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Rivista di Chirurgia Cardiaca, Vascolare e Toracica

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

lingua: Inglese

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


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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