Tortuous Carotid Artery Research Articles

Role of CT Angiography in Detection of Extracranial Carotid and Vertebral Artery Disease in Patients With Acutely Ruptured Intracranial Aneurysms

Introduction: Computed tomography (CT) and CT angiography are standard imaging modalities for suspected acute intracerebral hemorrhage due to ruptured intracranial aneurysms. In this clinical setting, several protocols of computed tomography and CT angiography may be implemented. The standard CT angiography protocol is limited to intracranial vessels. The extended protocol may also include carotid and vertebral arteries and the aortic arch.Objective: To define the CT angiography role in detection of extracranial carotid and vertebral artery disease and clinical significance of this method for patients with suspected acute intracerebral hemorrhages due to ruptured intracranial aneurysms.Materials and methods: The study included 275 neurosurgical patients with acute nontraumatic intracranial hemorrhages due to ruptured intracranial aneurysms who were treated in Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 1 (Krasnodar, Russian Federation) from September 2017 to August 2020. Computed tomography and CT angiography were performed in all patients. The scanned area included both intracranial and extracranial arteries (an arch-to-vertex angiogram) to detect extracranial carotid and vertebral artery diseases such as stenoses, occlusions, tortuosity, and hypoplasia.Results: Atherosclerosis of internal carotid and vertebral arteries was diagnosed in 95 patients (34.5% of the total number of patients included in the study). In 13 (4.7%) patients these stenoses were hemodynamically significant. We identified a high frequency of tortuous carotid and vertebral arteries (122 cases, 44.3%) and vertebral artery hypoplasia (59 cases, 21.5%). The carotid and vertebral artery stenoses and congenital anomalies of vertebral arteries (however, not of carotid arteries) were associated with a higher incidence of unfavorable outcomes after endovascular treatment of intracranial aneurysms.Conclusions: The optimal CT angiography protocol for acute nontraumatic intracranial hemorrhage should focus on the arteries of the head and neck (up to the aortic arch). This protocol shows higher detection rate of concomitant anomalies of carotid and vertebral arteries. These findings are important for planning and successful performance of endovascular treatment for intracranial aneurysms.

The medial wall and medial compartment of the cavernous sinus: an anatomic study using plastinated histological sections

The medial wall of the cavernous sinus (CS) has a significant role in evaluation and treatment of pituitary adenomas. This study was conducted to clarify the fine architecture of the medial wall and medial compartment of the CS at both macro- and micro-levels in twenty-one human cadaveric heads by using the epoxy sheet plastination technique. The sellar part medial wall is an intact dural layer that separates the CS from the pituitary gland. This dural wall adhered to the diaphragma sellae and the periosteum of the sella turcica to form fibrous triangles. Eight micro-protrusions of the pituitary gland were found at both sides of that wall. The thickness of the sellar part medial wall at its central portion was significantly thinner than that at the other surrounding portions. From the superior view, tortuous intracavernous carotid arteries can be divided into outward bending type and inward bending type. The inward bending intracavernous carotid was apt to bent towards the central part of the sellar part medial wall, where there were usually wide and short fibrous bands with more densely stained connective tissues between them. The micro-protrusion of the pituitary gland in the medial wall of the CS could provide an anatomical basis for the occult tumor invasion and the recurrence of residual tumor. Different bending facing states of tortuous intracavernous carotid arteries in the lateral direction may be a factor of the determination of the direction of growth of pituitary tumors.

Carotid Artery Stenting Using the Snake Hunt Technique for Highly Tortuous Carotid Artery Stenosis: A Technical Note.

In carotid artery stenting (CAS) for highly tortuous carotid stenosis, it is often difficult to guide rigid devices such as carotid stents. There are various adjunctive techniques using a guidewire: the buddy wire technique, the sheep technique, and the stiff guide technique. We report a case in which the tortuous vessel was straightened and a stent could be inserted. A 64-year-old man with amaurosis had highly tortuous left carotid stenosis. Despite the best medical treatments, he often had transient cerebral ischemic symptoms, so we planned CAS. We could insert the first stent, but the proximal vessel was kinked by the placement of the stent. It was so tortuous that the second stent could not be inserted by adjunctive techniques. Therefore, the proximal balloon was inflated and pulled back to straighten the tortuous vessel, and then we could insert the stent. We named this technique the “snake hunt technique” because it was just like catching a snake given that the tortuous vessel was stretched. This technique could be a troubleshooting step when it is difficult to insert a stiff device such as a stent or balloon even with the use of various adjunctive techniques.

Carotid artery stenting by non-femoral arterial approach in patients with difficult anatomy

Background: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are safe, effective, and standard methods to treat significant carotid artery stenosis. CAS is generally performed through femoral arterial access. We had six patients with significant carotid artery stenosis, who had difficult anatomy prohibiting a trans- femoral CAS. Those patients were given an option for CEA. However, they refused for surgical intervention. Aim: We investigated the feasibility of performing CAS from a non-femoral arterial approach in patients with difficult anatomies like severe aortic/aorto-iliac disease, tortuous aortic arch, and tortuous carotid artery origin. Materials and Methods: Six patients with difficult anatomy presented to us with either transient ischemic attack or stroke with high-grade carotid artery stenosis. Out of the six patients, three had aorto-iliac disease, one had high-grade coarctation of aorta, two had tortuous aortic arch and or tortuous carotid artery origin. All these patients were treated with CAS though non-femoral arterial route. Results: CAS could be done successfully in all these six patients; four of them were done through trans-brachial arterial route and two were done through a direct carotid artery puncture. There were no new neurological deficits seen in any of the patient post -procedure. Conclusion: CAS can be done safely through non-femoral arterial approach in patients with difficult anatomy.

Association between carotid artery tortuosity and carotid dissection: a case-control study.

Carotid artery dissections have long been associated with compromise of the structural integrity of the arterial wall from heritable connective-tissue disorders, hypertension, and trauma. However, an association between spontaneous internal carotid artery dissection and tortuous or redundant carotid anatomy has not been fully explored. Patients with CTA confirmed spontaneous cervical internal carotid artery dissections were compared to a group of age and sex matched controls who also received CTA of the neck. Patients with trauma or aortic dissections were excluded. Five radiologists reviewed the CTA images to evaluate internal carotid artery tortuosity (reported as loops, kinks or coils), retrojugular and retropharyngeal courses of the internal carotid artery, presence of fibromuscular dysplasia and presence of atherosclerotic disease. Baseline data collected included demographic characteristics (sex, age, smoking history) and cardiovascular comorbidities. A total of 83 cervical internal carotid artery dissection and their age and sex matched controls were included in this study. 46% of patients were female in each group and mean age was 49.2±10.6 years. The presence of any carotid tortuosity was 53% (N.=44) and 34% (N.=28) in the per-patient analysis of dissection and control groups, respectively (P=0.02). Loops were reported in 22% (N.=18) of dissection patients and 8% (N.=7) of controls (P=0.03). Retrojugular course of the internal carotid artery were seen in 23% (N.=38) of dissection patients and 9% (N.=15) of controls (P=0.0009) in the per-vessel analysis. Our study suggests that there is an association between the presence of tortuous carotid artery anatomy and spontaneous carotid artery dissection. This finding emphasizes the importance of the presence of tortuous arteries on CTA imaging to increase the index of suspicion for a potential dissection.

Building 3D anatomical model of coiling of the internal carotid artery derived from CT angiographic data.

The purpose of this study is to recreate live patient arterial anomalies using new recent application of three-dimensional (3D) printed anatomical models. Another purpose of building such models is to evaluate the effectiveness of angiographic data. With the help of the DICOM files from computed tomographic angiography (CT-A), we were able to build a printed model of variant course of the internal carotid artery (ICA). Images of coiling of the ICA taken by CT-A, were then converted into 3D images using Google SketchUp free software, and the images were saved in stereolithography format. Imaging helped us conduct the examination in details with reference to geometrical features of ICA, degree of curve, its extension, location and presence of loop. Challenging vascular anatomy was exposed with models of adverse curve of carotid anatomy, including highly angulated necks, conical necks, short necks, tortuous carotid arteries, and narrowed carotid lumens. It assisted us to comprehend spatial anatomy configuration of life-like models. 3D model can be very effective in cases when anatomical difficulties are detected through the CT-A, and therefore, a tactile approach is demanded preoperatively. 3D life-like models serve as an essential office-based tool in vascular surgery as they assist surgeons in preoperative planning, develop intraoperative guidance, teach both the patients and the surgical trainees, and simulate to show patient-specific procedures in medical field.

Tortuous Common Carotid Artery: A Report of Four Cases Observed in Cadaveric Dissections.

A tortuous common carotid artery poses a high risk of injury during tracheotomy. Preoperative diagnosis is therefore important to avoid serious complications. We found four cases of tortuous common carotid artery during an anatomical dissection course for students. The first case was a 91-year-old woman who had bilateral tortuous common carotid arteries without arteriosclerosis. Case 2 was a 78-year-old woman who had bilateral tortuous common carotid arteries without arteriosclerosis. Case 3 was an 86-year-old woman who died from bladder cancer and who also had a right tortuous common carotid artery without arteriosclerosis. Case 4 was an 89-year-old woman who had bilateral tortuous common carotid arteries and a tortuous brachiocephalic artery with severe arteriosclerosis. Case 4 was also examined using computed tomography to evaluate the arteriosclerosis. Computed tomography revealed severe calcification of the vascular wall, which was confirmed in the aortic arch and origins of its branches. In all four cases, the tortuosity was located below the level of the thyroid gland. Based on prior study results indicating that fusion between the carotid sheath and visceral fascia was often evident at the level of the thyroid gland, we speculated that the major region in which tortuosity occurs is at the same level or inferior to the level of the thyroid gland.

Tortuous Carotid Artery Extended to Neck Level IIb Mimicking the Metastatic Mass.

Specifically in neck level IIb, the expected normal anatomy does not contain any vital structures and consequently it might direct a surgeon to perform rapid surgical dissection of tissues. Therefore aberrant anatomy of the vessels in the patients may be overlooked during neck dissection. Unexpected and potentially devastating injuries can be avoided by respecting the possible aberrant anatomy in any level of the neck. In this case report, a 74-year-old man was presented with laryngeal carcinoma who was treated with laryngectomy and bilateral neck dissection. During the left side neck dissection, tortuous internal carotid artery imitating a metastatic mass was unexpectedly encountered in level IIb. As in this case, surgeons should keep in mind possible aberrant anatomy during the neck dissection and perform surgery staying in surgical principles to be safe for an unforeseen and potential dangerous injuries.

Distinctive neck swelling in a patient with a vein of Galen arteriovenous malformation.

A vein of Galen arteriovenous malformation (VGAM) is a rare intracranial shunt lacking a capillary bed and resulting in subsequent aneurysmal enlargement. VGAM has been previously reported to present as cardiovascular abnormalities, including increased right-sided cardiac load and pressure, cardiac dilatation, pulmonary hypertension and retrograde flow into the aortic arch. We report the first case of VGAM presenting as a gross right-sided neck swelling in a 39-week-old immediately at birth. Transthoracic echocardiography detected dilatation of the superior vena cava and innominate vein, increased right ventricular and pulmonary arterial pressure, and retrograde flow into the aortic arch. Follow-up neck ultrasound revealed tortuous carotid artery and bilateral dilatation of neck veins. Transcranial ultrasound revealed abnormally dilated vessels posterior to the third ventricle, confirming VGAM. Our case demonstrates that while the differential diagnoses of neck swelling are extensive, such a presentation upon Doppler and echocardiographic investigation, may be suggestive of extracardiac causes such as VGAM. The management of such a condition remains critical due to risk of hemorrhage and extensive cerebral involvement.

Artery buckling stimulates cell proliferation and NF-κB signaling

Tortuous carotid arteries are often seen in aged populations and are associated with atherosclerosis, but the underlying mechanisms to explain this preference are unclear. Artery buckling has been suggested as one potential mechanism for the development of tortuous arteries. The objective of this study, accordingly, was to determine the effect of buckling on cell proliferation and associated NF-κB activation in arteries. We developed a technique to generate buckling in porcine carotid arteries using long artery segments in organ culture without changing the pressure, flow rate, and axial stretch ratio. Using this technique, we examined the effect of buckling on arterial wall remodeling in 4-day organ culture under normal and hypertensive pressures. Cell proliferation, NF-κB p65, IκB-α, ERK1/2, and caspase-3 were detected using immunohistochemistry staining and immunoblot analysis. Our results showed that cell proliferation was elevated 5.8-fold in the buckling group under hypertensive pressure (n = 7, P < 0.01) with higher levels of NF-κB nuclear translocation and IκB-α degradation (P < 0.05 for both). Greater numbers of proliferating cells were observed on the inner curve side of the buckled arteries compared with the outer curve side (P < 0.01). NF-κB colocalized with proliferative nuclei. Computational simulations using a fluid-structure interaction model showed reduced wall stress on the inner side of buckled arteries and elevated wall stress on the outer side. We conclude that arterial buckling promotes site-specific wall remodeling with increased cell proliferation and NF-κB activation. These findings shed light on the biomechanical and molecular mechanisms of the pathogenesis of atherosclerosis in tortuous arteries.

症候性頚部頚動脈蛇行に対し手術的治療が奏功した1例

A 74-year-old woman presented with dysphagia, hoarseness, dry cough and deep pharyngeal pain that persisted and gradually progressed despite medication and nerve block anesthesia. A CT scan showed an unusually tortuous left cervical carotid artery that compressed and displaced the trachea and esophagus. Surgery was conducted to shorten the common carotid artery by resection of a 2-cm segment and to transpose the tortuous cervical internal carotid artery. Immediately following surgery, the patient’s pre-operative symptoms resolved. Tortuous cervical carotid artery is a rare cause of both specific and non-specific pharyngeal and laryngeal symptoms. Transposition and shortening of the tortuous artery is effective in reducing or eliminating the symptoms for cases in which the tortuous artery is identified as the cause of the symptoms.

An Experience of Surgical Treatment of Extacranial Aneurysm Concomitant with a High Grade of Tortuous Carotid Artery

An Experience of Surgical Treatment of Extacranial Aneurysm Concomitant with a High Grade of Tortuous Carotid Artery

E-031 070 Neuron conduit technique for intracranial delivery and deployment of 6 mm and 8 mm carotid stents in the setting of proximal vessel tortuosity

IntroductionEndovascular stenting is a common treatment modality for intravascular stenosis. Current intracranial devices are relatively atraumatic and flexible to allow for navigation through tortuous anatomy such as the carotid siphon...

Гемодинамика и механическое поведение бифуркации сонной артерии с патологической извитостью

Гемодинамика и механическое поведение бифуркации сонной артерии с патологической извитостью

Tortuous Carotid Artery Lumens in Takayasu's Arteritis

We report a 68-year-old woman who was incidentally diagnosed as having an occlusion in the right internal carotid artery on magnetic resonance angiography. On ultrasound, the right common carotid artery showed narrow and tortuous lumens, which suggest the uneven thickening of the arterial wall in the nonactive stage of Takayasu's arteritis. Although macaroni-like diffuse and circumferential thickening of the arterial wall is a known ultrasonographic finding of Takayasu's arteritis, the tortuous sign also appears to be characteristic as an ultrasonographic finding of the healed arteritis in aged patients.

Common Carotid Artery Imbrication as an Adjunct to Carotid Endarterectomy to Prevent Postoperative Carotid Kinking

Mobilization of a tortuous carotid artery during endarterectomy may produce redundancy of the carotid artery, and kinking. We reviewed our experience with common carotid artery (CCA) imbrication as a technique to shorten the common and internal carotid artery postendarterectomy and to avoid carotid kinking. A retrospective chart review of 163 patients who underwent carotid endarterectomy by the same surgeon between August 1998 and February 2006 was performed. All patients underwent conventional endarterectomy via a longitudinal arteriotomy with an indwelling shunt and patch angioplasty. Patients undergoing concomitant carotid artery imbrication were identified. Twelve patients who underwent carotid imbrication were identified. The mean age was 74.9 +/- 8.8 years. Nine patients underwent imbrication of the CCA, and in three cases, the internal carotid artery was plicated. Follow-up duplex ultrasound examinations were available for 10 individuals and mean follow-up time was 10.7 months (range, 1-58 months). There were no cases of peri- or postoperative cerebral accidents and there was no case of restenosis. CCA imbrication as an adjunct to carotid endarterectomy is a feasible technique in preventing postoperative carotid kinking.

Clinical features in a family with an R460H mutation in transforming growth factor β receptor 2 gene

Objectives: To describe the clinical findings and natural history in 22 carriers of an R460H mutation in the transforming growth factor β receptor 2 gene (TGFβR2) from a five-generation kindred...

New Techniques for Intracranial Stent Navigation in Patients with Tortuous Arteries

Purpose: We wanted to describe several new techniques of intracranial stenting that are helpful for navigating the stent delivery system in the tortuous carotid or vertebral arteries. Materials and Methods: Between May 1998 and June 2004, 65 patients with 73 symptomatic, stenotic intracranial arteries (more than 50%) were successfully treated with stent-assisted angioplasty. In eleven of the total cases, the standard technique failed to navigate the stent delivery system into the objective lesion because of the tortuous path of the carotid or vertebral arteries. In these cases, several new techniques were used to overcome the vessels' tortuous path. The several new techniques were 1) the waiting method (20-30 minutes) after advancement of microwire across the lesion; 2) the double wires technique using an additional microwire; and 3) the coaxial double guiding catheters technique using an additional smaller guiding catheter. Five lesions were located in the middle cerebral arteries, four were in the supraclinoid internal carotid arteries, and two were in the distal vertebral arteries. Results: In all difficult cases, intracranial artery stenting was performed successfully by using the several new techniques. The waiting method made smooth stent navigation possible in 5 cases, the double wire technique was successful in 4 cases and the coaxial double guiding catheter technique was successful in 2 case. There was no complication related to the new techniques. Conclusion: In difficult cases where the standard technique failed to navigate the stent delivery system into the objective lesion because of the vessels' tortuous path, these new techniques for intracranial stent navigation were usefully implemented.

A tortuous distal carotid artery: how to overcome the problem, with the aim of guaranteeing distal protection

A tortuous distal carotid artery: how to overcome the problem, with the aim of guaranteeing distal protection

The endarterectomy-produced common carotid artery step: a harbinger of early emboli and late restenosis.

This study analyzes the role of the carotid endarterectomy (CEA)-produced common carotid step or shelf on early and late CEA outcome. A simple method of reconstruction that covers the exposed media and intima of the step and smooths out the flow channel is presented. Since 1984 intraoperative geometric measurements were made on 1019 CEA. Duplex scans were made after surgery on 968 (95%); 234 (23%) were monitored for at least 5 years. Of the first 920 CEA, 261 (28%) had a step > or = 2 mm. Of the last 99 operations, the 27 (27%) with a step > or = 2 mm had inversion plication reconstruction of the step. Three patients had early post-CEA neurologic events attributed to a common carotid step, two had transient ischemic attacks, and one had a mild stroke. All three had a CEA-produced step > or = 2 mm (1.2% of 261, p = 0.03 when compared with no unexplained early neurologic events in the 659 without a step). Duplex scans were normal in all three except for a common carotid artery step. Six patients had seven reoperations for common carotid artery restenosis at 23 to 104 months (mean 73 months) after CEA. All had a step > or = 2 mm at the origin CEA (2.7% of 261, p = 0.001 when compared with no reoperations for common carotid artery stenosis in the 659 CEA without a step). All but one patient had > 75% restenosis. Four were asymptomatic. All seven with restenosis were within 2 mm of the original common carotid end point step. Four restenoses were concentric, two eccentric, and one ulcerated. Six of the seven arteries were originally reconstructed with a greater saphenous vein patch that extended 3 to 6 mm proximal to the step. Early postoperative duplex scans of the 27 recent CEA with step reconstruction demonstrated a tortuous but smooth common carotid artery flow channel. The CEA-produced common carotid artery step is a potential source of both early postoperative emboli and late restenosis. The incidence is approximately 4% in patients with a CEA step > or = 2 mm. CEA vein patch reconstruction does not prevent restenosis in the region of the step but may lower the incidence. Although not proven, reconstruction techniques directed at covering the exposed step media and intima and smoothing the flow channel may favorably alter outcome.