血管重建术治疗Metz Ⅲ级颈内动脉扭曲

目的 探讨血管重建术治疗Metz Ⅲ级颈内动脉扭曲的可能性及总结治疗经验.方法 2008年7月至2009年6月应用血管重建术治疗症状性颈内动脉扭曲患者5例,其中男性2例,女性3例;年龄53～68岁,平均62岁.手术在患者颈内动脉起始部环形切断,游离并拉直颈内动脉,根据扭曲的情况剪除多余的血管;2例动脉粥样硬化明显者首先行外翻式内膜切除术,然后吻合颈内及颈总动脉.结果 5例患者术后顺利恢复,脑缺血症状改善明显.除1例出现轻度高灌注综合征外无其他明显并发症,复查颈动脉CT血管造影,示扭曲血管已拉直,血管通畅良好.随访5～16个月,未再出现短暂脑缺血发作及脑梗死,复查颈动脉血管超声未发现再狭窄者.结论 血管重建术是治疗Metz Ⅲ级颈内动脉扭曲的有效方法,但该手术仍有一定的风险,术前应进行全面的评估,严格控制手术适应证.

Abstract：

Objective To evaluate and summarize the possibility and experience of reconstructive vascular operation for kinking of internal carotid artery. Methods Reconstructive vascular operation was performed on 5 patients with symptomatic kinking of internal carotid artery between July 2008 and June 2009. There were 2 male and 3 female patients,age ranged from 53 to 68 years( mean 62 years). Cutting the internal carotid artery at the bifurcation, mobilizing and stretching the internal carotid artery, then anastomosing the internal and common carotid artery. Two of them underwent endarteriectomy simultaneously. Results For the 5 patients, postoperative recovery went smoothly and symptoms were well improved. Except that mild high perfusion syndrome happened in 1 patient, no other obvious complications.Kinking of internal carotid artery had been stretched in the postoperative CT angiography. In the 5-16-month follow-up, no tranient ichemic attack or cerebral infarction happened, and no restenosis appeared.Conclusions Reconstructive vascular operation is an effective surgical approach to kinking and coiling of the internal carotid artery. For some risk exists, all-round evaluation should be performed before operation,and operative indication should be strictly controlled.     

Stenotic coiling and kinking of the internal carotid artery

Between January 1979 and December 1991, 174 of a total of 2304 carotid reconstructions (7.5%) were performed in 166 patients for stenotic coiling or kinking of the internal carotid artery. There was a 1.4 male predominance and the mean age of the patients was 66.3 ± 9.6 years (range 38 to 91 years). Seventeen patients (9.8%) were asymptomatic, 54 (31%) were symptomatic because of a previous stroke, and 103 (59.2%) had had transient ischemic attacks. The symptoms were hemispheric in 108 (62.1%) cases, ocular in 19 (10.9%), and vertebrobasilar in 30 (17.2%). The stenotic coiling or kinking was isolated in 35 (20.1%) cases and associated with other lesions of the internal carotid artery in 139 (79.9%). These included 119 atherosclerotic stenoses, 14 aneurysms, and six stenotic lesions due to fibromuscular dysplasia. Angioplasty of the carotid bifurcation was performed in 102 (58.6%) patients, associated with endarterectomy in 84 (48.3%) cases and with dilatation of dysplastic lesions in six (3.5%) cases. A bypass graft and resection and anastomosis of the carotid artery were performed in 36 (20.7%) patients each. There were four postoperative deaths (2.3%): two were due to neurologic causes, one to heart disease, and one to complications of an associated surgical procedure. Five patients (2.9%) had postoperative strokes and eight (4.6%) had transient ischemic attacks. At postoperative follow-up investigations four (2.3%) patients had carotid occlusions and 10 (5.7%) had morphologic abnormalities. At 5 years, actuarial survival was 80.97 ± 8.8%, patency was 96.12 ± 2.95%, and the ipsilateral stroke-free rate was 93.12 ± 4.49%. Treatment of stenotic coiling or kinking of the internal carotid artery yields satisfactory results, comparable to those of endarterectomy, for isolated atherosclerotic carotid stenoses and is effective in the prevention of ipsilateral ischemic stroke.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Reims, France, June 19–20, 1992.     

Extracranial internal carotid artery pseudoaneurysms after kinking reconstruction

The purpose of this report is to describe our experience of infected false aneurysm treatment following internal carotid artery (ICA) reconstruction. Five and 6 years before admission, bilateral reconstruction was done because of ICA kinking at a local health center. The patient was symptomless for 5 years but later became partially symptomatic (dizziness, vertigo, and visibly bilateral neck pulsatile masses). On routinely performed ultrasonography and multislice scanner examinations, the bilateral ICA pseudoaneurysms were revealed. The final treatment was surgery and aneurysmal sac resection followed by end-to-end arterial reconstruction. A right-sided wound swab was positive; Staphylococcus aureus was cultured. Antibiotics were administered: teicoplanin (Targocid) 800 mg as an initial dose followed by 400 mg maintenance doses over the following 4 days. After 1 month, left ICA reconstruction was done and a wound swab showed staphylococcal infection as well. At the 12-month follow-up, the patient was doing well; cerebral vascularization was well preserved. Infected false aneurysms are rare complications following carotid artery reconstruction. Aneurysmal sac resection and arterial reconstruction with end-to-end anastomosis or autologous saphenous vein are recommended. A wound swab is mandatory.     

Surgical approach to kinking and coiling of the internal carotid artery

AIM: Whether kinking or coiling of the internal carotid artery (ICA) simply represents a morphological variation without clinical relevance still remains an object of debate. While most patients are incidentally diagnosed in an asymptomatic state due to the broad use of non-invasive investigations (like colour coded Doppler sonography), associated neurological deficits are often unspecific and might be related to coexisting proximal stenotic lesions. Its etiology is unclear. Beside artherosclerotic genesis, a persistent embryological condition or underlying fibromuscular dysplasia is discussed. Moreover, in contrast to precise recommendations concerning the indication for endarteriectomy in carotid artery stenosis, general guidelines for surgical intervention in case of kinking or coiling are not yet established. METHODS: The characteristics of 16 patients who underwent a total of 21 reconstructive operations for isolated kinking or coiling of the ICA during 5 years of observation were retrospectively analyzed. RESULTS: In 10 out of 14 kinkings and 5 out of 7 coilings central nervous symptoms were noted including unspecific vertigo, syncope, tinnitus synchronous to pulse, transient ischemic attacks and manifest cerebral infarction. All these individual complaints disappeared postoperatively. In 1 patient presenting with an ICA coiling histological examination revealed signs of fibromuscular dysplasia. The other specimens showed typical changes of artherosclerotic disease. CONCLUSION: By precluding significant proximal stenosis and effective elimination of symptoms after surgical correction, a causal connection between cerebral dysfunction and severe ICA kinking or coiling can be supposed. An actual abnormality of the arterial wall structure only exists in exceptional cases. Rather, a sequential development from kinking to coiling was noticed.     

Anteposition of the internal carotid artery for surgical treatment of kinking

BACKGROUND: Kinking of the extracranial portion of the internal carotid artery (ICA) requires surgical reconstruction when it causes neurological symptoms. We suggest a simple surgical reconstruction without arteriotomy. METHOD: Anteposition of the ICA ventral to the digastric muscle has been performed in three patients. Kinks in the ICAs, proved by angiography, were thought to be responsible for clinical signs and symptoms. RESULTS: The operations resulted in improvement, both clinically and radiologically. CONCLUSION: The complications of arteriotomy can be avoided using the technique of ICA antepositioning described in this paper.     

Reconstructive surgery for segmental arterial mediolysis involving both the internal carotid artery and visceral arteries

Segmental arterial mediolysis (SAM) is a rare, nonatherosclerotic, noninflammatory arteriopathy. A 52-year-old man with sudden hemiparesis of the right side was found to have an aneurysm of the left internal carotid artery and concomitant multiple aneurysms of the extrahepatic, celiac, and superior mesenteric arteries. Reconstructive operations using autologous vein graft were performed to treat the aneurysms. The histopathology analyses of resected arterial and aneurysmal specimens showed characteristics consistent with SAM. To our knowledge, a successfully treated case of SAM affecting both the carotid artery and visceral arteries has not previously been described.     

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.     

A simple method for combined carotid endarterectomy and correction of internal carotid artery kinking

Occasionally symptomatic kinking of the internal carotid artery will require correction. More frequently one must rectify a kink that occurs after bifurcation endarterectomy when associated with a redundant internal carotid artery. Most procedures described for shortening of the carotid artery are somewhat cumbersome when endarterectomy is also performed or require the use of patch closure. Herein we described a technique for combined endarterectomy of the bifurcation and straightening of a critically angulated internal carotid artery. The approach obviates many of the difficulties encountered with other methods.     

Changes in the internal carotid artery in its loop-shaped kinking and their clinical significance

Loops and kinks of the internal carotid, common carotid, and vertebral arteries which were resected in operations on 45 patients were examined histologically and histochemically. Gross pathological changes were found in the arterial wall in the region of the loops and kinks: destruction of the smooth muscles and elastic fibrils and fragmentation of the internal elastic membrane. Fibrous tissue prevailed in all layers of the arterial wall, forming its soft framework and in this way preventing the straightening out of the kinked artery or its loop. The changes were most marked in the loops of the internal carotid artery, microaneurysms with parietal thrombosis were even encountered. The findings of microscopic and histochemical study compel the surgeon to resort to excision of the loop or kink and subsequent establishment of an end-to-end anastomosis or replacement of the whole pathologically changed arterial segment by a graft of autologous vein, as the most radical method of surgical treatment of this pathological condition. In children and in some adults, however, favourable results can be produced by total mobilization of the loop, its downward transposition, resection of its proximal segment, and reimplantation into the bifurcation of the carotid artery.     

Surgical therapy of the kinking of the internal carotid artery. Indications and limitations

Surgical treatment of a case of symptomatic kinking of the internal carotid suggested a review of the problem on the basis of the national and international literature. Opinions are not only extremely distant but not infrequently antithetical. In such a heterogeneous subjects that is often difficult to interpret, the most interesting approaches are examined in the light of new experimental and clinical findings.     

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.     

A fatal intraoperative cerebral ischemia following kinking of the internal carotid artery?]

Postoperative neurological deficit may result from ischaemic or hypoxic hypoxaemia. Postural cerebral hypoperfusion may ensue when a pre-existing asymptomatic vascular anomaly in combination with rotation of the head for surgical positioning compromises cerebral blood flow. CASE REPORT. A 30-year-old man was referred for recraniotomy for glioblastoma. Following uneventful induction of anaesthesia, increased diuresis and progressive hypothermia were observed. The postoperative period was complicated by a seizure, followed by apnoea requiring reintubation of the trachea. A CAT scan revealed global cerebral oedema with subtotal compression of the third ventricle. Intracranial pressure was 60 mm Hg as measured by an epidural probe. On the 1st postoperative day clinical and electroneurophysical signs of brain death were observed; the patient underwent organ explantation the next day. PATHOLOGY. Pathological examination revealed pronounced global hypoxaemic lesions and an S-shaped internal carotid artery with intimal proliferation (Fig. 1). The diagnostic conclusion was cerebral ischaemia following carotid occlusion caused by carotid kinking and completed by surgical positioning (rotation of the head). CONCLUSION. Carotid kinking is a rare abnormality, and patients at risk may not be identified preoperatively. Though it is questionable whether this disaster could have been prevented at all, electroneurophysiological monitoring would have been the only early monitoring system capable of detecting diminishing cerebral blood flow. Although a request for routine intraoperative neurophysiological monitoring seems unrealistic at present, it has to be acknowledged that only such monitoring could have provided the information needed to save this patient.     

Revascularization of the internal carotid artery for isolated,stenotic, and symptomatic kinking

HYPOTHESIS: The operation for isolated, stenotic, and symptomatic kinking of the internal carotid artery is safe and effective in preventing stroke and relieving the symptoms of cerebral ischemia. DESIGN: A consecutive sample clinical study with a mean follow-up of 44 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Fifty-four patients with a mean age of 67 years underwent 55 revascularizations of the internal carotid artery. The surgical procedures consisted of the following: shortening and reimplantation in the common carotid artery in 36 cases, bypass grafting in 15 cases, and transposition into the external carotid artery in 4 cases. MAIN OUTCOME MEASURES: Cumulative survival, primary patency, and stroke-free and neurologic symptom-free rates expressed by standard life-table analysis. RESULTS: No patients died in the postoperative period. The postoperative stroke rate was 1.8%. The cumulative rates (SEs) at 5 years were as follows: survival, 70% (10.2%); primary patency, 89% (7.8%); overall stroke free, 92% (6.8%); ipsilateral stroke free, 96% (5.3%); neurologic symptom free, 90% (7.5%); and ipsilateral symptom free, 93% (6.5%). CONCLUSION: Revascularization of the internal carotid artery for the treatment of isolated, stenotic, and symptomatic kinking is safe and effective in preventing stroke and relieving symptoms of cerebrovascular insufficiency.     

Stenting of segments of stenosis in the internal carotid artery

There are adduced the literature data and results of own investigations, devoted to diagnosis and treatment of the carotid arteries stenosis, which constitute the insult cause in 67% of patients. Conduction of endovascular interventions secures achievement of positive results of the patient's treatment, comparable with such while application of conventional surgical approach. Stenting of carotid arteries in majority of clinical situations constitutes the only available and the least risked method of treatment, especially in patients with complicated course of the main disease and in presence of concurrent illnesses.     

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)