significant medical comorbidities, and radiation-induced stenoses. The incidence of restenosis after CAS and its management remains ill defined. We evaluated the incidence and management of in-stent restenosis after CAS. METHODS: Patients with asymptomatic (61%) and symptomatic (39%) carotid stenosis of > or = 80% underwent CAS between September 1996 and May 2000; there were 50 procedures and 46 patients (26 men and 20 women). All patients were followed up clinically and underwent duplex ultrasonography (DU) at 3- to 6-month intervals. In-stent restenoses > or = 80% detected with DU were further evaluated by means of angiography for confirmation of the severity of stenosis. RESULTS: No periprocedural or late strokes occurred in the 50 CAS procedures during the 30-day follow-up period. One death (2.2%) that resulted from myocardial infarction was observed 10 days after discharge following CAS. During a mean follow-up period of 18 +/- 10 months (range, 1-44 months), in-stent restenosis was observed after four (8%) of the 50 CAS procedures. Angiography confirmed these high-grade (> or = 80%) in-stent restenoses, which were successfully treated with balloon angioplasty (3) or angioplasty and restenting (1). No periprocedural complications occurred, and these patients remained asymptomatic and without recurrent restenosis over a mean follow-up time of 10 +/- 6 months. CONCLUSIONS: We recommend CAS for post-CEA restenosis, primary stenoses in patients with high-risk medical comorbidities, and radiation-induced stenoses. In-stent restenoses occurred after 8% of CAS procedures and were managed without complications with repeat angioplasty or repeat angioplasty and restenting.     

False-negative magnetic resonance angiography with extracranial internal carotid artery stenosis

Magnetic resonance angiography (MRA) is increasingly used as a noninvasive means to assess internal carotid artery (ICA) stenosis. When used alone, however, MRA may not be sufficiently accurate in certain settings to determine whether ICA disease meets surgical criteria. Although MRA has been recognized to overestimate the degree of stenosis, the authors present two cases in which it severely underestimated arterial stenosis. Two male patients, 70 and 40 years old, respectively, were admitted with crescendo transient ischemic attacks. Their MRA studies suggested nonsurgical lesions of the ICA. After the patients continued to demonstrate clinical evidence of embolic disease, digital subtraction angiography (DSA) was performed on one patient, and the other received a gadolinium contrast-enhanced MRA. These tests revealed critical stenosis in each patient. Each was taken to the operating room for awake carotid endarterectomy with heparin anticoagulation and electroencephalographic monitoring. At surgery, both patients were found to have severely stenosed ICAs with complex plaques. MRA to determine whether ICA stenosis meets surgical criteria may not be sufficiently accurate in certain clinical settings. Additional imaging studies, such as confirmatory digital ultrasonography, MRA with gadolinium contrast, or DSA, may be required to determine the extent of carotid artery stenosis accurately.     

Indications for revascularization in patients with internal carotid artery stenosis

Three different strategies should be associated for ischaemic stroke prevention in patients with internal carotid artery stenosis: vascular risk factors control, anti-thrombotic agents, and carotid revascularization. Patients are selected for carotid revascularization on the basis of the presence of clinical symptoms and degree of stenosis. The optimal indication for carotid surgery is a severe recently symptomatic stenosis, since the benefits are marginal in high-grade asymptomatic stenosis, and in moderate symptomatic stenosis. Angioplasty with endoprothesis is an alternative to surgery, but it must be restricted to symptomatic stenosis either in randomized trials, or in severe stenosis in patients in whom surgery is contra-indicated.     

Quantitative common carotid artery blood flow: prediction of internal carotid artery stenosis

Common carotid artery (CCA) blood flow was measured noninvasively with a pulsed Doppler duplex scanner modeled after the Octoson (Ultrasonics, Inc., No. Yonkers, N.Y.). The aim of the study was to determine normal values and to assess the accuracy of CCA flow as a predictor of internal carotid artery (ICA) stenosis. One hundred one people who did not have disease were studied; the overall mean flow rate was 395 +/- 79 ml/min (mean +/- S.D.). There was no significant correlation with age, height, or body surface area but there was with body weight (p less than 0.05). A statistically significant difference was evident between men (424 +/- 88 ml/min) and women (371 +/- 62 ml/min) (p less than 0.001). The intrasessional variation (S.D./mean) was 13% and the intersessional variation, 16%. No significant difference was seen between the sides. Ninety-two patients who had carotid angiography were studied and the flow rates compared with the degree of ICA stenosis on each side. The flow rate for mild ICA stenosis (1% to 39%) was 404 +/- 109 ml/min, for moderate stenoses (40% to 69%), 390 +/- 91 ml/min, and for severe stenoses (70% to 99%), 351 +/- 109 ml/min. There was a significant difference in flows only between mild and severe grades of stenosis of the ICA (p less than 0.01). With unilateral stenosis, comparison of flow values in the normal and affected sides showed the greatest discriminatory power when the absolute difference of flow values was taken (p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)     

Objective tinnitus resulting from internal carotid artery stenosis

Objective tinnitus represents sound wave energy that, by definition, may be heard or recorded by an examiner. It may occur as a result of either muscular contraction or turbulent blood flow. We report two cases of vascular objective tinnitus resulting from internal carotid artery stenosis. The first patient, a 74-year-old man, underwent ligation of the right internal carotid artery because of the distal extent of atherosclerosis. The second patient, a 75-year-old man, underwent a right carotid endarterectomy. Both patients noted complete relief of their tinnitus. The spectrum of vascular causes and treatment options are reviewed. (J Vasc Surg 1997;25:581-3.)     

A case of internal carotid artery stenosis with discontinuance of carotid endarterectomy due to the tight adhesions around the internal carotid artery

A 73-year-old female visited her local doctor after repeatedly experiencing temporary weakness in her left upper and lower extremities. The patient underwent a cervical magnetic resonance imaging (MRI) scan and was diagnosed with right internal carotid artery stenosis. Despite administration of antiplatelet drugs, her symptoms continued, and she was referred to our department for medical treatment. Her medical history revealed hypertension, hyperlipidemia, and cholesteatoma. We diagnosed symptomatic internal carotid artery stenosis and performed carotid endarterectomy (CEA). However, tight adhesions between the carotid artery and surrounding tissue made separation difficult, and surgery had to be discontinued. Some of the extracted adherent tissue consisted of hyalinized fibrous tissue that had the appearance of soft tissue which had organized because of inflammation. Although there have been no reports of cholesteatoma directly causing adhesion around the internal carotid artery, it has been reported to have led to abscess formation in the parapharyngeal space adjacent to the carotid space. Because the boundaries of the parapharyngeal space and carotid space are anatomically incomplete, inflammation often affects the area between them. As far as we know, this report, which also includes a discussion of the literature, is the first to indicate that cholesteatoma causes strong adhesions around the carotid artery.     

�ⷭʽ��������Ĥ�г������ƾ��ڶ�����������խ

目的探讨外翻式颈动脉内膜切除术在预防脑缺血性“中风”的临床应用价值方法总结1999～2003年42例接受这一手术的病人的临床资料，分析其动脉阻断时间及术后并发症的发生情况结果手术均获成功，颈动脉平均阻断时间为16min，明显低于常规术式，术后并发症较少，结论外翻式颈动脉内膜切除术具有阻断时间短，再狭窄率低等优点，但对操作者的熟练程度及病人局部的情况具备较高要求。     

In-stent recurrent stenosis after carotid artery stenting: life table analysis and clinical relevance

OBJECTIVES: Carotid artery stenting has been proposed as an alternative to carotid endarterectomy in cerebral revascularization. Although early results from several centers have been encouraging, concerns remain regarding long-term durability of carotid artery stenting. We report the incidence, characteristics, and management of in-stent recurrent stenosis after long-term follow-up of carotid artery stenting. METHODS: Carotid artery stenting (n = 122) was performed in 118 patients between September 1996 and March 2003. Indications included recurrent stenosis after previous carotid endarterectomy (66%), primary lesions in patients at high-risk (29%), and previous ipsilateral cervical radiation therapy (5%). Fifty-five percent of patients had asymptomatic stenosis; 45% had symptomatic lesions. Each patient was followed up with serial duplex ultrasound scanning. Selective angiography and repeat intervention were performed when duplex ultrasound scans demonstrated 80% or greater in-stent recurrent stenosis. Data were prospectively recorded, and were statistically analyzed with the Kaplan-Meier method and log-rank test. RESULTS: Carotid artery stenting was performed successfully in all cases, with the WallStent or Acculink carotid stent. Thirty-day stroke and death rate was 3.3%, attributable to retinal infarction (n = 1), hemispheric stroke (n = 1), and death (n = 2). Over follow-up of 1 to 74 months (mean, 18.8 months), 22 patients had in-stent recurrent stenosis (40%-59%, n = 11; 60%-79%, n = 6; > or =80%, n = 5), which occurred within 18 months of carotid artery stenting in 13 patients (60%). None of the patients with in-stent recurrent stenosis exhibited neurologic symptoms. Life table analysis and Kaplan-Meier curves predicted cumulative in-stent recurrent stenosis 80% or greater in 6.4% of patients at 60 months. Three of five in-stent recurrent stenoses occurred within 15 months of carotid artery stenting, and one each occurred at 20 and 47 months, respectively. Repeat angioplasty was performed once in 3 patients and three times in 1 patient, and repeat stenting in 1 patient, without complications. One of these patients demonstrated asymptomatic internal carotid artery occlusion 1 year after repeat intervention. CONCLUSIONS: Carotid artery stenting can be performed with a low incidence of periprocedural complications. The cumulative incidence of clinically significant in-stent recurrent stenosis (> or =80%) over 5 years is low (6.4%). In-stent restenosis was not associated with neurologic symptoms in the 5 patients noted in this cohort. Most instances of in-stent recurrent stenosis occur early after carotid artery stenting, and can be managed successfully with endovascular techniques.     

Traumatic stenosis of the internal carotid artery in children

Two cases of stenosis of the internal carotid artery after blunt craniocervical trauma in children are described. Their neurological symptoms developed a few hours after the injury. A superficial temporal artery-middle cerebral artery anastomosis was performed in one, and the other was conservatively treated because of the spontaneous resolution of the stenosis. The pathophysiology and treatment of this clinical entity, especially in children, are discussed.     

颈动脉狭窄的血管内支架治疗

目的 总结颈内动脉狭窄血管内支架治疗的经验与并发症。方法 颈内动脉狭窄患者417例，全部患者行全脑血管造影及颈部超声检查。134例患者使用脑保护装置；283患者未使用保护装置，对其中202例(71．38％)进行预扩张，66例(23．32％)采取后扩张，3例未扩张。结果 417例患者术中，心率下降者105例(25．18％)；术中微栓子脱落5例，其中2例治疗后好转，2例留有一侧肢体运动障碍，术后颅内出血死亡1例。322例随诊，占77．22％，其中再狭窄15例，再狭窄发生率为3．6％。325例有临床症状的患者中，256例症状消失或好转，占78．77％；结论 采用正确的围手术期治疗及手术方法，颈内动脉狭窄的血管内支架治疗是安全的，应对术后脑血管过度灌注导致脑出血给予重视。     

Late carotid restenosis: aetiologic factors for recurrent carotid artery stenosis during long-term follow-up

During a fourteen-year-period 257 patients underwent carotid endarterectomy in an unselected population of 700,000 inhabitants. The incidence of haemodynamically significant restenosis was 13.5% in 133 vessels in 116 patients studied by duplex scanning 28 to 209 months following carotid endarterectomy. The most striking differences between patent and restenosed cases were in serum cholesterol, triglyceride and HDL-cholesterol levels. The patients with a long-term low cholesterol (less than 6.5 mmol/l), low triglyceride (less than 1.42 mmol/l) and high HDL cholesterol (greater than 1.0 mmol/l) levels had significantly less high grade restenosis (P less than 0.05). Apolipoprotein A-I and B had no significant effect, but if the lowest limit of normal apolipoprotein A-I level was considered as 1.27 g/l the difference was significant. The frequency of a high-grade restenosis in patients with diabetes mellitus and coronary heart disease was not significantly increased, but supports the view that these are risk factors in the development of atherosclerotic changes in an operated carotid artery. The incidence of recurrent stenosis appears to be unrelated to hypertension, claudication, obesity, smoking, operative factors or to the indication for surgery. Men were more prone than women to get a high-grade restenosis. Postoperative treatment with acetylsalicylic acid was most effective, the incidence was only half of that expected, whereas the anticoagulants or a combination of acetylsalicylic acid and dipyridamole were of no benefit. Haematocrit, RBC, platelet count and thrombocrit were contradictory.     

颈动脉内膜切除术治疗颈内动脉重度狭窄的临床经验

目的总结颈动脉内膜切除术(CEA)治疗颈内动脉重度狭窄的临床经验。方法 1998年10月至2009年7月,共为185例患者进行颈内动脉内膜切除术192例次。其中男115例,女70例;年龄51～86(平均66±5)岁。术前有短暂性脑缺血发作(TIA)117例,21例术前曾患脑梗死。患者术前均行选择性颈动脉造影检查,颈内动脉狭窄均大于70%,其中狭窄程度大于95%有112例,同时对侧颈动脉伴有狭窄或闭塞的患者有35例。86例患者存在冠状动脉病变,其中25例患者同期行冠状动脉搭桥术。结果术后146例患者临床症状明显改善,2例术后2周出现脑出血,其中1例治疗后好转出院,1例死亡。1例出现舌下神经损伤,4例出现面神经下颌缘支损伤。术后30天无TIA。随访6～60个月,151例获得随访,1例随访期间因心脏病死亡,余均病情稳定。结论 CEA是治疗颈内动脉重度狭窄的安全、有效的方法。