Diagnosis and Operative Management of Carotid Endarterectomy in Patients with Twisted Carotid Bifurcation

Abstract

Although carotid endarterectomy (CEA) is an established procedure, technical modifications are required when anatomical features are unusual. The present study aimed to determine the characteristics of diagnostic features, surgical management, and outcomes of patients with a twisted carotid bifurcation (TCB). We assessed 108 consecutive patients by cervical carotid echography (CCE) and black-blood magnetic resonance imaging (BB-MRI) before they underwent 115 CEA procedures. We classified carotid bifurcation (CB) anatomy based on anteroposterior findings of the internal carotid artery (ICA) and external carotid artery (ECA) determined by cerebral or three-dimensional computed tomographic angiography as follows. The ICA and ECA ran laterally and medially, respectively, in Type 1, overlapped in Type 2, and the ICA and ECA ran medially and laterally, respectively, in Type 3. We also classified the patients according to whether or not they had a TCB and compared their diagnostic findings, clinical characteristics, and surgical outcomes. The numbers of patients with Types 1, 2, and 3 were 74 (64.4%), 32 (27.8%), and 9 (7.8%), respectively, and 13 (11.3%) with a TCB included four patients with Type 2 and all nine patients with Type 3. The appearance of Type 3 differed from that of the other two types on CCE and BB-MR images. After correcting the anatomical location of a TCB, surgical duration and adverse event rates did not significantly differ between patients with and without a TCB. Patients with a TCB could safely undergo CEA after correcting the ICA to the normal position.

Comparison of Single and Dual Monitoring during Carotid Endarterectomy

“…We have reported details of the surgical maneuver for CEA in other articles. 21 , 22) In terms of using an internal shunt, if SSEP or SSEP+MEP showed a significant change at the time of clamping of the distal ICA, we initially asked the anesthesiologist to elevate systolic ABP up to 20–30% of the preoperative ABP. If the neuromonitor remained unimproved despite this increase in BP, we inserted the internal shunt immediately.…”

Carotid Endarterectomy Requiring Removal of the Superior Horn of Thyroid Cartilage: Case Report and Literature Review

“…This anomaly is called as lateral ECA, lateral position of ECA, or twisted carotid bifurcation. 2) Furthermore, the right carotid artery extended medial to the right greater horn of HB and the SHTC. Carotid artery stenting (CAS) was also considered, but the calcification was so severe in the entire circumference that CAS would be extremely difficult.…”

Surgical Technique for Carotid Endarterectomy: Current Methods and Problems

“…One advantage of head rotation ≥45° is the possibility of dissecting the internal carotid artery (ICA) more distally or accessing a twisted carotid bifurcation. 10 , 11) For expansion of the distal ICA, Takigawa et al used a radiolucent head frame to extend the patient’s neck. 12) In any case, the surgeon takes the head and neck position to expose the distal ICA for safe CEA ( Fig.…”

“…3B ). 11 , 13) Kazimierczak et al 14) reported a randomized study of camouflage (transverse) incision versus longitudinal incision. Although no significant difference in mortality or morbidity was seen between groups, scar assessment scale score was significantly better in patients with camouflage incision than in patients with longitudinal incision.…”

“…Mini-hooks with rubber bands are used for lifting and developing the surgical field. 11 , 16) The carotid artery is moved more superficially. Moreover, this system helps prevents nerve palsy and crush damage to surrounding tissues ( Fig.…”