External carotid endarterectomy with internal carotid artery transposition flap angioplasty for symptomatic internal carotid artery occlusion

The external carotid artery is an important collateral pathway for cerebral perfusion when the internal carotid artery is occluded. After internal carotid artery occlusion, there is a definite risk of ipsilateral neurological events. The authors retrospectively examined their experience with endarterectomy of the external carotid artery for symptomatic internal carotid artery occlusion. Results based on the authors' experience and on historical data show external carotid endarterectomy to be a safe procedure. Obliteration of the cul-de-sac appears to be a very important factor in the prevention of reocclusion or recurrence of symptoms after external carotid endarterectomy. Use of the internal carotid artery stump for patching of the endarterectomized external carotid artery is both safe and effective in treating symptomatic internal carotid artery occlusion.     

Past,Present and Future of Surgical Training in Belgium

The objective of the authors is to assess the natural history of carotid artery disease and the role of carotid intervention in preventing ipsilateral stroke. The development of endovascular techniques for correction of carotid artery stenoses made this less invasive technique very popular, with an inherent risk of unregulated overuse by a variety of medical specialists, who are not always well informed on the natural history of carotid artery disease. It re-opened the discussion on the value of carotid endarterectomy for stroke prophylaxis. This ongoing debate offers the opportunity to distil evidence-based guidelines for the management of extracranial carotid artery stenoses.

In recent papers, some authors expressed doubts on the validity and general applicability of the results of the pivotal randomised trials of carotid endarterectomy. The excellent results in terms of operative outcome and long term stroke prevention would, according to certain comments, not be attainable in routine practice.

Another criticism of carotid endarterectomy is its higher operative morbidity in terms of cranial nerve lesions and myocardial infarctions, compared to endovascular procedures. This consideration is, for some authors, the main reason to espouse carotid artery stenting as a better alternative to carotid endarterectomy. Any evidence supporting this point of view is missing. The supposed equivalence or non-inferiority of carotid artery stenting is purely speculative. The aim of this review paper is to summarize the crude data of carotid surgery trials. The authors aim to answer four questions. For which lesions is carotid endarterectomy most beneficial ? Are the results of randomised carotid surgery trials biased by the selection of patients ? Is operative morbidity, other than stroke, under-estimated ? Is carotid artery stenting safe and efficacious ?

An in-depth review with a critical analysis is made of recently published and on-going trials, comparing carotid surgery with percutaneous carotid angioplasty.     

Extrakranielle Karotisstenose beim herzchirurgischen Patienten

The optimal treatment for reduction of the risk of stroke in cardiac surgery patients with concurrent severe coronary and carotid artery atherosclerosis is controversially discussed. To date, no high-level evidence exists that combined carotid artery revascularization and coronary bypass grafting (CABG) confer any benefit over isolated CABG. While carotid artery revascularization can be beneficial in cases of symptomatic carotid stenosis, unilateral asymptomatic carotid stenosis with good cerebral reserve capacity, high-grade asymptomatic carotid stenosis with contralateral occlusion or high-grade bilateral carotid artery stenosis (cumulative >140%), there is no proven benefit for the large majority of patients with asymptomatic carotid disease. It is therefore recommended that the indications for carotid revascularization in patients undergoing CABG should be considered with caution.     

颈动脉体瘤的外科治疗

目的 探讨颈动脉体瘤的诊断与外科治疗.方法 分析山东大学附属省立医院血管外科2003年1月至2010年10月收治16例颈动脉体瘤患者,经数字减影血管造影术检查得以最终确诊.采用Shamblin分型标准分型:Ⅰ型3例,Ⅱ型11例,Ⅲ型2例,本组全部行外科手术治疗.3例ⅠⅠ型患者行单纯摘除术.11例Ⅱ型患者中,3例行单纯摘除术,3例行摘除术并颈外动脉切除,3例行摘除术、颈外动脉切除并颈动脉修补术,2例行摘除术、颈外动脉切除并颈内动脉重建术.2例Ⅲ型患者,1例行摘除术、颈外动脉切除并颈动脉修补术,1例行摘除术、颈外动脉切除并颈内动脉重建术.结果 16例患者病理均证实为颈动脉体瘤.无手术死亡、偏瘫和失明.术后并发症中以颅神经损伤最多见,共有7例(43.75%),经对症治疗,6例有不同程度改善,1例遗留永久性13角歪斜.随访13例(81.25%),随访时间2～76个月,平均(42.0±1.2)个月,未见肿瘤复发和远处转移.结论 数字减影血管造影术在颈动脉体瘤的诊断和治疗中具有重要意义,颈动脉体瘤应首选手术治疗,可根据瘤体与血管的关系选择适当的术式.

Abstract：

Objective To discuss the diagnosis and surgical treatment for carotid body tumors (CBT). Methods Retrospective analysis was made on 16 cases of carotid body tumors hospitalized in Shandong Provincal Hospital from January 2003 to October 2010. All patients were diagnosed by digital subtraction angiography, including 3 case of Shamblin type Ⅰ,11 cases of Shamblin type Ⅱ and 2 cases of Shamblin type Ⅲ. Three cases of type Ⅰ and 3 cases of type Ⅱ underwent carotid body tumor resection. Three cases of type Ⅱ underwent carotid body tumor plus external carotid artery resection, 3 cases underwent carotid body tumor plus external carotid artery resection plus carotid artery repairment, 2 cases did carotid body tumor plus external carotid artery resection plus internal carotid artery reconstruction. One of type Ⅲ underwent carotid body tumor plus external carotid artery resection plus carotid artery repairment, and the other one underwent carotid body tumor plus external carotid artery resection plus internal carotid artery reconstruction. Results Diagnosis of CBT was confirmed by pathology in all cases. There was no postoperative death、hemiplegia and blindness. The cranial nerve injury was caused in 7 cases, accounting for 43. 75%. 13 cases ( 81. 25% ) were followed up for 2 to 76 months ( mean 42 months), no tumor recurrence and metastasis was found. Conclusions Digital subtraction angiography (DSA) is important in the diagnosis and therapy of carotid body tumor. Surgical treatment is the choice of therapy for carotid body tumors.     

An external carotid artery shunt to prevent cerebral ischaemia during carotid surgery

The contribution of the external carotid artery to cerebral blood flow in the presence of an internal carotid occlusion or severe stenosis is well documented. This study was undertaken in order to try and exploit the external carotid artery as a collateral pathway to avoid cerebral ischaemia during carotid surgery. The main problem is to ascertain when the external carotid artery is relevant to cerebral perfusion, and to assess if the insertion of a shunt from the common to the external carotid artery is a useful way of ensuring adequate cerebral perfusion in patients with cerebral ischaemia during carotid clamping. In order to do this, it was necessary to assay the haemodynamic role of the external carotid artery by means of a technique which monitors cerebral function in a reliable way. We tried to evaluate this possibility by an intra-operative haemodynamic study during carotid surgery in 35 patients operated on under local anaesthesia. The insertion of a shunt between the common and external carotid artery was able to reverse brain ischaemia during clamping in four of eight patients with a neurological deficit during temporary carotid occlusion. In selected cases therefore cerebral protection with an external carotid shunt might be a valuable adjunct in the performance of carotid surgery.     

Lessons learnt from carotid artery trials

The objective of the authors is to assess the natural history of carotid artery disease and the role of carotid intervention in preventing ipsilateral stroke. The development of endovascular techniques for correction of carotid artery stenoses made this less invasive technique very popular, with an inherent risk of unregulated overuse by a variety of medical specialists, who are not always well informed on the natural history of carotid artery disease. It re-opened the discussion on the value of carotid endarterectomy for stroke prophylaxis. This ongoing debate offers the opportunity to distil evidence-based guidelines for the management of extracranial carotid artery stenoses. In recent papers, some authors expressed doubts on the validity and general applicability of the results of the pivotal randomised trials of carotid endarterectomy. The excellent results in terms of operative outcome and long term stroke prevention would, according to certain comments, not be attainable in routine practice. Another criticism of carotid endarterectomy is its higher operative morbidity in terms of cranial nerve lesions and myocardial infarctions, compared to endovascular procedures. This consideration is, for some authors, the main reason to espouse carotid artery stenting as a better alternative to carotid endarterectomy. Any evidence supporting this point of view is missing. The supposed equivalence or non-inferiority of carotid artery stenting is purely speculative. The aim of this review paper is to summarize the crude data of carotid surgery trials. The authors aim to answer four questions. For which lesions is carotid endarterectomy most beneficial ? Are the results of randomised carotid surgery trials biased by the selection of patients ? Is operative morbidity, other than stroke, under-estimated ? Is carotid artery stenting safe and efficacious ? An in-depth review with a critical analysis is made of recently published and on-going trials, comparing carotid surgery with percutaneous carotid angioplasty.     

Eversion endarterectomy of the internal carotid artery combined with open endarterectomy of the common carotid artery

The author presents a technique for endarterectomy and reconstruction of the carotid bifurcation in difficult cases when the plaque extends high into the internal carotid artery. The technique combines the aspects of the 2 most commonly performed procedures: carotid endarterectomy after a longitudinal arteriotomy extending from the common carotid artery into the internal carotid artery and eversion endarterectomy in which the plaque is removed from the internal carotid artery sectioned from the common carotid artery and everted. The author suggests applying this technique selectively in patients in whom the atherosclerotic plaque extends very high into the internal carotid artery. The technique offers the advantages of removing the plaque into the common carotid artery under direct vision and leaving the original dimensions and geometry of the internal carotid artery, theoretically decreasing the probability of early thrombosis and recurrent carotid disease. For routine cases, the author prefers and recommends standard carotid bifurcation endarterectomy with patch closure when the size of the arteries is reduced like in women and selected male patients.     

颈动脉转流管在颅外段血管手术中的应用

目的：探讨颈动脉转流管在颅外段血管手术中的保护作用。方法：男性16例，女性7例；年龄11--76岁，平均55岁。包括颈动脉硬化性狭窄12例(双侧3例)，行颈动脉硬化内膜剥脱术；颈动脉体瘤4例(双侧1例)，行颈动脉体瘤切除术；颈动脉假性动脉瘤4例(双侧1例)，行假性动脉瘤切除、颈动脉破口修补术；颈内动脉瘤2例，行瘤体大部切除缩缝成形术；颈动脉迂曲症1例，行颈动脉多余段切除、端端吻合术。以上手术均在颈动脉转流管保护下完成。结果本组无手术死亡，未发生与脑缺血有关的并发症，仅1例颈动脉体瘤患者并发Horner氏征。结论：颈动脉转流管在颅外段颈动脉有关疾病的手术中有良好的保护作用。     

Carotid Sinus Syndrome: Treatment by Carotid Sinus Denervation

Hypersensitive carotid sinus is a rare cause of spontaneous syncopal attacks. It must be differentiated from the other more common causes, such as intrinsic cardiac disease, vasovagal responses, postural hypotension and cerebrovascular insufficiency, although it may accompany these conditions. The definition of carotid sinus syncope is syncope elicited by stimulation of a hypersensitive carotid sinus.Nineteen patients with carotid sinus syncope were treated by carotid sinus denervation. Ages ranged from 48 to 83 with a mean of 65.5 years. Symptoms of marked dizziness or syncope were reproduced by gentle compression over the carotid bifurcation, while ECG monitoring revealed bradycardia or transient asystole. Seventeen patients had carotid arteriograms, eleven of which were normal. One patient had stenosis of the external carotid artery, while five had stenosis of the internal carotid. The right carotid sinus was involved in ten patients, the left in three and both sides in six. All patients underwent unilateral or bilateral carotid sinus denervation. Five patients with internal carotid stenosis had concomitant carotid endarterectomy. Complete relief of symptoms or marked improvement was noted in all but one patient. Postoperative follow-up ranged up to 15 years. Carotid sinus denervation is a simple, effective method of treating this disorder.     

The evolving surgical management of recurrent carotid stenosis.

The traditional approach to recurrent carotid stenosis has been repeat endarterectomy or patch angioplasty. Concern with the durability of repeat carotid endarterectomy has resulted in our use of carotid resection with autogenous graft interposition. This study was designed to determine the outcome and efficacy of carotid resection compared with repeat carotid endarterectomy in the management of recurrent carotid stenosis. From 1974 to 1991, 162 operations (repeat carotid endarterectomy 105, carotid resection 57) were performed for recurrent carotid stenosis. Indication for operation was hemispheric symptoms in 63% of patients, nonlateralizing symptoms in 25%, asymptomatic stenosis in 7%, and previous stroke in 5%. Ninety-one percent of patients had stenosis greater than 90% on arteriography. The perioperative stroke rate for carotid resection was 3.5%, with a subsequent rate of 0.0064 strokes per year. For repeat carotid endarterectomy, the perioperative stroke rate was 1.9% with a subsequent rate of 0.011 strokes per year. Graft patency after carotid resection was 93% (mean follow-up, 35 months). Four patients treated with carotid resection had graft thrombosis, and two of the four remained asymptomatic. After repeat carotid endarterectomy, one patient had carotid thrombosis, and recurrent stenosis greater than 50% developed in 23 patients (mean follow-up, 64 months). Twenty patients treated with repeat carotid endarterectomy underwent an additional operation for further symptomatic recurrent carotid stenosis. We conclude carotid resection is a safe and effective alternative to repeat carotid endarterectomy for patients undergoing operation for recurrent carotid stenosis.     

Reoperative carotid surgery

Fourteen patients underwent carotid reoperation for symptomatic recurrent carotid stenosis after previous ipsilateral carotid endarterectomy. Eight of these patients presented with focal transient ischemic attacks, two with strokes, and four with vertebrobasilar insufficiency. Recurrent symptoms in eight patients were similar to those prompting the initial carotid endarterectomy. Symptoms recurred early after previous carotid endarterectomy in 2 patients and late in 12 patients. Eleven patients underwent repeat endarterectomy and carotid patch angioplasty, two patients underwent patch angioplasty alone, and one patient underwent carotid artery replacement with a vein graft. Persistent or recurrent focal symptoms referable to the reoperated carotid artery were not present during follow-up (mean 27.4 months, range 4 to 79 months). Vertebrobasilar symptoms were relieved by carotid reoperation in each patient. Although the natural history of asymptomatic postoperative carotid restenosis is unknown, reluctance to reoperate on symptomatic patients is unwarranted, since carotid reoperation can be performed safely with the expectation that recurrent focal and nonfocal vertebrobasilar symptoms will be relieved.     

Optimal training strategies for carotid stenting

Future participation in the treatment of carotid occlusive disease is dependent on training to perform carotid stent placement. Reviewed herein are strategies for training in carotid stenting. Included in this discussion are; the skills required for carotid stenting, the carotid stent learning curve, a comparison of training and credentialing, and the roles of simulators, courses, and hands-on experience in carotid stent training.     

Strategies for embolization of the internal carotid artery for cavernous sinus tumors

Skull base tumors, in addition to blood supply from the external carotid artery, frequently receive a portion of their blood supply from the cavernous portion of the internal carotid artery, especially when the cavernous sinus is invaded by tumor. Preoperative embolization routinely includes obliteration of the supply to the tumor from the external carotid system. However, a variety of strategies are available that enable preoperative embolization of supply from the internal carotid artery as well. These include direct catheterization of cavernous branches of the internal carotid artery, temporary occlusion of the internal carotid artery during external carotid embolization, embolization of the internal carotid artery supply during temporary or permanent occlusion of the internal carotid artery, and internal carotid artery sacrifice. The angiographic anatomy in any particular case dictates these options.     

Surgeries on the carotid arteries

The article lays emphasis on the main causes of restenosis after endarterectomy from the bifurcation of the carotid artery and shows the methods of its prevention. A new method for endarterectomy of the bifurcation of the carotid artery is suggested, which consists in reimplantation of the internal carotid artery. The authors claim this method to be optimal in combined affection: atherosclerotic constriction of carotid artery bifurcation and pathological tortuosity of the internal carotid artery. The authors possess an experience in 351 operations on the carotid arteries, 177 of them were conducted for loops and kinks of the carotid arteries; 152, for endarterectomy in atherosclerotic affection of the carotid arteries; and 22 for other, less frequently encountered affections of the carotid arteries.     

Assessment of vessel wall thickness in carotid atherosclerosis using spiral CT angiography.

OBJECTIVES: the purpose of this study was to evaluate the amount of vessel wall thickening in the internal and common carotid arteries in patients undergoing spiral CT angiography for the investigation of significant atherosclerotic disease. MATERIALS AND METHODS: forty-five carotid systems in patients with a 70% or greater stenosis (according to carotid duplex) were imaged with CT spiral angiography using a standardised protocol. The vessel wall thickness of the distal common and mid internal carotid artery was measured using axial CT sections. RESULTS: vessel wall thickness was greater and more variable within the common carotid artery than within the internal carotid artery. The mean proportion of total vessel diameter constituted by vessel wall thickness was significantly greater in the common carotid artery as compared to the internal carotid artery: 28+/-12% (SD) vs 15+/-6%, respectively (p < 0.001). CONCLUSIONS: significant and extended wall thickening is commonly present in the internal and common carotid arteries of patients with atherosclerotic disease, but the internal carotid artery is significantly less affected than the common carotid artery. These observations question the validity of using the common carotid artery as a reference vessel for angiographic stenosis measurements.     

Strategies for Embolization of the Internal Carotid Artery for Cavernous Sinus Tumors

Skull base tumors, in addition to blood supply from the external carotid artery, frequently receive a portion of their blood supply from the cavernous portion of the internal carotid artery, especially when the cavernous sinus is invaded by tumor. Preoperative embolization routinely includes obliteration of the supply to the tumor from the external carotid system. However, a variety of strategies are available that enable preoperative embolization of supply from the internal carotid artery as well. These include direct catheterization of cavernous branches of the internal carotid artery, temporary occlusion of the internal carotid artery during external carotid embolization, embolization of the internal carotid artery supply during temporary or permanent occlusion of the internal carotid artery, and internal carotid artery sacrifice. The angiographic anatomy in any particular case dictates these options.     

Karotisstenose

Since 2004, several large randomized trials have provided important data about the comparison of carotid endarterectomy and carotid artery stenting of more than 2000 patients with predominantly symptomatic carotid artery stenosis. None of these trials demonstrated clearly an equivalent periprocedural risk of both techniques. Long-term evaluation is also pending. Thus carotid endarterectomy remains the gold standard in treatment of symptomatic carotid artery stenosis. The frequently performed endovascular treatment of asymptomatic carotid stenosis is not supported by study data.     

Carotid artery stenosis]

Since 2004, several large randomized trials have provided important data about the comparison of carotid endarterectomy and carotid artery stenting of more than 2,000 patients with predominantly symptomatic carotid artery stenosis. None of these trials demonstrated clearly an equivalent periprocedural risk of both techniques. Long-term evaluation is also pending. Thus carotid endarterectomy remains the gold standard in treatment of symptomatic carotid artery stenosis. The frequently performed endovascular treatment of asymptomatic carotid stenosis is not supported by study data.     

First clinical experience with excimer assisted high flow bypass surgery of the brain

Summary A new type of revascularization of the brain is used in patients with brain ischaemia, caused by an occlusion of one or both internal carotid arteries, and in patients in whom the internal carotid artery has been deliberately occluded for the treatment of a giant aneurysm of the internal carotid artery.A so-called high flow extra-intracranial bypass operation is performed. An arterial or venous transplant is interposed between a branch of the external carotid artery or the external carotid artery itself and the intracranial portion of the internal carotid artery. The anastomosis with the intracranial portion of the internal carotid artery is made without temporary occlusion of the recipient artery and with the aid of the newly developed Excimer laser assisted anastomosis technique.The results of animal experiments and of a clinical series of 9 patients are reported.     

Benefit of external carotid endarterectomy in patients with advanced cerebrovascular disease

The external carotid artery and its branches may serve as critical collateral pathways to the cerebral hemisphere when the internal carotid artery is occluded. In this setting, a stenotic lesion of the external carotid artery can result in hypoperfusion as well as lead to embolic phenomena via enlarged collaterals. This is a report of an experience with six external carotid endarterectomies in five patients from April 1983 to March 1986. All five of the patients had an internal carotid artery occlusion ipsilateral to a significant external carotid artery stenosis. Each patient had symptomatic cerebrovascular insufficiency with four of the five patients demonstrating clear cut symptoms, which lateralized to the side with external carotid stenosis and internal carotid occlusion. These symptoms included amaurosis fugax in four patients and transient extremity weakness in two patients. Four out of five patients were completely relieved of their symptoms after external carotid endarterectomy with follow up periods ranging from 6 months to 2 and one half years. There were no perioperative neurological deficits or complications. The duplex scan was useful in identifying possible candidates for this operation. Important technical details include use of an arterial shunt and closure of the internal carotid artery stump, which may be a source of further emboli. It is concluded that with appropriate patient selection, external carotid endarterectomy can be safely employed with gratifying results in patients with advanced cerebrovascular disease.