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

doi:10.1016/S0741-5214(94)70117-2

Journal of Vascular Surgery

Volume 19, Issue 1, January 1994, Pages 23-31

Presented at the Forty-First Scientific Meeting of the International Society for Cardiovascular Surgery, North American Chapter, Washington, D.C., June 7-8, 1993.

https://doi.org/10.1016/S0741-5214(94)70117-2 Get rights and content

Abstract

Purpose: 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.

Methods: 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.

Results: 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.

Conclusions: 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. (J VASC SURG 1994;19:23-31.)

Section snippets

PATIENTS AND METHODS

Between July 1981 and December 1992, 1045 standard CEAs were performed by the author. Of these, 1027 were primary CEAs in patients who underwent preoperative arteriography. Of this group, 18 internal carotid arteries in 17 patients had a small or poorly visualized internal carotid artery. All had patent common and external carotid arteries and high-grade stenosis at the bifurcation. There were 10 male and seven female patients with a mean age of 68 years. Only patients who had an apparent

RESULTS

At CEA, all patients had high-grade atherosclerotic stenosis of the origin of the internal carotid artery. Six pathologic or anatomic findings of the internal carotid artery were identified. These are demonstrated schematically in Fig. 4.

. Schematic of six anatomic and pathologic operative findings. Type I is normal internal carotid artery distal to stenosis with low flow and dye streaming. Type II is like type I with trailing partially occluding thrombus loosely adherent to vessel wall. Type

Results

CEA is a safe and effective treatment for patients with symptomatic high-grade atherosclerotic disease of the carotid bifurcation. This may not be the case for patients with high-grade carotid artery bifurcation stenosis and an apparent small-diameter or poorly visualized extracranial internal carotid artery, where the anatomy may be poorly defined in spite of technically satisfactory arteriograms. In this setting, only surgical examination of the internal carotid artery gives an accurate

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Cited by (33)

A Systematic Review and Updated Metaanalysis for Carotid Near-Occlusion
2020, Annals of Vascular Surgery
Citation Excerpt :
The other 25 articles were observational analyses. Seven articles reported the treatment of CEA,5,18,26,30,32–34 11 articles reported the treatment of CAS8,10,12,16,17,19–21,27,29 and 3 articles reported BMT6,24,28 separately. CEA and BMT were reported together in 4 studies1,13,31,35; CAS and BMT were reported together in one article.4
Carotid near-occlusion (CNO) is distal luminal collapse of the internal carotid artery beyond a tight stenosis. CNO is a relatively rare condition accounting for 3% in symptomatic carotid stenosis and about 20% in severe (≥70%) symptomatic stenosis. The optimal treatment for CNO remains controversial.
This systematic review and metaanalysis were performed in accordance with the Meta-analysis of Observational Studies in Epidemiology guidelines (MOOSE). We searched MEDLINE, the Cochrane Library, and EMBASE for articles published from inception date to November 2018. Methodological Index for Non-randomized Studies (MINORS) was used to evaluate the methodological quality of studies. We defined primary outcome as any stroke, death and myocardial infarction (MI) within 30 days after intervention and the operative risks of carotid endarterectomy (CEA) and carotid artery stenting (CAS) were evaluated by the incidence rate (IR) of the primary outcome. Secondary outcome was defined as ipsilateral stroke, neurogenic or cardiac death and MI during the follow-up. Long-term risk was evaluated by the IR of secondary outcome. The analyses used the IRs of secondary outcome and restenosis per person-year (p-y) were performed to evaluate long-term risk and restenosis. Pooled analyses of different therapy groups were calculated.
Twenty-eight articles of 26 studies met the inclusion criteria and were eligible for pooled analysis. Pooled IR of secondary outcome was 4.26 per 100 p-ys (95% CI, 2.92–6.20 per 100 p-ys) in intervention group (heterogeneity, I² = 56.1%, P < 0.01; Egger test, P = 0.73) and 13.3 per 100 p-ys (95% CI, 5.54–31.95 per 100 p-ys) in best medical treatment (BMT) group (heterogeneity, I² = 88.3%, P < 0.01; Egger test, P = 0.76). No significant difference was demonstrated in operative risk (CEA: 4.82%, 95% confidence interval [CI]: 3.07–7.55%; CAS: 5.39%, 95% CI: 3.69–7.88%) and long-term risk (CEA: 4.47 per 100 p-ys, 95% CI: 3.35–5.97 per 100 p-ys; CAS: 4.71 per 100 p-ys, 95% CI: 2.37–9.37 per 100 p-ys) between CEA and CAS group.
BMT alone may be not enough to support a better prognosis than CEA or CAS for patients with CNO. No significant difference was found between patients with CNO who underwent CAS and CEA in both perioperative period and long-term follow-up.
Effective Intraluminal Shunt in Carotid Endarterectomy for Carotid Artery Near Occlusion: Technical Report
2017, World Neurosurgery
Citation Excerpt :
Two main concerns exist regarding carotid artery near occlusion. First, the distal ICA is prone to collapse, so accurate evaluation of tandem stenosis or the patency of the distal ICA is often difficult preoperatively.15,16 Differentiating focal stenosis with a collapsed poststenotic ICA from successive organized lesions can be problematic.17,18
Carotid artery near occlusion is a critical degree of stenosis whereby blood flow is decreased and the distal cervical and intracranial internal carotid arteries (ICAs) are prone to collapse. Considering the diminished perfusion and risk of progression to total occlusion and periocclusive embolism, we performed carotid endarterectomy for carotid artery near occlusion.
Accurate evaluation of tandem stenosis or patency of the poststenotic ICA in carotid artery near occlusion is often difficult preoperatively. Thus we performed carotid endarterectomy in a hybrid operating room where intraoperative digital subtraction angiography (DSA) and endovascular angioplasty or stenting for distal lesions can be performed if necessary. In addition, to evaluate the distal ICA intraoperatively, we used an intraluminal shunt for shunt angiography, with injection of contrast material through the shunt tube, as a replacement for conventional DSA. Furthermore, an intraluminal shunt held the collapsed lumen open and provided a scaffold for suturing, which prevented postoperative stenosis of the distal ICA.
The present report is intended to underline the merits of intraluminal shunt as a replacement for conventional DSA and as a scaffold for suturing.
Management of Patients with Internal Carotid Artery Near-total Occlusion: An Updated Meta-analysis
2015, Annals of Vascular Surgery
Citation Excerpt :
The meta-analysis was conducted using StatsDirect (StatsDirect, Cheshire, UK) statistical software. After review of the literature, 5 articles on BMT5–7,13,14 (186 patients, 429 p-ys), 13 articles on CEA5–8,13–21 (758 patients, 1789 p-ys), and 11 articles on CAS22–32 (357 patients, 576 p-ys) were deemed eligible (Fig. 1 and Tables I and II). Among the patients who received CAS, almost 83% were symptomatic, whereas almost 84% of the patients treated with CEA were symptomatic.
The decision for revascularization in patients with near-total internal carotid artery (ICA) occlusion still remains controversial. We undertook an extensive review of the literature and conducted a meta-analysis aiming to investigate the appropriate therapeutic approach for patients with near-total ICA occlusion.
A multiple electronic health database search was performed on all articles published up to December 2014. All available data were analyzed giving emphasis on the applied therapeutic approach (best medical therapy [BMT], carotid endarterectomy [CEA], and carotid artery stenting [CAS]), whereas the main endpoints of the meta-analysis were transient ischemic attack (TIA), stroke, stroke-related death, myocardial infarction (MI), major adverse event (MAE), overall mortality, and restenosis.
Five articles on BMT and CEA, 8 articles on CEA, and 11 articles on CAS were deemed eligible. A statistically significant difference was recorded in pooled stroke incidence rates (IRs) per 100 patient-years (p-ys) of BMT (IR = 6.19) compared with CEA (IR = 2.24, P = 0.002) and CAS (IR = 1.64, P < 0.001) studies. No statistically significant differences were recorded in pooled IRs per 100 p-ys between CEA and CAS, concerning TIA (P = 0.96), stroke (P = 0.44), stroke-related death (P = 0.30), and MAE (P = 0.99), whereas a borderline significance was recorded concerning overall mortality (P = 0.08) and restenosis (P = 0.08). No nominally significant effects were demonstrated with respect to almost all the studied potential modifiers in meta-regression analysis among the eligible studies.
An intervention is probably indicated for patients with near-total ICA occlusion. The results of our study underline the need for including patients with near-total ICA occlusion in future randomized controlled trials. Meanwhile, the treatment of these patients should be individualized.
Assessment of Apparent Internal Carotid Occlusion on Ultrasound: Prospective Comparison of Contrast-enhanced Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography
2008, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Further, the annual incidence of ipsilateral stroke in patients with an occluded ICA on conventional US (in the absence of ongoing symptoms) is only 2%.4 Nevertheless, many clinicians would offer surgery to patients with apparent carotid occlusion on conventional US if near-occlusion (rather than true occlusion) was found on confirmatory DSA5,6 in the face of recent ipsilateral hemispheric TIAs despite maximal medical therapy7 and evidence of hemispheric perfusion from the ipsilateral ICA. It remains critical therefore, to establish whether the ICA is occluded or has a tight stenosis.
Modern conventional ultrasound is sensitive to slow flow, but may misclassify some tight stenoses as occlusion. Symptomatic patients with tight proximal internal carotid artery stenoses may benefit from carotid endarterectomy but those with occlusion or long-segment disease do not.
A prospective study of the diagnostic accuracy of contrast-enhanced ultrasound (CE-US), 2D time-of-flight magnetic resonance angiography (2D-TOF MRA) and contrast-enhanced magnetic resonance angiography (CE-MRA) against a reference standard of digital subtraction angiography (DSA) in patients with apparent carotid occlusion on conventional ultrasound.
Thirty-one patients with apparent carotid occlusion on conventional ultrasound and with recent ispilateral hemispheric transient ischaemeic attacks (TIAs) were studied. The primary endpoint was confirmation of occlusion with a secondary endpoint of identification of a surgically correctible lesion.
The sensitivity and specificity of CE-US, 2D-TOF MRA and CE-MRA for patency were 1 & 1, 0.33 & 1 and 0.6 & 1 respectively and for the detection of a surgically correctible lesion were 1 & 0.96, 0.67 & 1 and 1 and 0.96 respectively. CE-US was difficult to interpret, precluding confident diagnosis in 5 cases.
2D-TOF MRA had poor sensitivity for patency and cannot be recommended as a second-line investigation to assess vessels apparently occluded on conventional ultrasound. Confident diagnosis on CE-US and CE-MRA accurately identified occlusion. If occlusion is confirmed by either of these modalities, no further imaging is required. The relative advantages of CE-US or CE-MRA in this situation are uncertain.
Management of the near total internal carotid artery occlusion
2005, European Journal of Vascular and Endovascular Surgery
The risk of stroke in patients with near total internal carotid artery (ICA) occlusion is perceived to be high as stroke risk increases with severity of the stenosis. The management of this entity has not been addressed specifically in the existing randomised trials and thus it remains controversial.
Systematic review of the relevant literature.
The management of patients with near total ICA occlusion remains controversial: some favour intervention whereas others have condemned it as dangerous or of no benefit. A prospective multicentre randomised trial regarding intervention versus best medical treatment for patients with symptomatic near total ICA occlusion seems difficult because of the large number of patients required to power the study. Nevertheless, it appears hard to decline surgery based on the current evidence.
Because of the current controversy over the best management of the near total ICA occlusion, prospective observational studies are needed to demonstrate its prevalence in the symptomatic and asymptomatic population and any associated excess stroke risk. Based on the current evidence, surgery is the treatment of choice in most centres but its validity over best medical treatment remains untested.
Emergency carotid endarterectomy
2002, International Congress Series
Although carotid endarterectomy (CEA) is an established treatment, evaluation of emergency revascularization is still obscure, especially in patients with stroke. The purpose of this study is to discuss the efficacy and limitation of emergency CEA.
The subjects are 88 patients who had acute atherothrombotic TIAs or stroke, and angiographically critical stenosis (>90%) of the cervical ICA. A patient with apparent low-density lesion on the initial CT was not included. There were 86 men and 4 women, aged 49 to 78 years. All patients were admitted and diagnosed within 6 h after the last attack, and treated by CEA in different timing or medical treatment. Results of treatment were evaluated.
In 33 patients with only TIAs, results of CEAs were excellent compared with medical treatment group. In 29 with mild neurologic deficits, results of CEAs were more satisfactory in emergency procedures in comparison with delayed surgery. In other 26 patients with profound deficits, sufficient results were not obtained in any treatments.
In conclusion, emergency CEA should be selected without hesitation, in patients with critical ICA stenosis and TIAs or mild ischemic stroke.
We also present our small experiences and discuss about endovascular PTA/stenting in this clinical category.

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

Abstract

Section snippets

PATIENTS AND METHODS

RESULTS

Results

Am J Surg

J VASC SURG

J VASC SURG

Spontaneous dissection of the internal carotid artery

Arch Surg

The poststenotic carotid string sign: spurious internal carotid hypoplasia

Mayo Clin Proc

Atheromatous disease of the carotid artery

J Neurosurg

The importance of arteriographic interpretation in occlusion or pseudo-occlusion of the carotid artery

Surg Gynecol Obstet