Aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia: Results of surgical management

Between January 1977 and December 1990, eight patients underwent surgical correction of aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia. Mean age of patients was 50 years (range 31 to 70 years). Five patients presented with neurologic hemispheric symptoms. Most aneurysms were saccular and occurred preferentially at the level of C2 or C3. All of these patients underwent operation through conventional cervicotomy. Resection-anastomosis was performed in three cases whereas resection-graft was performed in five. Histopathological examination of the eight specimens was consistent with fibromuscular dysplasia of the media. There was no central nervous system-related mortality and morbidity. Seven patients were alive and free of new neurological manifestations at mean follow-up of 156 months (18 to 180 months). One patient died of myocardial infarction at 96 months. All patients had postoperative duplex scanning or arteriograms. These revealed that carotid restorations were patent in seven whereas one patient had asymptomatic occlusion at 18 months.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 21–22, 1991, Marseille, France.     

Transluminal dilatation of internal carotid artery in fibromuscular dysplasia: A preliminary report

A patient with transient ischemic attacks and fibromuscular dysplasia of the internal carotid artery was treated by Grüntzig balloon-catheter dilatation of the involved area of the internal carotid artery. The clinical and angiographic results were excellent.     

Spontaneous carotid-cavernous fistula with fibromuscular dysplasia

Summary A young woman presented with a spontaneous carotid-cavernous fistula. She also had fibromuscular dysplasia of the extracranial cerebral arteries. The possible relationship of the two diseases brought up important questions concerning how to manage the patient. Treatment by obliteration of the carotid circulation on one side would be expected to increase blood flow on the other side. If the cavernous carotid artery on the second side was weakened by fibromuscular dysplasia, the increased flow might predispose to the formation of a second carotidcavernous fistula. We first attempted to avoid surgery. When progressive symptoms occurred, the cavernous sinus was obliterated with bronze wire, thus preventing venous shunting.     

肌纤维发育异常研究进展

肌纤维发育异常(fibromuscular dysplasia,FMD)是非炎症性动脉疾病,病因不明,可累及全身各动脉,可导致高血压、头痛、搏动性耳鸣、休克、腹部/侧腹部疼痛等.药物、血管成形术及外科手术是目前治疗FMD的主要方式,三者之间各有利弊.近年来,国内外对其研究逐渐加深,且在一些方面达成专家共识.现将FMD的研究进展综述如下.     

颈内动脉完全闭塞的手术治疗

目的 探讨颈动脉血运重建治疗完全性颈内动脉闭塞的临床疗效.方法 2001年6月～2010年4月,收治颈动脉狭窄患者397例,术前行磁共振血管造影(MRA)检查,确诊并行颈动脉内膜切除术(CEA)治疗颈内动脉闭塞患者28例,术中切除标本送病理检查,术后复查颈部MRA,并对术后情况进行随访.结果 术后即时通畅率为92.8％,术后平均随访时间10个月,22例颈内动脉通畅,通畅率为78.5％,无脑缺血事件发生;6例颈内动脉闭塞患者中,2例在术后4个月发生短暂性脑缺血及腔隙性梗死;3例术后仍偶有头晕,其中2例单侧肢体麻木;1例记忆力减退.结论 对于有症状的颈内动脉闭塞患者,CEA加取栓术是安全有效的方法.     

Carotid artery fibromuscular dysplasia

Extracranial carotid artery fibromuscular dysplasia (FMD) is a rare finding that is frequently incidental and asymptomatic. It usually occurs in middle-age women and is secondary to medial fibrodysplasia or, less commonly, intimal fibrodysplasia. The carotid artery may be elongated or kinked and associated aneurysms have been reported. Symptoms including transient ischemic attack or stroke are uncommon and are due to low flow or embolization of platelet aggregates. Digital subtraction angiography demonstrates high-grade stenosis with the characteristic "string of beads" pattern. Antiplatelet medication with sequential imaging is the accepted therapy for asymptomatic lesions. Graduated endoluminal dilation under direct vision should be reserved for patients with documented lateralizing symptoms.     

Trauma-related occlusion with spontaneous recanalization of the internal carotid artery

Summary. We present a case report concerning spontaneous recanalization of the internal carotid artery occlusion after an accident with contusion of the cerebrum and hyperextension trauma of the cervical spine.      

Stenosis of one carotid artery with occlusion of the contralateral carotid

Summary 23 patients with unilateral internal carotid artery stenosis (>70%) and contralateral internal carotid artery occlusion in the neck are reported. The symptoms are referable to the side of the occlusion in 13 cases (57%), to the side of stenosis in 7 cases (30%) and non-localizing in 3 cases (13%). All 23 patients had a carotid endarterectomy performed on the side of the stenotic lesion. There was no operative mortality. Late neurological symptomatology after surgery was referable to the side of stenosis in 13% and to the side of occlusion in 9%. The authors consider that, in cases of significant stenosis (greater than 70%) of an internal carotid artery with a contralateral occlusion, preference should always be given to endarterectomy of the stenotic side, reserving extra-intracranial by-pass of the occluded side for patients who remain symptomatic after endarterectomy of the stenotic side.     

Outcomes of carotid stenting in patients with fibromuscular dysplasia

ObjectiveFibromuscular dysplasia (FMD) is a noninflammatory arterial disease that affects the extracranial carotid arteries in young patients. The ideal treatment of FMD has continued to be debated, and the role of carotid artery stenting (CAS) is controversial. The aim of the present study was to assess the feasibility and outcomes of CAS for patients with FMD.MethodsA retrospective analysis of patients who had undergone CAS was performed using the Vascular Quality Initiative database from December 2012 to May 2021. Patients who had undergone CAS for atherosclerosis and FMD were included and matched 1:1 by age, gender, and clinical presentation. The demographics, clinical parameters, and procedural data were analyzed. The end points included postoperative stroke and transient ischemic attack (TIA), and adverse events (perioperative and 1-year mortality, neurologic changes, access site complications, hematoma or bleeding, infection, congestive heart failure, arrhythmia, myocardial infarction, reperfusion symptoms), and hospital length of stay.ResultsAfter matching, 55 patients had undergone CAS for FMD (mean age, 58.7 ± 14 years; 62% women; 69% White; mean body mass index, 28 ± 6 kg/m²). Most of these procedures (69%) were elective. The FMD group had had a lower rate of hypertension (55% vs 82%; P = .002), smoking (35% vs 80%; P < .001), diabetes (13% vs 45%; P < .001), and coronary artery disease (9% vs 45%; P < .001) compared with the non-FMD group. In the FMD group, prior TIA and stroke was identified in 39 (71%) and 31 (57%) patients, respectively. The mean interval from a prior stroke or TIA to the index surgery was 160 days. Additionally, 23 patients (42%) had had anatomically high lesions above the level of the second cervical vertebra. In the FMD group, the transfemoral approach was used for 43 patients (78%), with distal embolic protection used for 40 patients (93%). Flow reversal was used for nine patients (23%). Most cases were performed with local anesthesia (58%). Three patients (6%) in the FMD group had had access site complications that were managed nonoperatively. No differences were found between the FMD and non-FMD groups in perioperative stroke, TIA, or 30-day mortality. The length of stay was similar between the two groups, and the 1-year survival was 100% for both groups. All the patients in the FMD group were discharged without neurologic complications, and 50 patients (91%) were receiving dual antiplatelet therapy. The median follow-up was 328 days (interquartile range, 1-732 days) with no mortality or reinterventions during follow-up.ConclusionsCAS for FMD is a feasible and safe procedure with favorable technical success, a low incidence of neurologic complications, and good clinical outcomes at 1 year of follow-up.     

Cerebral haemodynamics in internal carotid artery trial occlusion

Summary The purpose of this study was to analyse the cerebral haemodynamic changes brought about by trial occlusion of the internal carotid artery (ICA). Sixteen patients with surgically inaccessible cerebral aneurysms, carotid cavernous fistulas or neck neoplasms were monitored with transcranial Doppler ultrasonography (TCD) during 90–120 s angiographie ICA balloon occlusion or ICA closure with a Selverstone clamp. The blood velocity (V) was registered continuously in both middle cerebral arteries (MCA) while the pulsatility index (PI_MCA) and haemodynamic tension (U_hemmca ) were calculated.ICA closure led to an instantaneous drop in the ipsilateral V _mca , PI _mca and U_hemmca . The V _mca thereafter increased gradually until reaching a stable level. The subjects were grouped into those with initial drops in V _mca to 60% of pre-occlusion value (group 1) and those that fell to < 60% (group 2), respectively. In group 1 autoregulatory mechanisms made the PI _mca decline further, while the U_hemmca remained unaltered during ICA closure. In group 2, however, the PI _mca did not change further, while the U_hemmca increased slightly. The cerebral haemodynamic features during ICA test occlusion were thus essentially different in the two groups. On re-opening the ICA, there was an overshoot in V _mca and U_hemmca . Contralaterally, the V _mca was increased during ICA occlusion.Seven of the patients later had their ICA closed permanently. While none of five group 1 patients developed haemodynamic complications, two group 2 individuals experienced haemodynamic stroke. Assuming ICA sacrifice is feasable when test occlusion results in an ipsilateral initial reduction in V _mca to 60% of preocclusion value, the corresponding limit for the U_hemmca is 40%. In the pre-operative evaluation of the haemodynamic risk related to ICA loss, TCD emerges as a reliable method. It also seems to allow for the reduction of test occlusion time to 90–120 s.     

Long-term outcome after surgical kidney revascularization for fibromuscular dysplasia and atherosclerotic renal artery stenosis

PURPOSE: At a time of minimally invasive surgery in urology, the role of surgical kidney revascularization in the management of renal artery disease has changed during the last decade. Our experience with surgical kidney revascularization, and the long-term clinical outcomes of fibromuscular dysplasia (FMD) and atherosclerotic renal artery stenosis are reviewed. MATERIALS AND METHODS: The study group comprised 140 patients with renovascular hypertension, 72 with FMD and 68 with atherosclerotic renal artery disease, who underwent surgical revascularization between 1982 and 1999. The indications for surgical revascularization were the treatment of hypertension and the preservation of renal function in 17 patients with renal artery occlusion, 55 with ostial stenosis, 52 with branch stenosis, 6 with bilateral artery stenosis, 7 with solitary kidney renal artery stenosis and 3 with solitary kidney renal artery occlusion. RESULTS: Postoperative blood pressure and renal function were monitored for 1 to 17 years (mean 11.3). Long-term blood pressure control was observed in 93% of patients with FMD and in 71% of those with atherosclerosis. Improvement or stabilization of renal function was observed in 92% of patients with FMD and in 68% of those with atherosclerosis. The preoperative estimated glomerular filtration rate compared to postoperative was significantly increased in both groups. CONCLUSIONS: Surgical kidney revascularization is effective in secondary hypertension with a high long-term efficacy in the normalization of blood pressure and in the preservation of renal function, especially in patients with a solitary or 1 functional kidney.     

Direct and primary carotid endarterectomy for common carotid artery occlusion. Report of 2 cases

BACKGROUND: Cerebral ischemia associated with chronic CCA occlusion is a rare condition and raises strategic dilemma when the revascularization is needed. METHODS: Two patients with CCA occlusion presented with ischemic symptom associated with the affected side. Both patients underwent vascular reconstruction by direct carotid endarterectomy to achieve primary restoration of CCA to ICA flow. RESULTS: Successful reopening of the vessels was obtained in both patients without the evidence of postsurgical ischemic event. Follow-up MRA was obtained at later than 6 months after surgery, which demonstrated patent CCA-ICA in both patients. CONCLUSIONS: Direct carotid endarterectomy of the occluded CCA can be safely performed if the preoperative angiography suggest still patent vessels distal to carotid bifurcation and the substantial "back flow" is obtained from ICA during arteriotomy.     

Intolerable pulse-synchronous tinnitus caused by occlusion of the contralateral common carotid artery

Summary A case with severe pulsatile tinnitus of the left side caused by occlusion of the right common carotid artery was reported. Tinnitus in this case was supposed to be due to the rich blood flow of the external carotid systems developed as collateral routes resulting from the occlusion of the right common carotid artery. It subsided with the establishment of a bypass using a vein graft between the ascending aorta and the residual patent portion of the right common carotid artery.     

Fibromuscular dysplasia of the renal artery: Management and outcome

SUMMARY: Renovascular hypertension may be caused by atherosclerotic disease or less commonly by fibromuscular dysplasia (FMD) of the renal arteries. Fibromuscular dysplasia is the commonest cause of renal artery stenosis in the younger age group and affects women predominantly. A review of our clinical database identified all patients with renovascular hypertension. All relevant clinical, biochemical and radiological findings on those with FMD were noted. the outcome of percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery was evaluated. Eight out of 62 (13%) patients with hypertension secondary to renovascular disease had FMD (all female; bilateral in four; mean age at diagnosis 37.6 years; age range 12–70 years). the mean duration of hypertension before the diagnosis of FMD was 3.3 years (range 3 months-10 years). A renal artery bruit was detected in five, hypertensive retinopathy in three and one had mild renal insufficiency. Twelve PTRAs were attempted on 10 stenotic lesions in six women. This cured the hypertension in three, while the other three have required less antihypertensive therapy. Percutaneous transluminal renal angioplasty was complicated by a trivial renal artery dissection in one, and a small upper pole infarction in another. One patient required a repeat PTRA. the other two women presented before the availability of PTRA and had successful reconstructive surgery. Fibromuscular dysplasia was the cause of hypertension in eight out of 62 (13%) patients with renovascular hypertension. Percutaneous transluminal renal angioplasty has shown encouraging results with a low complication rate. If technically feasible, PTRA should be attempted on all patients with FMD of the renal artery.     

Multiple basilar artery trunk aneurysms associated with fibromuscular dysplasia

Summary An association between fibromuscular dysplasia (FMD) and intracranial aneurysms has been proposed but the occurrence of multiple aneurysms on the trunk of basilar artery (BA) associated with FMD has not been previously reported.     

Fibromuscular dysplasia of the renal artery: Management and outcome

Renovascular hypertension may be caused by atherosclerotic disease or less commonly by fibromuscular dysplasia (FMD) of the renal arteries. Fibromuscular dysplasia is the commonest cause of renal artery stenosis in the younger age group and affects women predominantly. A review of our clinical database identified all patients with renovascular hypertension. All relevant clinical, biochemical and radiological findings on those with FMD were noted. The outcome of percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery was evaluated. Eight out of 62 (13%) patients with hypertension secondary to renovascular disease had FMD (all female; bilateral in four; mean age at diagnosis 37.6 years; age range 12–70 years). The mean duration of hypertension before the diagnosis of FMD was 3.3 years (range 3 months–10 years). A renal artery bruit was detected in five, hypertensive retinopathy in three and one had mild renal insufficiency. Twelve PTRAs were attempted on 10 stenotic lesions in six women. This cured the hypertension in three, while the other three have required less antihypertensive therapy. Percutaneous transluminal renal angioplasty was complicated by a trivial renal artery dissection in one, and a small upper pole infarction in another. One patient required a repeat PTRA. The other two women presented before the availability of PTRA and had successful reconstructive surgery. Fibromuscular dysplasia was the cause of hypertension in eight out of 62 (13%) patients with renovascular hypertension. Percutaneous transluminal renal angioplasty has shown encouraging results with a low complication rate. If technically feasible, PTRA should be attempted on all patients with FMD of the renal artery.     

Traumatic occlusion of the internal carotid artery in a healthy young male: Effects on the regional cerebral blood flow

Summary The effects of acute right internal carotid artery occlusion in a previously healthy young male, was studied over a period of 10 months, with angiography, TransCranial Doppler ultrasonography (TCD) and SPECT-rCBF.A clinically observed inability to meet increased metabolic demand in the right hemisphere was concommitant to a decreased Pulsatility Index (PI) in the right middle cerebral artery (MCA). Autoregulation studies showed almost maximal dilatation of the resistance vessels in the right middle cerebral artery territory, at rest.A decreased blood flow velocity, in the right middle cerebral artery 7 months after the accident, suggesting a decreased rCBF, could not be confirmed by SPECT-rCBF studies. This finding strongly cautions against interpretation of chronical blood flow velocity changes in terms of changes in regional blood flow.The present study shows the benefits in the combined use of angiography, SPECT-rCBF, and TCD.     

Long-term results after carotid endarterectomy for carotid artery stenosis with contralateral occlusion

Patients with one internal carotid artery occlusion and a contralateral stenosis run a significantly higher risk of stroke. We performed endarterectomy of the stenotic carotid in 44 such patients and followed them for mean 54 months (range 1–172 months). Early mortality was 2%. Life-table analysis shows that the incidence of a new stroke was 0.6% per year, the survival rate was 78% after three years, and 70% after five years. We conclude that carotid endarterectomy can be safely performed in patients with contralateral internal carotid artery occlusion and can significantly improve the long-term prognosis of these patients.     

颈内动脉闭塞术的初步临床应用

目的探讨颈内动脉闭塞术治疗颈内动脉血管性病变的价值。方法共5例患者,1例鼻咽癌行放疗后清创术,并发难以制止的鼻咽部大出血,双侧后鼻孔填塞无效;1例巨大颈内动脉眼段动脉瘤,无法手术夹闭;3例外伤后颈内动脉海绵窦瘘,单纯闭塞瘘口失败。采用Seldinger技术经股动脉穿刺置管行全脑血管造影,经球囊闭塞试验或病变侧压颈试验,病人耐受良好后方行闭塞术。闭塞材料为3例应用可脱弹簧圈,2例应用可脱球囊,闭塞位置为病变近端及瘘口。结果所有病例闭塞颈内动脉后,即行对侧颈动脉造影复查,可见前交通动脉和/或后交通动脉代偿良好,患者无明显并发症发生,病变未见显影。临床症状消失、无合并症发生,病变未见复发。结论颈内动脉闭塞术作为一种治疗颈动脉血管性疾病的方法,可以在不危及病人生命、加重病人病情的情况下,取得良好的治疗效果。     

Ruptured intracranial aneurysm associated with spontaneous occlusion of internal carotid artery

Summary Out of 921 patients diagnosed and treated for intracranial aneurysm in 5 cases (0,5%) the co-existence of ruptured aneurysm and occlusion of the internal carotid artery was found. 4 patients were treated surgically-aneurysm clipping-without serious post-operative complications and 6 months follow-up showed satisfactory results. In 4 of 5 cases the aneurysm was located on the anterior communicating artery (ACA); this fact may support the hypothesis concerning a possible role of enhanced blood flow in aneurysm formation and rupture. In cases with good collateral blood flow extra-/intracranial bypass before aneurysm occlusion seems not to be necessary. The risk of operation in those patients is not as high, as might be expected.