Bifurcation Of Common Carotid Artery Research Articles

The hemodynamic and geometric characteristics of carotid artery atherosclerotic plaque formation.

Ischemic stroke, which has a high incidence, disability, and mortality rate, is mainly caused by carotid atherosclerotic plaque. The difference in the geometric structures of the carotid arteries inevitably leads to the variability in the local hemodynamics, which plays a key role in the formation of carotid atherosclerosis. At present, the combined mechanisms of hemodynamic and geometric in the formation of carotid atherosclerotic plaque are not clear. Thus, this study characterized the geometric and hemodynamic characteristics of carotid atherosclerotic plaque formation using four-dimensional (4D) flow magnetic resonance imaging (MRI). Ultimately, 122 carotid arteries from 61 patients were examined in this study. According to the presence of plaques at the bifurcation of the carotid artery on cervical vascular ultrasound (US), carotid arteries were placed into a plaque group (N=69) and nonplaque group (N=53). The ratio of the maximum internal carotid artery (ICA) inner diameter to the maximum common carotid artery (CCA) inner diameter (ICA-CCA diameter ratio), bifurcation angle, and tortuosity were measured using neck three-dimensional time-of-flight magnetic resonance angiography (3D TOF-MRA). Meanwhile, 4D flow MRI was used to obtain the following hemodynamic parameters of the carotid arteries: volume flow rate, velocity, wall shear stress (WSS), and pressure gradient (PG). Independent sample t-tests were used to compare carotid artery geometry and hemodynamic changes between the plaque group and nonplaque group. The ICA-CCA diameter ratio between the plaque group and the nonplaque group was not significantly different (P=0.124), while there were significant differences in the bifurcation angle (P=0.005) and tortuosity (P=0.032). The bifurcation angle of the plaque group was greater than that of the nonplaque group (60.70°±20.75° vs. 49.32°±22.90°), and the tortuosity was smaller than that of the nonplaque group (1.07±0.04 vs. 1.09±0.05). There were no significant differences between the two groups in terms of volume flow rate (P=0.351) and the maximum value of velocity (velocitymax) (P=0.388), but the axial, circumferential, and 3D WSS values were all significantly different, including their mean values (all P values <0.001) and the maximum value of 3D WSS (P<0.001), with the mean axial, circumferential, 3D WSS values, along with the maximum 3D WSS value, being lower in the plaque group. The two groups also differed significantly in terms of maximum PG value (P=0.030) and mean PG value (P=0.026), with these values being greater in the nonplaque group than in the plaque group. A large bifurcation angle and a low tortuosity of the carotid artery are geometric risk factors for plaque formation in this area. Low WSS and low PG values are associated with carotid atherosclerotic plaque formation.

The efficacy and efficiency of percutaneous lidocaine injection for minimizing the carotid reflex in carotid artery stenting: A single-center retrospective study.

To assess whether local anesthetic infiltration could minimize the carotid baroreceptor reflex (CBR) which has an incidence after carotid artery stenting (CAS) that varies from 29% to 51%. This retrospective single-center study included 51 patients (mean age, 70.47 years) who underwent CAS for carotid stenosis. The groups included patients who underwent CAS for asymptomatic ischemic stroke (n=41) or symptomatic disease (n=10). Preprocedural percutaneous lidocaine injections (PPLIs) were administered to 70.6% and 5.9% of patients who underwent elective CAS and emergency CAS, respectively. Among patients who received PPLIs, the mean degree of stenosis was 80.5% (95% confidence interval [CI]: ±10.74, 51-98%). The mean distance from the common carotid artery bifurcation to the most stenotic lesion (CSD) was 8.3 mm (95% CI: ±0.97, 6.3-10.2 mm); the mean angle between the internal carotid artery and common carotid artery (CCA) trunk (IAG) was 65.6° (95% CI: ±2.39, 61-70°). Among patients who did not receive PPLIs, the mean degree of stenosis was 84.0% (95% CI: ±8.96, 70-99%). The mean CSD was 5.9 mm (95% CI: ±1.83, 1.9-9.9 mm); the mean IAG was 60.4° (95% CI: ±4.41, 51-70°). The procedure time was longer in the PPLI group than in the no PPLI group (28.19 [n=39] vs. 18.88 [n=12] days) (P=0.057); the length of intensive care unit stay was shorter in the PPLI group (20.01 [n=36] vs. 28.10 [n=5] days) (P=0.132). Targeted PPLI administration to the carotid bulb decreased aberrant heart rates and blood pressure changes induced by carotid stent deployment and balloon inflation. As CBR sensitivity increases with decreasing distance to the stenotic lesion from the CCA bifurcation, PPLIs may help stabilize patients during procedures for stenotic lesions closer to the CCA.

The Accelerator and Brake Modulatory System of Carotid Body Sensitivity

The carotid body (CB) is the primary sensor of arterial gases in the human body that through reflex pathways maintains cardiovascular homeostasis. It is known that CB chemosensitivity increases upon repeated stimulation as well as disease states; however, the molecular basis for this remains elusive. Objectives: To investigate the effect of excitatory and inhibitory amino acids in mediating CB afferent activity. Hypothesis: We hypothesised that glutamate and γ-aminobutyric acid (GABA) act to modulate CB sensitivity. Methods: Electrophysiological recordings of carotid sinus nerve (CSN) afferent discharge were made from an ex vivo arterially perfused common carotid artery bifurcation preparation. Effects of agents on CB sensitivity were assessed from responses evoked by cyanide (CN−) (1.23 μmol bolus). Results: The CSN response to CN− consisted of a rapid high amplitude discharge that was quenched abruptly, leading to a low amplitude tail. Glutamate administration augmented the CSN response to CN− by 2-fold compared to baseline ( p=0.0005). In contrast, GABA administration suppressed the CN− response by 2-fold ( p = 3.71 x 10−5). An N-methyl-D-aspartic acid (NMDA) receptor antagonist (MK801; 100 μM) increased the response amplitude resulting in one single high amplitude discharge (160% increase from baseline), abolishing the low amplitude tail. Such an effect was also observed following GABAA receptor blockade with bicuculline (500 μM), when an 80% increase was observed. The CN− response was blocked by PPADS (a P2X receptor antagonist; 100 μM) (242 ± 154 vs 4.82 ± 2.23 % change from baseline; p=0.03), suggesting it to be solely mediated by purinergic transmission. Summary of the data: We propose that CN-evoked excitation of CB chemosensory cells leads to the co-release of ATP and glutamate. ATP activates directly P2X receptors on petrosal chemosensory afferents, while glutamate acting via NMDA receptors on chemosensory cells leads to activity-induced potentiation of ATP release and co-release of GABA to quench ATP-mediated CSN discharge in a time-controlled manner. This is supported by our finding that blockade of either excitatory (NMDAR) or inhibitory (GABAA) receptors both heighten the CN− evoked CB response. A statement of the conclusions: Our results suggest an intrinsic ‘accelerator and brake’ paracrine mechanism within the CB involving glutamate and GABA controlling CB afferent sensitivity. Research was supported by the Health Research Council of New Zealand and the Sidney Taylor Trust. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Comprehensive ultrasound assessment of the state complex intima-media brachiocephalic arteries in patients with metabolic syndrome

Objective. Comprehensive ultrasound assessment of the state complex intima-media (CIM) of brachiocephalic arteries in patients with metabolic syndrome (MS). Materials and methods. 82 patients were examined, including 62 patients with MS and 20 practically healthy individuals. All patients underwent biochemical blood analysis, ultrasound of the extracranial sections of the brachiocephalic arteries with an assessment of the qualitative and quantitative characteristics of CIM bifurcation of the brachiocephalic trunk (BCT), common carotid arteries (CCA) and vertebral arteries (VA).Results. 100% of patients with MS, changes in the echostructure of CIM were recorded in the form of pathological layering, 9 (14.5%) patients – in the form of hyperechogenic inclusions. Thickness of CIM in the bifurcation of BCT and CCA in patients with MS statistically significantly exceeds the same indicator in practically healthy persons and demonstrates direct correlation between the components of MS. The modified Carnegan index patients with MS is statistically significantly higher than the same indicator in practically healthy individuals and demonstrates direct correlation with the thickness of CIM estimated in different segments of the brachiocephalic arteries (BCT k 0.356, RCCA k 0.718, LCCA k 0.846, in the bifurcation of CCA on the right k 0.431, on the left k 0.519).Conclusion. Comprehensive ultrasound assessment of the state brachiocephalic arteries in patients with MS allows us to obtain complex of qualitative and quantitative signs characteristic of metabolic angiopathy.

A Global Bibliometric Analysis of the Top 100 Most Cited Articles on Carotid Body Tumors.

The carotid body, situated at the common carotid artery bifurcation, comprises specialized glomus cells responsible for sensing blood oxygen, carbon dioxide, pH, and temperature changes, crucial for regulating breathing and maintaining oxygen homeostasis. Carotid body tumors (CBTs), arising from these cells, are rare, representing only 0.5% of head and neck tumors, often presenting as benign, slow-growing, vascularized masses. In February 2023, this bibliometric analysis was conducted, which involved screening 1733 articles from the Web of Science database. The screening process was based on citation count, and articles were selected for inclusion based on specific criteria that focused on CBTs located within the carotid bifurcation. Rigorous selection involved independent screening and data extraction by four authors. The top 100 articles, published between 1948 and 2019, totaled 6623 citations and were authored by 98 unique first authors from 22 countries and 77 institutions, spanning 42 journals. Treatment articles were the predominant category, comprising 49% of the literature. This analysis offers insights into publication trends, identifies literature gaps, and outlines areas of research focus, providing a valuable resource to guide future studies on CBTs.

Single-cell transcriptome analysis reveals tumoral microenvironment heterogenicity and hypervascularization in human carotid body tumor.

Carotid body tumor (CBT) is a rare neck tumor located at the adventitia of the common carotid artery bifurcation. The prominent pathological features of CBT are high vascularization and abnormal proliferation. However, single-cell transcriptome analysis of the microenvironment composition and molecular complexity in CBT has yet to be performed. In this study, we performed single-cell RNA sequencing (scRNA-seq) analysis on human CBT to define the cells that contribute to hypervascularization and chronic hyperplasia. Unbiased clustering analysis of transcriptional profiles identified 16 distinct cell populations including endothelial cells (ECs), smooth muscle cells (SMCs), neuron cells, macrophage cells, neutrophil cells, and T cells. Within the ECs population, we defined subsets with angiogenic capacity plus clear signs of later endothelial progenitor cells (EPCs) to normal ECs. Two populations of macrophages were detectable in CBT, macrophage1 showed enrichment in hypoxia-inducible factor-1 (HIF-1) and as well as an early EPCs cell-like population expressing CD14 and vascular endothelial growth factor. In addition to HIF-1-related transcriptional protein expression, macrophages1 also display a neovasculogenesis-promoting phenotype. SMCs included threepopulations showing platelet-derived growth factor receptor betaand vimentinexpression, indicative of a cancer-associated fibroblastphenotype. Finally, we identified three types of neuronal cells, including chief cells and sustentacular cells, and elucidated their distinct roles in the pathogenesis of CBT and abnormal proliferation of tumors. Overall, our study provided the first comprehensive characterization of the transcriptional landscape of CBT at scRNA-seq profiles, providing novel insights into the mechanisms underlying its formation.

The value of color doppler ultrasonography combined with computed tomography angiography and magnetic resonance angiography in the preoperative quantification and classification of carotid body tumors: a retrospective analysis

BackgroundComputed tomography angiography (CTA) and magnetic resonance angiography (MRA) provide accurate vascular imaging information, but their use may be contraindicated. Color Doppler ultrasonography (CDU) provides simple, safe, noninvasive, and reproducible imaging. We therefore investigated the role of preoperative CDU combined with CTA and MRA in the quantification, typing, and diagnosis of carotid body tumors (CBTs).MethodsWe retrospectively analyzed patients with CBTs categorized into group A (type I [n = 1] and type II [n = 10]) or group B (type III [n = 56]) per the intraoperative Shamblin classification. CDU, CTA, and MRA characteristics of CBTs were observed, surgical results were correlated, and the diagnostic threshold of the CBT classification was calculated.ResultsCBTs were usually located at the common carotid artery bifurcation, encircling the carotid artery. An increased angle was found between the internal and external carotid arteries. On CDU, CBTs primarily presented as homogeneous hypoechoic masses with clear boundaries, rich flow signals, and a high-speed, low-resistance artery-like flow spectrum. CTA showed uniform or heterogeneous marked enhancement. MRA showed mixed T1 and slightly longer T2 signals and uniform or uneven obvious enhancement. With increases in the lesion size, amount of blood transfused, and operation time, the intraoperative classification level and possibility of skull-base invasion increased. When the maximum diameter of the lesion, the volume of the tumor, the distance between the upper margin of the tumor to the mastoid and the mandibular angle were 3.10 cm, 10.15 cm3, − 3.26 cm, and 0.57 cm, respectively, the largest Youden index was the best diagnostic boundary value for Shamblin type III tumors.ConclusionsCDU combined with CTA and MRA can accurately evaluate the size and classification of CBTs.

A Cadaveric Study On Clinical Correlations of the Internal Jugular Vein and its Variations

Introduction: The largest paired vein is the internal jugular vein (IJV), which rests laterally adjacent to the main the common carotid artery (CCA) within the carotid triangle at the extremities of the neck. It is the main source of blood flow down from the sigmoid sinus of dural venous sinuses. The obstruction of blood flow or distension of the internal jugular vein can lead to increasing intracranial pressure in the brain and face. The increased the right atrial pressure can be a sign of heart failure, cardiovascular problems, and pulmonary embolism. The aims are to study and note down variations in the course and relations of the internal jugular vein and variations of tributaries of right IJV and left IJV diameter and effects on cardiovascular diseases. Materials and Methods: An observational based cadaveric study was conducted on twenty-four unclaimed embalmed cadavers were dissected from March 2021 to August 2023 in Bidar Institute of Medical Sciences, Bidar, Karnataka, India. Dissection procedure was followed by Cunningham’s manual of practical anatomy volume-3 book. Variations and pattern of bilateral internal jugular veins were observed. Results: External jugular vein access is a highly advantageous location for a heart catheterization. The tributaries of the internal jugular vein form the trunk and overlap on the common carotid artery bifurcation, which leads to adverse effects on baroreceptors and chemoreceptors at the level of divisions of internal and external carotid arteries. The pattern of the right and left internal jugular is quite significant. Conclusion: The study will generate information that would be useful for surgeons, and other clinical physicians and give necessary morphometric data on the internal jugular vein in the South Indian population.

Variations in external carotid artery branches and common carotid bifurcation level: a computed tomography angiography study

BackgroundThe common carotid bifurcation level is an important surgical landmark during head and neck surgery, especially endarterectomy, that could be omitted in patients with high bifurcation levels to reduce damage to neighboring structures like the hypoglossal nerve. Additionally, having a thorough understanding of the variations in the external carotid artery branches is crucial for head and neck cancer surgeries and thyroidectomy. However, cadavers were employed in the majority of studies on these variations. In previous research, there were significant disparities in the incidence of these variations according to gender, laterality, and ethnicity. In order to identify these changes in Egyptian patients and to compare them in terms of gender and laterality, we used computed tomographic angiography.MethodsThe level of the common carotid bifurcation was assessed in a cross-sectional study utilizing computed tomographic angiography, which included 80 patients (160 carotid sides) for comparing the common carotid artery bifurcation level with the relevant vertebrae and anterior neck structures, and they were compared with regard to gender and laterality. Variations in the external carotid artery branches were also evaluated.ResultsThe most frequent location of the common carotid bifurcation level was between C3 and C4 (33.8%). It was 36.9% between the thyroid and the hyoid. 47.5% of patients had a high common carotid bifurcation (higher than the C3/4 level). The highest bifurcation was at C2, while the lowest was at D1. For external carotid artery branches variations, the superior thyroid artery emerged at and below the level of the common carotid bifurcation, respectively, at 19.4% and 23.7%. The facial artery had the largest diameter (2.38 ± 0.44 mm), while the ascending pharyngeal artery had the smallest (1.17 ± 0.11 mm). Seven types of trunks were found; the ascending pharyngeal artery-occipital artery trunk was the most common (25%) and was followed by the lingual artery-facial artery trunk (20%).ConclusionsMultiple anatomical variations in the external carotid artery branches and the common carotid bifurcation level were found by computed tomographic angiography. As a result, it can be utilized as a useful imaging technique to evaluate these variations before surgery.

Carotid geometry is independently associated with complicated carotid artery plaques.

Complicated carotid artery plaques (cCAPs) are associated with an increased risk of rupture and subsequent stroke. The geometry of the carotid bifurcation determines the distribution of local hemodynamics and could thus contribute to the development and composition of these plaques. Therefore, we studied the role of carotid bifurcation geometry in the presence of cCAPs. We investigated the association of individual vessel geometry with carotid artery plaque types in the Carotid Plaque Imaging in Acute Stroke (CAPIAS) study. After excluding arteries without plaque or with insufficient MRI quality, 354 carotid arteries from 182 patients were analyzed. Individual parameters of carotid geometry [i.e., internal carotid artery (ICA)/common carotid artery (CCA) ratio, bifurcation angle, and tortuosity) were derived from time-of-flight MR images. The lesion types of carotid artery plaques were determined according to the American Heart Association classification of lesions by multi-contrast 3T-MRI. The association between carotid geometry and a cCAP was studied using logistic regression after adjusting for age, sex, wall area, and cardiovascular risk factors. Low ICA/CCA ratios (OR per SD increase 0.60 [95%CI: 0.42-0.85]; p = 0.004) and low bifurcation angles (OR 0.61 [95%CI: 0.42-0.90]; p = 0.012) were significantly associated with the presence of cCAPs after adjusting for age, sex, cardiovascular risk factors, and wall area. Tortuosity had no significant association with cCAPs. Only ICA/CCA ratio remained significant in a model containing all three geometric parameters (OR per SD increase 0.65 [95%CI: 0.45-0.94]; p = 0.023). A steep tapering of the ICA relative to the CCA and, to a lesser extent, a low angle of the carotid bifurcation were associated with the presence of cCAPs. Our findings highlight the contribution of bifurcation geometry to plaque vulnerability. Thus, assessment of carotid geometry could be helpful in identifying patients at risk of cCAPs.

Abstract Number ‐ 66: Symptomatic Chronic Internal Carotid Artery Occlusion Managed With Bilateral Common Carotid Angioplasty: A Case Report

Introduction Several guidelines have addressed symptomatic or asymptomatic carotid artery stenosis treatment with intensive medical management and surgical management based on the severity of stenosis [1]. In acute occlusions, endovascular treatment (EVT) and carotid endarterectomy (CEA) with or without prior thrombolytics provide the best recanalization and functional outcomes when compared to intravenous or intra‐arterial thrombolysis alone. There is, however, less robust evidence on management of symptomatic chronic internal carotid artery (ICA) occlusion occurring in tandem with significant contralateral ICA stenosis [2]. In chronic ICA occlusion (ICAO), EVT and carotid endarterectomy (CEA) are technically unfeasible, but indirect procedures have been arising as safe and effective alternatives, notably CEA or stenting of contralateral stenotic ICA [3] and CEA or stenting of ipsilateral external carotid artery (ECA) [4]. We hereby report a case of symptomatic chronic ICAO that was managed with staggered angioplasty and stenting of bilateral common carotid artery (CCA) bifurcations. Methods We hereby present a case report. Results A 62‐year‐old male with atrial fibrillation and hypertension woke up with sudden dysarthria and right upper extremity and facial weakness. NIHSS at presentation was 4. Last seen normal 9 hours prior. Non‐contrast head computerized tomography (CT) did not show acute intracranial abnormality, CT angiogram of head and neck showed severe right ICA stenosis and complete occlusion of the left ICA at cervical, petrous and cavernous segments, with distal reconstitution at the supraclinoid segment with left proximal middle cerebral artery (MCA) thrombus. CT perfusion showed a core infarct volume of 8cc in left MCA territory, mismatch volume of 78cc and ratio of 10.8. Risks of acute neuro‐intervention were deemed to outweigh benefits. Given favorable perfusion imaging, and in concordance with the EXTEND trial [5], tPA was administered. The patient remained stable without hemorrhagic complications with residual deficits of mild right upper extremity weakness and mild expressive aphasia. MRI confirmed left ICA territory ischemic infarcts. Patient underwent stenting of the asymptomatic right ICA at the CCA bifurcation first, followed by left CCA stent after one month with impressive improvement in subsequent perfusion imaging. Conclusions Our case encourages consideration of well‐timed angioplasty and stenting in cases of chronic bilateral carotid artery disease especially when the asymptomatic side is also significantly stenotic

Variations in origins of External, Internal Carotid Artery and Superior Thyroid Artery Branching Pattern: A Cadaveric Study

Introduction: The rich vascularity of most parts of the head and neck is mainly maintained by the carotids and their branches. However, variations in the External Carotid Artery (ECA) and Superior Thyroid Artery (STA) can pose risks during neck surgeries. Aim: This study aimed to examine relationship of ECA at point of origin and variations in the origin of superior thyroid artery. Materials and Methods: A cross-sectional study was conducted at the Department of Anatomy, Government Medical College Kota, Rajasthan, India. Fifty common carotid arteries were obtained from 20 adult human cadavers and five sagittal sections of head and neck specimens. The specimens were dissected bilaterally, resulting in a total of 50 carotids observed. Data analysis was performed using SPSS software version 25. Results: In 86% of the specimens, the ECA originated at the upper border of the thyroid cartilage, while in 14% of the specimens, it was at a higher level. Transposition of the ECA laterally was observed in 4% of the specimens, and medial transposition was observed in 96% of the specimens. The STA originated from the ECA in 76% of the specimens, from the carotid bifurcation in 16% of the specimens, and from the Common Carotid Artery (CCA) in 8% of the specimens. Conclusion: The anatomical level of the CCA bifurcation is crucial clinically and surgically. These findings contribute to our understanding of the vascular anatomy of the carotid triangle, aiding students, radiologists, and surgeons in preventing complications and improving head and neck surgeries.

Cervicocerebral Computed Tomography Angiography for Older Patients Based on Time to Peak and Number of Time Points to Peak in the Test Bolus Technique.

This study sought to optimize image quality and reduce the contrast dose by adjusting contrast agent and normal saline doses used in cervicocerebral computed tomography angiography (CTA) of older patients. Older patients who underwent cervicocerebral CTA were divided into group A (n = 110) and group B (n = 124). In the angiography scan, patients in group A were injected with 1.0 mL/kg contrast agent, followed by 40 mL saline chaser. In group B, contrast agent and normal saline doses were adjusted based on time to peak and number of time points to peak in the test bolus technique. The CT attenuation values, noise, signal-to-noise ratio, and contrast-to-noise ratio of target arteries and the right transverse sinus were objectively compared. Compared with group A, the contrast retention and artifacts in the right subclavian vein, right brachiocephalic veins, and superior vena cava were significantly decreased in group B. Furthermore, in group B, the noise at the bifurcation of the right common carotid artery increased by 1.7%, and the signal-to-noise ratio of the left middle cerebral artery M1 segment decreased by 6.6%. The contrast dose in group B decreased significantly (18.2%) as compared with group A. Based on time to peak and number of time points to peak with the test bolus, adjusting contrast and normal saline doses in cervicocerebral CTA for older people reduces contrast retention and artifacts in the veins of the injection side. Further, it also decreases the contrast dose needed to obtain image quality that satisfies diagnostic requirements.

Variations of Bifurcation of the Common Carotid Artery, and Origin of Superior Thyroid Artery, in Sudanese: A Cadaveric Study

Background: Knowledge of the bifurcation level of the common carotid artery (CCA) is important during surgery, mummification, and radiological studies. This study aim to evaluate the anatomical variations in the bifurcation level of CCA, and the origin of the superior thyroid artery (STA), in Sudanese populations. Their knowledge reduces risk during surgery and helps in arterial ligation. Materials and Methods: 30 neck cadaveric specimens were evaluated on sides, using natural anatomical tools and methods for the anatomical studies. Results: The bifurcation of CCA was found at 36.7% at the level of the upper border of thyroid cartilage (TC), 61.7% above, and 1.6% below. No big differences were found in carotid bifurcation on both sides. The right side showed 30% were normal, 66.7 % high, and 3.3% were low-level bifurcation, left showed 43.3% were normal, 56.7% high, and no low level of bifurcation was observed. Origin of STA either from external 50% or bifurcation 46.7% was nearly about the same, with a few incidences 3.3% from the common carotid. Significance differences were observed in origin STA between both sides, on the right the artery commonly originates from external, and on the left commonly from the bifurcation. Conclusion: CCA bifurcates at a higher level in Sudanese, with no big difference in carotid bifurcation on both sides. Statistically, a significant difference was found in the origin of STA on both sides. Recommendation: higher bifurcation of CCA, and side variations in origin of STA, should be put into consideration during surgery and radiology.

Anatomical variations in the origin of the superior thyroid artery

Superior thyroid artery (STA) is first and lowest branch of external carotid artery (ECA) and it supplies thyroid, parathyroid, upper larynx and neck region. The STA origins either from ECA, common carotid artery (CCA) or its bifurcation level. Various researchers have reported differences in its origin. The STA commencing from the ECA is comparatively more in Indian and Ethiopian but its derivation from CCA bifurcation point is more in Turkey and Korean. Origin of STA in relative to upper border of thyroid cartilage is used as a landmark. The CCA bifurcates into external and internal carotid arteries at same level and occasionally bifurcates at a higher or lower level than its usual site. Origin of STA from CCA is associated with high bifurcation and its origin from the ECA is related with the low CCA division. Comparatively STA origin from CCA or its bifurcation level is more on right side. The CCA developed from third aortic arch and any alteration in development of aortic arches might also contribute to these variations. The STA is an artery of abundant clinical significance and it is recommended to do detailed study of its origin, course, branches, size, and positional relation with the external laryngeal nerve, hyoid bone and thyroid cartilage. Understanding of these variations is immense importance in academic and clinical arena for planning and performing surgical procedures in neck region.

Inadvertent intra-arterial catheterisation using ultrasound guidance and endocavitary electrocardiography in a paediatric patient.

Venous access in small infants is difficult and central venous catheter placed into the brachiocephalic vein is often the preferred approach. Ultrasound guided vein cannulation is standard practice and endocavitary electrocardiography is a reliable catheter tip location method. We report a not immediately recognised 2 month old case of inadvertent intra-arterial catheterisation with a 3 Fr - 8 cm catheter during right innominate vein cannulation under ultrasound guidance. Endocavitary electrocardiography showed an increased amplitude P wave with a low P/R wave ratio but further insertion of the catheter resulted in a reduction of the P wave amplitude. At ultrasound re-evaluation of the innominate vein, the catheter seemed to be inside the vessel into the proximal part of the vein, but distally appeared to surpass the vein to get into the brachiocephalic artery at the level of the bifurcation of the right common carotid artery and the right subclavian artery. Cardiac ultrasound from the suprasternal notch view identified the catheter into the aortic arch. Contrast-enhanced CT scan with 3D reconstruction confirmed the intra-arterial catheterisation and showed that the innominate vein was shifted and partially compressed but not transfixed by the catheter. The catheter was non-surgically removed uneventfully. During innominate vein cannulation the catheter cannot always be visualised into the distal tract of the vein and the maximal P wave may have a low P/R ratio; a chest X-ray can identify intra-arterial but false negative results are possible. We recommend always using a real time ultrasound tip navigation and location protocol, like the Neo-ECHOTIP protocol, to confirm the correct position of the guidewire and the catheter. If the catheter cannot be identified inside the venous system, we suggest systematically visualising the aortic arch from the suprasternal notch view and the aortic root from the parasternal view to identify arterial malposition.

Angiographic Characteristics of Cerebral Perfusion and Hemodynamics of the Bridging Artery After Surgical Treatment of Unilateral Moyamoya Disease.

PurposeTo investigate the characteristics of cerebral perfusion and hemodynamics of bypass grafting in the treatment of moyamoya disease (MMD) using the iFlow color-coded flow map in comparison with magnetic resonance imaging–perfusion-weighted imaging (MRI–PWI) and computational fluid dynamic (CFD) analysis.Materials and MethodsPatients with MMD treated with bypass grafting who had undergone MRI PWI and digital subtraction angiography for iFlow color-coded map was retrospectively enrolled and CFD was performed for calculating the hemodynamic stresses around the bypass grafting.ResultsForty-five patients with unilateral MMD treated with bypass surgery were enrolled. The bypass surgery was successful in all patients, with no severe neurological complications during the periprocedural period. Followed up for 4–12 months (median 5.5), the neurological function was good in all patients. The cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) were significantly (p < 0.05) improved in the middle cerebral artery distribution area on the surgical side before and after vascular bypass, and the difference of TTP (s) measured from the proximal bifurcation of common carotid artery to the confluence of sinus was also significant (p < 0.05). A significant (p < 0.05) positive correlation existed in the perfusion parameters between the iFlow blood perfusion and the MRI–PWI perfusion, with r-value for TTP of 0.765 (p < 0.01). The iFlow color-coded blood flow map showed warm color changes on the diseased side, similar to those on the contralateral side. In CFD analysis, the hemodynamic stresses were all improved, in and around the bypass grafting and distal vessels, which were beneficial to blood flow entering distal arterial branches.ConclusionThe iFlow color-coded flow map can be used to analyze cerebral perfusion after bypass grafting for MMD, similar to MRI–PWI, and CFD can be used to analyze the hemodynamics after bypass grafting, revealing improved hemodynamics to promote blood flow entering distal arteries.

Prognostic value of subclinical atherosclerosis in patients with a SCORE risk &lt;5%: data from a 10-year follow-up

Aim. To evaluate the contribution of subclinical atherosclerosis to the stratification of patients with a SCORE risk of cardiovascular events (CVEs) &lt;5% based on a 10-year follow-up.Material and methods. The study included 379 patients with SCORE risk of CVEs &lt;5% (82 men, 297 women). In 2009, all patients underwent clinical examination, carotid artery (CA) ultrasound with the detection of plaques, total CA occlusion, intima-media thickness (IMT) of the common carotid artery (CCA). The plaque number was determined as the total number of all plaques in 6 following segments: both CCAs, both CCA bifurcations and both internal carotid arteries. The total stenosis was calculated as the sum of stenoses in 6 CA segments in %. In 2019, a telephone survey of patients was conducted with a questionnaire assessing the following CVEs: all-cause death, cardiovascular death, myocardial infarction (MI), stroke, myocardial revascularization, cardiovascular hospitalizations, and composite endpoint.Results. The initial patients’ age ranged from 35 to 67 years (51,1±7,5 years). Plaques from 20% to 50% were detected in 303 participants (79,94%). Over the past 10 years, there have been 5 cardiovascular deaths (1,3%), 7 MIs (1,8%), 5 cases of unstable angina (1,3%), 12 cases of myocardial revascularization (3,2%), 15 strokes (4,0%), 51 cardiovascular hospitalizations (13,5%). The proportion of patients with registered endpoints (CVE+) was 22,4% (n=85). The groups of patients with and without CVEs differed in the level of systolic blood pressure (BP) and blood triglycerides, and did not differ in the level of diastolic BP, lipid profile, glucose, heart rate, smoking status, sex, and age. In the CVE+ group, there were higher values of CCA IMT (0,65 (0,64; 0,70) mm vs 0,62 (0,62; 0,66) mm, p&lt;0,05), total CA stenosis (102,5 (88,1; 120,8)% vs 80 (72,5; 88,1)%, p=0,01), and the CA plaque amount (4,0 (2,8; 3,9) vs 3,0 (2,6; 3,1), p=0,01), respectively. Total CA stenosis was an independent predictor of CVEs when adjusted for sex, age, systolic and diastolic BP (β=0,149; p&lt;0,05), but not for lipid profile. A ROC-analysis revealed a cut-off point for total CA stenosis of 82,5% (AUC=0,598, 95% confidence interval 0,5243-0,673, p&lt;0,05).Conclusion. The total CA stenosis has shown itself to be an independent predictor of CVEs in patients with a SCORE risk &lt;5%.

Three anatomical variations in the arterial system of the neck of a female donor body: a case study

The common carotid artery (CCA) bifurcates into the external carotid artery (ECA) and internal carotid artery (ICA) at the level of the intervertebral disc between third and fourth cervical vertebra. After the bifurcation, the ICA normally lies posterolateral to the ECA. While ICA does not give off any branches in the neck, superior thyroid (STA), lingual (LA), facial artery, ascending pharyngeal, and occipital arteries arise from the ECA within the carotid triangle of the neck. During a routine dissection to demonstrate the neurovasculature of the neck, three anatomical variations in the arterial system were noted on the left side of a female donor body (Race: Caucasian, Age: 51 years). First, the CCA bifurcated into ECA and ICA below the level of the cricoid cartilage, approximately between the sixth and seventh cervical vertebra, at a distance of 5.7 cm from the arch of the aorta. Second, after the bifurcation, the ICA laid posteromedial to the ECA. Finally, despite the low bifurcation of CCA, STA and LA arose from a common thyrolingual trunk off the ECA (7.7 cm from the carotid bifurcation), between the second and third cervical vertebra. As a result, STA was 6 cm in length from its origin to its termination on the superior aspect of the thyroid gland. While each of these anatomical variations have been reported in the literature, to our knowledge, this is the first description of a ‘triple’ variation in the arterial network of the neck. Clinically, the knowledge of these anatomical variations may be important during surgical procedures involving the neck and its arterial network.

Long-term results of carotid endarterectomy and carotid artery stenting in patients with high bifurcation of common carotid artery: a multiple-center study

To analyze in-hospital and long-term results of eversion carotid endarterectomy (CEE), carotid endarterectomy with patch repair and carotid artery stenting (CAS) in patients with high bifurcation of common carotid artery. A retrospective multiple-center open study included 1983 patients who underwent internal carotid artery (ICA) repair for severe stenosis between 2010 and 2021. Three groups of patients were distinguished depending on revascularization option: group 1 (n=638) - eversion CEE; group 2 (n=351) - CEE with patch repair; group 3 (n=994) - CAS. In-hospital postoperative mortality and incidence of stroke and myocardial infarction were similar. All bleedings (n=39) occurred after CEE. ICA thrombosis was diagnosed in groups 1 and 2 due to intimal detachment after insertion of temporary bypass tube. Incidence of laryngeal paresis, neuropathy of hypoglossal and glossopharyngeal nerves, Horner syndrome, damage to salivary glands was comparable in groups 1 and 2. Long-term mortality was the highest (n=10; 2.8%) after CEE with patch repair due to fatal stroke. In turn, the highest incidence of ICA restenosis and restenosis-induced ischemic stroke was observed after CEE with patch repair and CAS. 1. Classical and eversion CEE in patients with high CCA bifurcation is followed by high in-hospital incidence of damage to cranial nerves and salivary glands, laryngeal paresis, Horner syndrome, bleeding and risk of ICA thrombosis. 2. In patients with high CCA bifurcation, CAS and CEE with patch repair are accompanied by high incidence of ICA restenosis, restenosis-induced stroke and mortality in long-term postoperative period. 3. Eversion CEE demonstrates the lowest rates of all adverse cardiovascular events in long-term follow-up period.