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The Journal of Cardiovascular Surgery 2003 February;44(1):79-85

Copyright © 2009 EDIZIONI MINERVA MEDICA

language: English

Rationale of the surgical treatment of carotid kinking

Grego F., Lepidi S., Cognolato D., Frigatti P., Morelli I., Deriu G. P.

Department of Vascular Surgery University of Padova, Padua, Italy


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Aim. Elon­ga­tion and tor­tu­osity of the ­internal ­carotid ­artery (­ICAET) is a ­common angio­graphic, ­angioMR or ­Duplex scan­ning ­finding: it can be “­pure” and, in a ­great ­majority of ­cases, it is not cor­re­lated to neu­ro­log­ical symp­toms. It can be asso­ciated ­with ath­e­ros­cle­rotic bifur­ca­tion ­plaque, there­fore in ­this ­case, indi­ca­tions to sur­gery ­follow ­that of ­carotid sten­osis. On the ­other ­hand in ­some ­patients ­ICAET ­seems poten­tially cor­re­lated to hem­i­spheric or non hem­i­spheric symp­toms: ­ICAET may ­show as ­kinking ­with a ­wide or ­narrow ­acute ­angle, ­single (< shaped) or ­double (Z ­shaped), or ­less fre­quently as a ­coiling (S,U, or C ­shaped). Sur­gical indi­ca­tions are con­tro­ver­sial. In the ­author’s ­opinion, sur­gery may rep­re­sent the ­safest ­tool in the pre­ven­tion of a ­stroke due to ­carotid occlu­sion, in ­selected ­patients. The aim of ­this ­study is to ­describe the ­author’s expe­ri­ence in the sur­gical treat­ment of ­carotid ­kinking not asso­ciated ­with sig­nif­i­cant ath­e­ros­cle­rotic ­lesions.
­Methods. ­From ­March 1994 to ­March 2001, 29 ­patients (11 ­male, 18 ­female) ­with a ­pure ­ICAET under­went sur­gery. ­Patients pre­sented hem­i­spheric symp­toms (24.13%), non hem­i­spheric symp­toms (41.3%) or ­both (27.5 %). Two asymp­to­matic ­patients (6.9%) under­went sur­gery ­because of con­tra­lat­eral ­carotid occlu­sion.
­Results. The post­op­er­a­tive (­within 30 ­days ­from oper­a­tion) ­results, no mor­tality was ­observed, 1 ­patient pre­sented a ­stroke (3.4%), and 1 ­patient had a TIA at awak­ening (neg­a­tive cere­bral CT ­scan). All ­patients ­with hem­i­spheric symp­toms (15 ­patients) had com­plete remis­sion, ­whereas ­only 6 out of 12 ­patients (50%) pre­senting non-hem­i­spheric symp­toms had remis­sion (1 ­patient under­went a con­tro­lat­eral ­ICAET cor­rec­tion).
Con­clu­sion. The nat­ural his­tory of symp­to­matic and asymp­to­matic ­ICAET is prac­ti­cally ­unknown, but in ­some ­cases ­selected indi­ca­tion to sur­gery is jus­ti­fied. Sur­gery was indi­cated for ­patients ­with tran­sient ­ischaemic ­attacks ( hem­i­spheric symp­toms); in asymp­to­matic ­patients pre­senting a ­kinking ­with an ­angle infe­rior to 30°, and a con­tra­lat­eral ­carotid ­artery occlu­sion; in ­patients ­with non hem­i­spheric symp­toms, ­after a ­screening to ­exclude all ­other pos­sible neu­ro­log­ical or non-neu­ro­log­ical ­causes ­with ­duplex ­scan pos­i­tive for sig­nif­i­cant ­increase of ­flow ­velocity in ICA and pos­i­tive cere­bral CT ­scan or MR ­scan for ­ischaemic ­lesions in the homo­lat­eral hem­i­sphere, and/or a ­flow inver­sion in ante­rior cere­bral ­artery or ­flow reduc­tion in the ­middle cere­bral ­artery, ­according to dif­ferent ­head posi­tions (rota­tion and ­flex-exten­sion).

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