Carotid endarterectomy for stenoses of twisted carotid bifurcations

Abstract 

Background

The twisted carotid bifurcation is a variant in which the ICA courses medially to the ECA. Because descriptions in the literature have been limited, we here document clinical features and surgical experience of CEA for cases of twisted carotid bifurcation.

Methods

Seventy-five out of a total of 106 consecutive cases with surgically treated carotid stenoses underwent CEA. The angle of twist was measured in the axial view of MDCT angiography as the medially deviated degree.

Results

Seven cases (9.3%) demonstrated twisted carotid bifurcations. Six were found on the right side and one was on the left. The average angle of twist was 80.0° ± 17.6°, whereas that with a normally positioned bifurcation was −7.4° ± 7.7°. Six patients (85.7%) had diabetes mellitus and 5 patients (71.4%) had hypertension as a coexisting disease. Carotid endarterectomy was successfully performed with correction of the carotid position except in 1 case. Postoperative MDCT angiography revealed twisted position as in the preoperative state in 4, complete correction to the normal position in 2, and half-correction in 1.

Conclusions

Twisted carotid bifurcations were preferentially found in right severely atherosclerotic carotids in patients with diabetes mellitus and/or hypertension. Carotid endarterectomy of twisted carotids can be safely accomplished, sometimes with correction of the carotid position. Multidetector computed tomography angiography was useful for perioperative evaluation. Variation should be considered by the neurosurgeon and neurologists concerned in the evaluation and treatment of carotid stenoses.

Abbreviations: 3D-DSA, 3-dimensional digital subtraction angiography, AP, anterior-posterior, CCA, common carotid artery, CEA, carotid endarterectomy, DICOM, digital imaging and communication in medicine, ECA, external carotid artery, ECST, European carotid surgery trial, ICA, internal carotid artery, IMT, intima-media thickness, MDCT, multidetector computed tomography, US, ultrasonography

Keywords: Carotid endarterectomy, Carotid stenosis, Carotid bifurcation, Internal carotid artery, External carotid artery