Ligation Of Internal Carotid Artery Research Articles

Salvage Surgery for Recurrent Nasopharyngeal Carcinoma

To evaluate the efficacy of salvage surgery in the treatment of recurrent nasopharyngeal carcinoma (NPC) at the primary site. A retrospective investigation of the outcome of salvage surgery for 28 patients with recurrent NPC after definite radiation therapy. The nasopharynx was approached anteroposteriorly by the transmaxillary approach (maxillary swing, maxillectomy) or inferior approach (midline mandibulotomy or median labiomandibular glossotomy), or laterally by modified facial translocation or transpterygoid approach; intentional ligation of the internal carotid artery was performed after establishment of extracranial-intracranial (EC-IC) bypass in one patient; postoperative irradiation was given to the patients with positive pathological margins. Nine patients lived without disease for 20 to 93 months (mean interval, 52 mo) after surgery; among them, eight patients had T1 tumors that were resected totally by surgery via anteroposterior approaches and the other patient had postoperative irradiation to control the disease. Seven patients had local recurrence 8 to 21 months after treatment. Four patients developed distant metastases, including one patient with a T2b tumor that was totally resected through modified facial translocation approach with ligation of internal carotid artery. Eight patients died of other causes; internal carotid artery blowout was the cause of death in four of these eight patients. In most cases of recurrence, T1 nasopharyngeal tumors can be resected totally by anteroposterior approaches; for T2 or larger tumors, postoperative irradiation is usually necessary. Otherwise, facial translocation offers a better chance to completely resect the tumors. Internal carotid artery is better ligated if patients have received greater than 70 Gy irradiation or if the artery must be exposed during the surgery. We suggest that EC-IC bypass be used to avoid the possible complications (or cerebral ischemic stroke) caused by ligation of internal carotid artery. The transmaxillary approach is favored in the management of nasopharyngeal tumor recurrence with nasal cavity extension, and midline mandibulotomy is more suitable for resection of posterior margin of nasopharyngeal tumor recurrence. Facial translocation offers the widest operative field and is the most versatile approach for radical resection of nasopharyngeal tumor recurrence, but the surgeon should be skilled in the management of the facial nerves to reduce morbidity.

Long-term patency of radial artery graft bypass for reconstruction of the internal carotid artery. Technical note.

Reconstruction of the carotid artery by using a radial artery graft is a useful option that can produce reliable long-term patency for the surgical treatment of giant and/or large aneurysms of the cavernous and paraclinoid internal carotid artery (ICA). During the past 10 years, 43 patients with intracavernous and paraclinoid giant aneurysms of the ICA have been treated by reconstruction of the ICA with radial artery grafts after ligation of the cervical ICA. The long-term patency of the grafted radial artery was evaluated over more than a 5-year period (mean 7.2 years) in 20 of these patients by using magnetic resonance angiography or conventional angiography. There was no late occlusion of the graft in any of these cases. Stenotic graft changes were observed in two cases.

未破裂脳動脈瘤

The indication of radical surgery for unruptured cerebral aneurysms (uAN) remains obscure. To prevent bleeding, we have aggressively performed radical surgery for uAN even in elderly patients (over 70 years old) and in patients with cerebral ischemia, with concurrent bypass surgery for ischemic patients if necessary. We evaluated our surgical strategy in this study by analyzing the results of patients, especially the ratio of surgical mortality/morbidity and its causes.Ninety-six patients (141 aneurysms) were treated. In 34 patients, aneurysms had been diagnosed without neurological symptoms. The remaining patients had been diagnosed at the examination due to precedent neurological diseases: subarachnoid hemorrhage (28 patients), hypertensive intracerebral hemorrhage (12), cerebral infarction (10), and the others (12). Distribution of the aneurysms were 57 internal carotid artery, 48 middle cerebral artery, 11 anterior cerebral artery, 10 anterior communicating artery, 8 basilar artery, 4 vertebral artery, and 2 posterior cerebral artery. Of the 141 aneurysms, 133 were clipped, and one was wrapped. Ligation or trapping of internal carotid artery with high flow EC-IC bypass using saphenous vein graft was done on 7 giant internal carotid aneurysms or symptomatic cavernous internal carotid aneurysms. Surgical mortality was 0 and morbidity was 5 cases (5.2%). Inappropriate handling of spatula and resultant cerebral contusion worsened the result of Case 1. Optic nerve compression with oxycellulose at dural repair after Dolenc approach caused ipsilateral blindness in Case 2. The cause of these morbidity was obviously carelessness. However, there was no apparent causal factor found in the following three cases (3, 4, 5). The three cases had common features as follows: 1) relatively high age (64, 67, 79 years old), 2) IC aneurysms, 3) large aneurysms, 4) not parent artery occlusion/stenosis but perforator injury suspected. One of the 3 patients received reoperation soon after the paresis had presented. But the clip was well placed, parent vessels were patent, and perforators looked healthy. Angiography of the remaining 2 cases showed no remarkable abnormality. Therefore, we cannot explain the neurological deficits in these cases.Good results were obtained with our strategy. Precedent neurological diseases may not influence the result, even cerebral ischemia if precise and careful preparation is performed. Concurrent bypass surgery may not be avoided. Care should be taken for elderly patients with IC large aneurysms because perforator injury by unknown causes occasionally occurs.

Flow-induced vascular remodeling in the rat carotid artery diminishes with age.

Vascular remodeling is regulated by a combination of hemodynamic, environmental, and genetic factors and may be influenced by age. To evaluate age-dependent remodeling in rats, we developed and used a quantitative highly reproducible model of carotid flow alteration. Fourteen juvenile (99+/-3 g) and 9 adult (199+/-5 g) male inbred Fischer rats underwent ligation of the left internal and external carotid arteries under anesthesia. Left common carotid blood flow immediately decreased by approximately 93%, whereas flow in the contralateral carotid increased by approximately 46%. After 4 weeks, the left carotid outer diameter (OD) significantly decreased in both juvenile and adult rats (as measured in vivo and by histological morphometry) compared with sham-operated rats. Changes in shear stress acutely mirrored the changes in blood flow. OD increased and shear stress returned to initial values after chronic exposure to increased flow in juvenile but not adult rats. To develop a simple quantitative index of remodeling that would not require killing the animals, we measured the OD in vivo and compared the ratio of right to left OD (OD ratio [ODR]) between groups. The initial ODR for all groups was approximately 1.0. After 4 weeks of altered flow, the ODR was significantly greater in juvenile than in adult rats (1.48+/-0.05 versus 1.29+/-0.04, respectively; P=.030), indicating that juvenile rats experienced more extensive remodeling than did the adult rats. We also found that unilateral carotid ligation caused a left versus right difference in endothelial NO synthase protein levels after 4 weeks that was not present in the sham-operated animals. Thus, the model described here shows that flow-induced vascular remodeling is dependent on age and supports the hypothesis that the driving force for remodeling involves shear stress and possibly NO. Because the model is quantitative, it allows dissection of the genetic factors that regulate remodeling in inbred rat strains.

Objective tinnitus resulting from internal carotid artery stenosis

Objective tinnitus represents sound wave energy that, by definition, may be heard or recorded by an examiner. It may occur as a result of either muscular contraction or turbulent blood flow. We report two cases of vascular objective tinnitus resulting from internal carotid artery stenosis. The first patient, a 74-year-old man, underwent ligation of the right internal carotid artery because of the distal extent of atherosclerosis. The second patient, a 75-year-old man, underwent a right carotid endarterectomy. Both patients noted complete relief of their tinnitus. The spectrum of vascular causes and treatment options are reviewed.

海綿静脈洞部巨大動脈瘤の外科治療

We present 24 cases of intracavernous giant aneurysms which we have treated so far. All the cases were unruptured and showed neurological signs such as ocular movement disorder and visual dysfunction. There were 11 males and 13 females and the age of the patients ranged between 11 and 75 years (mean 51 years). The follow-up periods were between 6 months and 19 years (mean 6.7 years). Among the cranial nerves, the abducens nerve was affected in 17 cases, oculomotor nerve in 11 cases, optic nerve in 6 cases, trigeminal nerve in 5 cases and trochlear nerve in 4 cases. In addition to conventional angiography, balloon test occlusion (BTO), slow injection angiography, aneurysmorraphy and SPECT with BTO were used to determine a method of treatment. Treatment options were as follows; nonsurgical treatment in 4 cases, common carotid artery ligation (CC ligation) in 7 cases, internal carotid artery ligation (IC ligation) in 2 cases, STA-MCA anastomosis with IC ligation or IC trapping in 6 cases, high flow vein bypass with IC ligation in 3 cases and direct clipping in 2 cases. Although only 2 cases showed early and late ischemic complications, other cases demonstrated improvement of cranial nerve dysfunction relatively soon after treatment and long-term prognoses were good. We conclude that selecting an adequate surgical treatment by using sophisticated diagnostic methods plays an important role for obtaining good outcome for intracavernous giant aneurysms.

血管内超音波による画像診断：内頚動脈解離に対する応用 Ｔｅｃｈｎｉｃａｌ Ｃａｓｅ Ｒｅｐｏｒｔ

Intravascular ultrasound sonography was employed in a patient with traumatic dissection of the cervical internal carotid artery (ICA) . A 21-year-old male presented with right hemiparesis and motor aphasia 36 days after a motorcycle accident. CT and MR imaging showed an infarction in the left middle cerebral artery area. Cerebral angiograms showed dissection and pseudoaneurysm in the left cervical ICA. Intravascular ultrasound images demonstrated multiple dissections of the ICA beginning at the C2 vertebral level up to the carotid canal. The extent of the dissection was larger than that shown by angiography. The minimum diameter of the true lumen was 3.0 mm. Balloon expansion to deliver short stents carried a high risk of distal embolism, and the diameter of the true lumen was not large enough to allow placement of a long stent. As a result, ligation of the proximal ICA combined with anastomosis of the superficial temporal artery to the middle cerebral artery was chosen as the treatment. Intravascular ultrasound imaging was useful for evaluating the morphology of the dissection and the true lumen in the cervical ICA and for selecting an appropriate treatment.

Assessment of outcome of internal carotid artery ligation using intraoperative back pressure monitoring

Assessment of outcome of internal carotid artery ligation using intraoperative back pressure monitoring

Cerebral blood flow and carbon dioxide reactivity in neonates during venoarterial extracorporeal life support.

a) To determine if cerebral blood flow is symmetric after internal carotid artery and ipsilateral internal jugular vein ligation in infants during venoarterial extracorporeal life support. b) To determine the cerebral CO2 reactivity (delta cerebral blood flow/delta torr CO2) of neonates during venoarterial extracorporeal life support and its correlation to neurodevelopmental outcome. Prospective, clinical study. University hospital pediatric intensive care unit. Fourteen neonates with respiratory failure who were receiving venoarterial extracorporeal life support. PaCO2 was altered by adjusting the CO2 gas flow through the membrane oxygenator. Cerebral blood flow was measured over both parietal-temporal regions at three PaCO2 values using xenon-133 clearance methodology. Cerebral blood flow measurements were made early (< or = 12 hrs of extracorporeal life support, n = 10) or late (> or = 48 hrs of extracorporeal life support, n = 10). In six of 14 infants, both early and late cerebral blood flow rates were measured. PaO2, mean arterial pressure, pump flow rate, and temperature were stable during each study period. Neurodevelopmental outcome was assessed in the neonatal follow-up clinic. Right and left hemispheric cerebral blood flow rates were significantly correlated with each other during early and late extracorporeal life support (p = .0001; r2 = .91). Overall, hemispheric cerebral blood flow was statistically symmetric. There was no association of CO2 reactivity (delta cerebral blood flow/delta torr PCO2, range 0.04 to 1.36 mL/min/100 g/torr) with short-term neurodevelopmental outcome. Infants with normal neurodevelopmental outcome had variable CO2 reactivity (range 0.04 to 0.67 mL/min/100 g/torr). Normal short-term neurodevelopmental outcome was observed in two infants with cerebral blood flow of < 10 mL/min/100 g. Hemispheric cerebral blood flow was symmetric in infants during early and late venoarterial extracorporeal life support. Some subgroups showed a trend toward decreased right hemispheric cerebral blood flow, but the small number of patients limited interpretation of this finding. CO2 reactivity and cerebral blood flow were highly variable in this population, and were not predictive of short-term neurodevelopmental outcome. Stressed neonates with extremely low cerebral blood flow rates may have relatively normal short-term neurodevelopmental outcome after venoarterial extracorporeal life support.

Serpentine Aneurysm: Regrowth after a Superficial Temporal Artery-Middle Cerebral Artery Bypass and Internal Carotid Artery Ligation

GIANT SERPENTINE ANEURYSMS (GSAs) are infrequent. We present a 37-year-old patient with a giant serpentine aneurysm of the left middle cerebral artery that was treated with a superficial temporal artery to middle cerebral artery bypass and ligature of the left internal carotid artery. After 2 years, the patient presented new symptoms of neurological deterioration and the computed tomographic scan and arteriography showed regrowth of the aneurysm, which was excised. Enlargement of a giant serpentine aneurysm once it has been treated with ipsilateral carotid ligation and/or bypass anastomosis is rare, and only two cases have been described previously.

Carotid endarterectomy when the distal internal carotid artery is small or poorly visualized.

This is a report of the operative findings and results of carotid endarterectomy (CEA) when the conventional arteriogram demonstrates an internal carotid artery with a high-grade origin stenosis and a small or poorly visualized distal extracranial segment with an apparent diameter of 2 mm or less. Eighteen CEA were performed on 17 patients with this preoperative finding and patent common and external carotid arteries. The indications for CEA were transient ischemia in seven patients, completed minor stroke in five and amaurosis fugax in four patients. One patient had bilateral findings and global cerebral ischemic symptoms. At CEA 16 internal carotid arteries had atherosclerotic very high-grade origin stenosis, and two had chronic occlusion. Ten of the 16 open arteries had true external diameters of 4 mm or more. Of these, seven were normal above the stenosis, two had a long, trailing intraluminal thrombus that was removed, and one had high-grade distal stenosis. Of the six arteries with true diameters of 3 mm or less (hypoplastic), two had a thick fibrotic wall. The carotid stump back pressure for the 16 open internal carotid arteries was 56 +/- 15 mm Hg (mean +/- SD). This was significantly higher than the 39 +/- 14 mm Hg back pressure measured in 1016 arteries without a string sign (p < 0.001). There was one 30-day postoperative death after a stroke. There was no systemic or neurologic morbidity. Post-CEA duplex scans demonstrated eight normal, five mildly stenotic, and five occluded internal carotid arteries. Two of the occlusions were found at CEA and the other three occluded arteries had low flow after CEA, two of which were hypoplastic and the other had a distal stenosis. Patients with symptoms with these findings on arteriograms should undergo CEA. However, the success of CEA in this setting depends on the internal carotid artery anatomy and disease, which is difficult to determine before CEA. Patients with a truly normal extracranial internal carotid artery have an excellent probability of a successful CEA, but this is not the case when the artery is small or fibrotic. Low internal carotid artery flow after a technically satisfactory CEA is a harbinger of thrombosis and should be managed by internal carotid artery ligation and external CEA.

Primitive trigeminal artery associated with cavernous aneurysm: Case report

A case of unruptured aneurysm at the junction of the cavernous segment of the right internal carotid artery and the primitive trigeminal artery (PTA) is presented. The posterior circulation was not dependent on PTA, thus the PTA was of an adult type in this case. This patient was successfully treated by external carotid artery-anterior temporal artery long vein graft bypass, internal carotid artery ligation at neck, and PTA clipping through the right subtemporal approach. A follow-up angiography showed thrombotic occlusion of the aneurysm. In review of the literature, there are 27 cases reported of PTA aneurysm; among them only 11 cases, including ours, treated surgically. The surgical treatment plan for PTA aneurysm, according to the review of literature is discussed.

Endovascular management of carotid cavernous fistulae: observation on angiographic and clinical results

Twenty-five patients with carotid cavernous fistulae (CCFs) were managed at our institute during a five-year period. Transarterial and transvenous treatment of traumatic carotid cavernous fistulae using the detachable balloon technique was performed in 21 patients resulting in angiographic and clinical cure in 20 patients and fatal outcome in one patient following venous rerouting. Surgical ligation of the infraclinoid internal carotid artery was needed in one patient. Preservation of the carotid artery was possible in 16 patients. Four patients with spontaneous CCFs were advised digital compression of carotid arteries resulting in complete closure of the fistula in one and considerable clinical improvement in two patients. One patient required transarterial obliteration of the fistula via the middle meningeal artery by means of a platinum coil and normal butyl cyanoacrylate (NBCA) resulting in total radio anatomical cure.

Endovascular coil embolization of a recurrent giant internal carotid artery aneurysm via the posterior communicating artery after cervical carotid ligation: Case report

The case of a 29-year-old man with a giant fusiform aneurysm of the left internal carotid artery (ICA) is presented. The aneurysm, treated by cervical ICA ligation and extracranial-intracranial bypass, recurred 4 years later owing to recruitment of the posterior communicating artery (PCoA). Because of the previous bypass surgery a direct surgical approach was excluded. After an initial failure with balloon embolization, the aneurysm was embolized successfully with occlusive platinum microcoils through the microcatheter navigated into the aneurysm via the enlarged PCoA. Endovascular coil embolization may be useful in the treatment of cerebral aneurysms not amenable to direct surgery or balloon embolization.

巨大内頸動脈瘤に対するcarotid ligationの有用性

The authors describe the efficacy and safety of carotid ligation designed especially for surgical treatment of a giant aneurysm of the internal carotid artery (ICA) in clinical and experimental studies. To determine the safety of ICA ligation, the balloon Matas test was administered for the ipsilateral ICA in nine patients with ICA aneurysms, seven of whom had giant aneurysms. Neither ischemic symptoms nor EEG changes developed during testing of the giant ICA aneurysms. Further, angiograms demonstrated that the contrast material filled poorly into the intracranial arteries distal to the aneurysm. In four of the seven giant aneurysms. ICA ligation effected good results with no complications.Using five models of an experimental giant aneurysm made of a canine descending aortic segment, the intra-arterial pressures of the common carotid artery was measured at the proximal and distal portions of the aneurysm with the transcatheter technique. Significant reductions of the arterial blood pressure and pulse pressure at the distal portion of the giant aneurysm model were noted.The data suggest that reductions of the mean pressure and pulse pressure in the distal ICA of the giant ICA aneurysm promote the development of collateral circulation. Thus, in many cases of giant aneurysm, ICA ligation would tend to preclude hemodynamic ischemia. When the neck of a giant aneurysm is difficult to clip, carotid ligation may be a safe alternative surgical treatment that yields good results.

Neurosurgical vascular complications associated with aneurysm clips evaluated by postmortem angiography

Neurosurgical vascular complications were evaluated by postmortem angiography in a consecutive prospective series of 63 patients in Helsinki who suffered a fatal outcome following neurosurgery for ruptured intracranial aneurysm. Operative vascular complications were revealed in 28 (44%) of the cases. Massive intraoperative bleeding resulting from rupture of the aneurysm or adjacent major artery during dissection or clip application complicated the operation in 16 (25%) patients. Clip-induced obstruction of cerebral arteries was detected by angiography in seven cases (11%). In six of the patients an adjacent cerebral vessel was accidentally clipped. In one case a kinking of the clip had caused obstruction of the right anterior cerebellar artery with resulting frontal infarct. A combination of rupture of the internal carotid artery and accidental ligation of the left posterior cerebellar artery occurring simultaneously during the clipping of a ruptured basilar aneurysm was detected in one patient (2%). Other types of complication were revealed in four cases (6%): detachment of clip with re-bleeding; clipping of an uninvolved aneurysm instead of the ruptured one; displacement of the clip beneath the ruptured aneurysm. Operations on ruptured basilar artery aneurysm were significantly ( P < 0.01) more prone to complications. The results indicate that operative vascular complications play a significant role in the mortality of aneurysm patients. Post-mortem angiographic technique with contrast medium that vulcanizes at room temperature is particularly suitable for demonstration of the haemodynamic significance of clip-induced cerebrovascular accidental occlusions, and is the only method at autopsy to reveal an occlusion caused by a kinking of a properly placed aneurysm clip.

What's New in Pediatric Surgery—1989

The recent developments in pediatric surgical research as well as new concepts and clinical applications in the specialty are emphasized in this report. There is no attempt to make this review all inclusive. Rather, it focuses on specific areas in which new data or techniques will influence future investigations or the management of patients. EXTRACORPOREAL MEMBRANE OXYGENATION No area has commanded more investigational effort than extracorporeal membrane oxygenation (ECMO). By oculopneumoplethysmography Foglia et al1 assessed the effects of right internal carotid artery ligation on cerebral perfusion in lambs during ECMO. Postnormoxic lambs had good right hemispheric perfusion after right internal carotid artery ligation, and posthypoxic animals showed marked initial depression of ipsilateral hemispheric perfusion which improved progressively and was comparable to the normoxic model at 20 hours. Foglia et al postulated a loss of autoregulation and/or intracranial edema, both of which were reversible. It is known that ECMO is associated with an early increase in inflammatory mediators. Simoni et al2 documented a second peak of complement activation and prostaglandin synthesis after 72 hours of high-flow ECMO. They reported increased levels of endotoxin, free radical activity, and tumor necrosis factor, all markers of systemic sepsis. Early weaning, meticulous technique, and periodic replacement of the ECMO circuit for the extended run are emphasized. Crombleholme and co-workers3 proposed using ECMO as a bridge to transplantation with reduced-size lung grafts. They demonstrated the technical feasibility of the procedure in immature swine recipients. The graft was ventilated preferentially and accepted the entire cardiac output. Ongoing studies by Stolar and Dillon4 demonstrated a biphasic prostanoid response in newborn lambs undergoing ECMO perfusion.

Treatment of a Giant Aneurysm of the Cavernous Internal Carotid Artery Associated with a Persistent Primitive Trigeminal Artery: Case Report

Abstract A case of an unruptured giant aneurysm of the cavernous portion of the left internal carotid artery associated with a persistent primitive trigeminal artery (PTA) is presented. The usual surgical approach to giant aneurysms at this site. including ligation of the ipsilateral internal carotid artery (ICA) and an extracranial-intracranial (EC-IC) bypass, was inadequate because of continued blood supply to the aneurysm via the PTA from the vertebrobasilar system. The patient was successfully treated with a combination of EC-IC bypass surgery, ICA ligation, and simultaneous intravascular balloon obliteration of the ICA just distal to the junction of the PTA and immediately proximal to the aneurysmal neck. Follow-up radiological investigations showed thrombosis of the aneurysm.

Treatment of a giant aneurysm of the cavernous internal carotid artery associated with a persistent primitive trigeminal artery

A case of an unruptured giant aneurysm of the cavernous portion of the left internal carotid artery associated with a persistent primitive trigeminal artery (PTA) is presented. The usual surgical approach to giant aneurysms at this site, including ligation of the ipsilateral internal carotid artery (ICA) and an extracranial-intracranial (EC-IC) bypass, was inadequate because of continued blood supply to the aneurysm via the PTA from the vertebrobasilar system. The patient was successfully treated with a combination of EC-IC bypass surgery, ICA ligation, and simultaneous intravascular balloon obliteration of the ICA just distal to the junction of the PTA and immediately proximal to the aneurysmal neck. Follow-up radiological investigations showed thrombosis of the aneurysm.

Giant Internal Carotid Aneurysm at the Cavernous Portion with Abrupt Disappearance of N20 100 Minutes after Carotid Occlusion

A 69-year-old female with bilateral giant internal carotid aneurysms at the cavernous portion was admitted with complaints of diplopia and radiating pain. The aneurysm on the left side was larger and symptomatic, and treated with the internal carotid artery ligation and the superficial temporal artery-middle cerebral artery (STA-MCA) double bypasses. However, intraoperative somatosensory evoked potential (SEP) monitoring revealed the disappearance of N20 100 minutes after the carotid occlusion and rapid recovery of N20 following flow restoration. Therefore, a high-flow bypass using radial artery grafting was installed, and carotid ligation was performed again without any change in SEP. Postoperative angiograms demonstrated complete disappearance of the aneurysm and sufficient blood supply through a patent high-flow bypass. Although both STA-MCA double bypasses were occluded, no change in cerebral blood flow was detected by single photon emission computed tomography. Her neurological deficits improved, and she is being followed as an outpatient with a plan of second surgery for the remaining aneurysm.