Aneurysms of the Extracranial Internal Carotid Artery Due to Fibromuscular Dysplasia: Results of Surgical Management Pascal Bour, MD, Iradj Taghavi, MD, Serge Bracard, MD, Nicolas Frisch, MD, G6rard Fi6v6, MD, Nancy, France
Between January 1977 and December 1990, eight patients underwent surgical correction of aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia. Mean age of patients was 50 years (range 31 to 70 years). Five patients presented with neurologic hemispheric symptoms. Most aneurysms were saccular and occurred preferentially at the level of C2 or C3. All of these patients underwent operation through conventional cervicotomy. Resection-anastomosis was performed in three cases whereas resection-graft was performed in five. Histopathological examination of the eight specimens was consistent with fibromuscular dysplasia of the media. There was no central nervous system-related mortality and morbidity. Seven patients were alive and free of new neurological manifestations at mean follow-up of 156 months (18 to 180 months). One patient died of myocardial infarction at 96 months. All patients had postoperative duplex scanning or arteriograms. These revealed that carotid restorations were patent in seven whereas one patient had asymptomatic occlusion at 18 months. (Ann Vasc Surg 1992;6:205-208). KEY WORDS:
Aneurysm; internal carotid artery; fibromuscular dysplasia.
The origin of fibromuscular dysplasia (FMD) remains unknown. Involvement of the cephalic arteries, first reported in 1964 by Palubinskas and Ripley [1], and representing the second most common site of this disease after the renal arteries, is observed rarely. The incidence of FMD of the carotid artery, as reported by autopsy series, is approximately 1% [2], while the arteriographic incidence of carotid lesions has been reported to range from 0.6% to
2.5% [3,4]. Arteriographic findings in carotid FMD are generally similar to those found in the renal artery. An atypical form, noted at the level of the carotid arteries by Houser and Baker [5], is called the saccular macroaneurysm, and it should be differentiated from mural microaneurysm lesions, which are often encountered in multifocal involvement of FMD. Fibromuscular dystrophy of this type generally predominates in the media [6]. In this study, we describe eight cases of fibromuscular dystrophic aneurysms of the extracranial internal carotid artery treated surgically.
From the Service de Chirurgie Vasculaire, H6pital Central, and the Service de Neuroradiologie, H6pital Saint Julien, Nancy, France.
PATIENTS AND METHODS
Presented at the Annual Meeting o f the SociOt~ de Chirurgie Vasculaire de Langue Franfaise, June 21-22, 1991, Marseille, France. Reprint requests: Pascal Bour, MD, Service de Chirurgie Vasculaire, H6pital Central, 29 avenue du MarOchal de Lattre de Tassigny, 54037 Nancy, France.
From January 1977 to December 1990, eight patients (six men, two women) underwent operation for aneurysms of fibromuscular dysplastic origin in the extracranial portion of the internal carotid 205
ANNALS OF
A N E U R YSMS OF THE EXTRA C R A N I A L 1CA
206
VASCULAR SURGERY
TABLE i.DCircumstances of discovery of aneurysms
Hemispheric TIA Hemispheric CVA Cervical mass Cervical bruit
Ipsilateral
Contralateral
Bilateral
Total
1 2 2 -
1 1 -
1
2 3 2 1
T I A = transient ischemic attack; C V A = cerebrovascular accident
artery. Mean age was 50 years, with ages ranging from 31 to 70 years. The conditions under which the aneurysm was discovered are listed in Table I. Of five patients (62%) who had central neurologic hemispheric symptoms, two had experienced a contralateral neurologic accident. These were due to atheromatous stenosis of the intrapetrous internal carotid artery in one and multifocal fibromuscular dysplasia in the other. Four patients experienced hypertension, which was related to FMD of the renal arteries in one case. Three patients smoked heavily while one patient was taking oral contraceptive medication. All patients had arteriograms except one who was operated on emergently after sonograms of neck vessels were obtained. The aneurysm was saccular in seven cases and fusiform in one. The size of the aneurysm ranged from 15 to 40 mm in its greatest diameter. All aneurysms were located on the cervical internal carotid artery, two at the level of C2, three at the level of the interspace C2-C3, and one at the level of C3 (Fig. 1). Three extended from C2 to C4 (Fig. 2). Associated lesions included five instances of carotid tortuosity, one being the site of aneurysm; three instances of carotid or vertebral kinking; and two atheromatous stenoses of the contralateral internal carotid artery. Cephalic computed tomographic (CT) scans were obtained in two patients, and these showed ischemic hypodensity
Fig, 1. Carotid arteriograms showing a saccular fibromuscular dysplastic aneurysm of the internal carotid artery at level of C2-C3 in a 68-year-old woman.
i Fig. 2. Carotid arteriogram in a 37-year-old woman with fibromuscular dysplastic aneurysm of the internal carotid artery extending from C2 to C4.
corresponding to the vascular bed of the aneurysmal lesion. The aneurysm was approached through a presternocleidomastoid incision extended behind the lobule of the ear. Exposition of the lesion required extended dissection of the internal carotid artery with retraction of the hypoglossal and glossopharyngeal nerves and division of the digastric muscle in two patients. An internal shunt was inserted in one patient because of stump pressure inferior to 50 mmHg after clamping of the lower carotid artery. The carotid lesion was treated by resection-vein graft in five cases and resection-anastomosis in three cases because of excessive length of the artery. In one case" complementary intraoperative transluminal dilatation was performed because of distal dysplastic stenosis. The gross aspect of the aneurysm's endothelium was normal. The aneurysm communicated with the vascular lumen through either a thin, unique or regular double neck. A thrombus was found in the aneurysmal sac in four patients. All eight specimens
VOLUME 6 No 3 - 1992
ANEURYSMS OF THE EXTRACRANIAL 1CA
had evidence of medial fibromuscular dysplasia, without signs of dissection.
RESULTS There was no perioperative (30 days) central nervous system-related mortality or morbidity. Two patients experienced transient paralysis of the hypoglossal nerve. Mean follow-up was 156 months ranging from 18 to 180 months. Seven patients were alive and free of new neurological manifestations. One patient died of myocardial infarction at 96 months. All eight patients had routine duplex scanning or arteriograms at their last consultation. One patient had an asymptomatic occlusion of his graft at 18 months. There was no recurrence of aneurysm in this series.
DISCUSSION Because of the risk of thromboembolism related to all types of aneurysm, as well as the possible complications inherent in the symptomatic course of fibromuscular disease of the carotid artery [7,15], we believe that surgery is indicated in all cases of aneurysm associated with fibromuscular dysplasia of the extracranial internal carotid artery. Fibromuscular dysplastic aneurysm represents an atypical form of fibromuscular disease. Most often, the aneurysm is an ovoid or round, lateral, saccular appendix [5]; more rarely it has a fusiform shape [7]. This radiological presentation corresponds to the medial form described by Harrison and McCormack in 1971 [8] and modified by Stanley and associates in 1975 [9]. These findings were confirmed by pathology in all our specimens. Mural microaneurysms, also a form of medial dysplasia, whose radiological appearance corresponds to multifocal dysplasia with "pearl strings" [10], were excluded from our study. While Kincaid and colleagues [1 I] have reported 12 cases of fibromuscular dysplasia at the level of the renal arteries [1I], the number of cases in the cervical vessel studies does not exceed three [5,12,13], the prevalence being 4%, according to Osborn and Anderson [4]. Poor knowledge of the natural history of FMD [14,15] has led several authors to refute operation in asymptomatic forms [14,16]. None of these series, however, included aneurysms. For others [17], aneurysms in the neck carry with them a risk of thromboembolism, irrespective of their cause, and therefore mandate surgical correction. Thrombotic material was found in 50% of the aneurysms in our patients, and the occurrence of embolic cerebral ischemia corresponding to the aneurysmal vascular
207
bed in two of our patients seems to confirm this point of view. The location of lesions in our series explains their surgical accessibility. Aneurysms can, however, be located more cephalad, at the level of C1 [18] and require an extended surgical approach [19]. In these high locations, ligation associated with intra-extracranial bypass [20] or detachable balloon occlusion [21] have been proposed. Although rarer, more proximal locations have also been observed, as reported by Houser and coworkers [5] and as seen in three cases of the present series. Isolated dysplastic aneurysms of the extracranial internal carotid artery raise the question of their nosological relationships with dissecting aneurysms [22]. They could, in fact, be a consequence of dissection. While spontaneous dissection is a recognized complication of medial FMD [10,23,24], in the absence of pathological proof, it seems difficult to confirm the dysplastic origin of an internal carotid artery aneurysm just by the radiological aspect [I0]. In our series, pathology reports of the specimen did not show any evidence in favor of dissection. Dissecting aneurysms can either regress or stabilize [22,25] and, as aneurysms of fibromuscular dysplasia origin, they can also increase in size and lead to the same thromboembolic complications that justify their surgical treatment [26-28]. On the other hand, better knowledge of the natural history of small, asymptomatic aneurysms should allow definition of the therapeutic indications of these lesions when they are located at the base of the skull.
REFERENCES 1. PALUBINSKAS AJ, RIPLEY HR. Fibromuscular hyperplasia in extrarenal arteries. Radiology 1964;82:451--455. 2. H E F F E L F I N G E R M J, HOLLEY KE, HARRISON EG Jr, et al. Arterial fibromuscular dysplasia studied at autopsy (abstract). Am J Clin Pathol 1970;54:274. 3. CORRIN LS, SANDOK BA, HOUSER OW. Cerebral ischemic events in patients with carotid artery fibromuscular dysplasia. Arch Neurol 1981;38:616--618. 4. OSBORN AG, ANDERSON RE. Angiographic spectrum of cervical and intra-cranial fibromuscular dysplasia. Stroke 1977;8:617-626. 5. HOUSER OW, BAKER HL, SANDOK BA, et al. Cephalic arterial fibromuscular dysplasia. Radiology 1971;101:605611. 6. MC CORMACK LJ, POUTASSE EF, MEANEY TF, et al. A pathologic arteriographic correlation of renal arterial disease. Am Heart J 1966;72:188--198. 7. SO EL, TOOLE J, DALAL P, et al. Cephalic fibromuscular dysplasia in 32 patients (clinical findings and radiologic features). Arch Neurol 1981;38:619-622. 8. HARRISON EG Jr, MC CORMACK LJ. Pathologic classification of renal arterial disease in renovascular hypertension. Mayo Clin Proc 1971;46:161-167. 9. STANLEY JC, GEWERTZ BL, BOVE EL, et al. Arterial fibrodysplasia. Arch Surg 1975;110:561-566. 10. M A N E L F E C, CLARISSE J, FREDY D, et al. Dysplasies
208
11.
12. 13. 14.
15. 16. 17. 18. 19.
A N E U R Y S M S OF THE E X T R A C R A N I A L ICA
fibromusculaires des art~.res cervico-crphaliques. (A propos de 70 cas). J Neuroradiol 1974;1:149-231. KINCAID OW, DAVIS GD, H A L L E R M A N N FJ, et al. Fibromuscular dysplasia of the renal arteries: arteriographic features, classifcation, and observations on natural history of the disease. A m J Roentgenol 1968;104:271-282. METTINGER K, ERICSON K. Fibromuscular dysplasia and the brain observations on angiographic, clinical and genetic characteristics. Stroke 1982;13:46-52. SANDMANN W, HENNERICI M, AULICH A, et al. Progress in carotid artery surgery at the base of the skull. J Vasc Surg 1984;1:734--743. E H R E N F E L D WK. Dysplasie fibromusculaire de la carotide: indications chirurgicales et rrsultats. In: KIEFFER E, BOUSSER MG (eds). Indications et R~sultats de la Chirurgie Carotidienne. Paris: AERCV, 1988, pp. 241-244. E F F E N E Y DJ, E H R E N F E L D WK, STONEY ILl, et al. Why operate on carotid fibromuscular dysplasia? Arch Surg 1980;115:1261-1263. STEWART MT, MORITZ MW, SMITH RB, et al. The natural history of carotid fibromuscular dysplasia. J Vasc Surg 1986;3:305-310. PAINTER TA, HERTZER N, BEVEN EG, et al. Extracranial carotid aneurysms report of six cases and review of the literature. J Vasc Surg 1985;2:312-318. M O R G E N L A N D E R JC, GOLDSTEIN LB. Recurrent transient ischemic attacks and stroke in association with an internal carotid web. Stroke 1991 ;22:94--98. MERCIER C, TOURNIGAND P, PIQUET P, et al. Chirurgie de l'art~.re carotide interne juxta-cr~nienne. In: KIEFFER E, NATALI J (eds). Aspects Techniques de la Chirurgie Carotidienne. Paris: AERCV, 1987, pp. 241-248.
nun
ANNALS OF VASCULAR SURGERY
20. E H R E N F E L D WK, STONEY RJ, WYLIE EJ. Relation of carotid stump pressure to safety of carotid artery ligation. Surgery 1983;93:299-305. 21. NORDESTGAARD AG, WHITE GH, COBB S, et al. Blunt traumatic dissection of the internal carotid artery treated by balloon occlusion. Ann Vasc Surg 1987;1:610-615. 22. D'ANGLEJAN-CHATILLON J, RIBEIRO V, MAS JL, et al. Dissection de l'art~re carotide interne extracr~nienne. Presse Med 1990;19:661--667. 23. MOKRI B, STANSON AW, HOUSER OW. Spontaneous dissections of the renal arteries in a patient with previous spontaneous dissections of the internal carotid arteries. Stroke 1985;16:959-963. 24. WELLING RE, TAHA A, GOEL T, et al. Extracranial carotid artery aneurysms. Surgery 1983;93:319-323. 25. SELLIER N, CHIRAS J, BENHAMOU M, et al. Dissections spontan~es de la carotide interne: aspects cliniques, radiologiques et ~volutifs. (Apropos de 46 cas). J Neuroradiol 1983;10:243-259. 26. HOUSER OW, MOKRI B, SUNDT TM Jr, et al. Spontaneous cervical cephalic arterial dissection and its residuum: angiographic spectrum. A J N R 1984;5:27-34. 27. RUOTOLO C, KIEFFER E. An~vrysmes dissrquants chroniques de la carotide interne: place du traitement chirurgical. In: KIEFFER E, BOUSSER MG (eds). Indications et R(sultats de la Chirurgie Carotidienne. Paris: AERCV, 1988, pp. 253-258. 28. PETRO GR, WlTWER GA, CACAYORIN ED, et al. Spontaneous dissection of the cervical internal carotid artery: correlation of arteriography, CT, and pathology. A JR 1987;148:393-398.
Between January 1977 and December 1990, eight patients underwent surgical correction of aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia. Mean age of patients was 50 years (range 31 to 70 years). Five patients presented with neurologic hemispheric symptoms. Most aneurysms were saccular and occurred preferentially at the level of C2 or C3. All of these patients underwent operation through conventional cervicotomy. Resection-anastomosis was performed in three cases whereas resection-graft was performed in five. Histopathological examination of the eight specimens was consistent with fibromuscular dysplasia of the media. There was no central nervous system-related mortality and morbidity. Seven patients were alive and free of new neurological manifestations at mean follow-up of 156 months (18 to 180 months). One patient died of myocardial infarction at 96 months. All patients had postoperative duplex scanning or arteriograms. These revealed that carotid restorations were patent in seven whereas one patient had asymptomatic occlusion at 18 months. (Ann Vasc Surg 1992;6:205-208). KEY WORDS:
Aneurysm; internal carotid artery; fibromuscular dysplasia.
The origin of fibromuscular dysplasia (FMD) remains unknown. Involvement of the cephalic arteries, first reported in 1964 by Palubinskas and Ripley [1], and representing the second most common site of this disease after the renal arteries, is observed rarely. The incidence of FMD of the carotid artery, as reported by autopsy series, is approximately 1% [2], while the arteriographic incidence of carotid lesions has been reported to range from 0.6% to
2.5% [3,4]. Arteriographic findings in carotid FMD are generally similar to those found in the renal artery. An atypical form, noted at the level of the carotid arteries by Houser and Baker [5], is called the saccular macroaneurysm, and it should be differentiated from mural microaneurysm lesions, which are often encountered in multifocal involvement of FMD. Fibromuscular dystrophy of this type generally predominates in the media [6]. In this study, we describe eight cases of fibromuscular dystrophic aneurysms of the extracranial internal carotid artery treated surgically.
From the Service de Chirurgie Vasculaire, H6pital Central, and the Service de Neuroradiologie, H6pital Saint Julien, Nancy, France.
PATIENTS AND METHODS
Presented at the Annual Meeting o f the SociOt~ de Chirurgie Vasculaire de Langue Franfaise, June 21-22, 1991, Marseille, France. Reprint requests: Pascal Bour, MD, Service de Chirurgie Vasculaire, H6pital Central, 29 avenue du MarOchal de Lattre de Tassigny, 54037 Nancy, France.
From January 1977 to December 1990, eight patients (six men, two women) underwent operation for aneurysms of fibromuscular dysplastic origin in the extracranial portion of the internal carotid 205
ANNALS OF
A N E U R YSMS OF THE EXTRA C R A N I A L 1CA
206
VASCULAR SURGERY
TABLE i.DCircumstances of discovery of aneurysms
Hemispheric TIA Hemispheric CVA Cervical mass Cervical bruit
Ipsilateral
Contralateral
Bilateral
Total
1 2 2 -
1 1 -
1
2 3 2 1
T I A = transient ischemic attack; C V A = cerebrovascular accident
artery. Mean age was 50 years, with ages ranging from 31 to 70 years. The conditions under which the aneurysm was discovered are listed in Table I. Of five patients (62%) who had central neurologic hemispheric symptoms, two had experienced a contralateral neurologic accident. These were due to atheromatous stenosis of the intrapetrous internal carotid artery in one and multifocal fibromuscular dysplasia in the other. Four patients experienced hypertension, which was related to FMD of the renal arteries in one case. Three patients smoked heavily while one patient was taking oral contraceptive medication. All patients had arteriograms except one who was operated on emergently after sonograms of neck vessels were obtained. The aneurysm was saccular in seven cases and fusiform in one. The size of the aneurysm ranged from 15 to 40 mm in its greatest diameter. All aneurysms were located on the cervical internal carotid artery, two at the level of C2, three at the level of the interspace C2-C3, and one at the level of C3 (Fig. 1). Three extended from C2 to C4 (Fig. 2). Associated lesions included five instances of carotid tortuosity, one being the site of aneurysm; three instances of carotid or vertebral kinking; and two atheromatous stenoses of the contralateral internal carotid artery. Cephalic computed tomographic (CT) scans were obtained in two patients, and these showed ischemic hypodensity
Fig, 1. Carotid arteriograms showing a saccular fibromuscular dysplastic aneurysm of the internal carotid artery at level of C2-C3 in a 68-year-old woman.
i Fig. 2. Carotid arteriogram in a 37-year-old woman with fibromuscular dysplastic aneurysm of the internal carotid artery extending from C2 to C4.
corresponding to the vascular bed of the aneurysmal lesion. The aneurysm was approached through a presternocleidomastoid incision extended behind the lobule of the ear. Exposition of the lesion required extended dissection of the internal carotid artery with retraction of the hypoglossal and glossopharyngeal nerves and division of the digastric muscle in two patients. An internal shunt was inserted in one patient because of stump pressure inferior to 50 mmHg after clamping of the lower carotid artery. The carotid lesion was treated by resection-vein graft in five cases and resection-anastomosis in three cases because of excessive length of the artery. In one case" complementary intraoperative transluminal dilatation was performed because of distal dysplastic stenosis. The gross aspect of the aneurysm's endothelium was normal. The aneurysm communicated with the vascular lumen through either a thin, unique or regular double neck. A thrombus was found in the aneurysmal sac in four patients. All eight specimens
VOLUME 6 No 3 - 1992
ANEURYSMS OF THE EXTRACRANIAL 1CA
had evidence of medial fibromuscular dysplasia, without signs of dissection.
RESULTS There was no perioperative (30 days) central nervous system-related mortality or morbidity. Two patients experienced transient paralysis of the hypoglossal nerve. Mean follow-up was 156 months ranging from 18 to 180 months. Seven patients were alive and free of new neurological manifestations. One patient died of myocardial infarction at 96 months. All eight patients had routine duplex scanning or arteriograms at their last consultation. One patient had an asymptomatic occlusion of his graft at 18 months. There was no recurrence of aneurysm in this series.
DISCUSSION Because of the risk of thromboembolism related to all types of aneurysm, as well as the possible complications inherent in the symptomatic course of fibromuscular disease of the carotid artery [7,15], we believe that surgery is indicated in all cases of aneurysm associated with fibromuscular dysplasia of the extracranial internal carotid artery. Fibromuscular dysplastic aneurysm represents an atypical form of fibromuscular disease. Most often, the aneurysm is an ovoid or round, lateral, saccular appendix [5]; more rarely it has a fusiform shape [7]. This radiological presentation corresponds to the medial form described by Harrison and McCormack in 1971 [8] and modified by Stanley and associates in 1975 [9]. These findings were confirmed by pathology in all our specimens. Mural microaneurysms, also a form of medial dysplasia, whose radiological appearance corresponds to multifocal dysplasia with "pearl strings" [10], were excluded from our study. While Kincaid and colleagues [1 I] have reported 12 cases of fibromuscular dysplasia at the level of the renal arteries [1I], the number of cases in the cervical vessel studies does not exceed three [5,12,13], the prevalence being 4%, according to Osborn and Anderson [4]. Poor knowledge of the natural history of FMD [14,15] has led several authors to refute operation in asymptomatic forms [14,16]. None of these series, however, included aneurysms. For others [17], aneurysms in the neck carry with them a risk of thromboembolism, irrespective of their cause, and therefore mandate surgical correction. Thrombotic material was found in 50% of the aneurysms in our patients, and the occurrence of embolic cerebral ischemia corresponding to the aneurysmal vascular
207
bed in two of our patients seems to confirm this point of view. The location of lesions in our series explains their surgical accessibility. Aneurysms can, however, be located more cephalad, at the level of C1 [18] and require an extended surgical approach [19]. In these high locations, ligation associated with intra-extracranial bypass [20] or detachable balloon occlusion [21] have been proposed. Although rarer, more proximal locations have also been observed, as reported by Houser and coworkers [5] and as seen in three cases of the present series. Isolated dysplastic aneurysms of the extracranial internal carotid artery raise the question of their nosological relationships with dissecting aneurysms [22]. They could, in fact, be a consequence of dissection. While spontaneous dissection is a recognized complication of medial FMD [10,23,24], in the absence of pathological proof, it seems difficult to confirm the dysplastic origin of an internal carotid artery aneurysm just by the radiological aspect [I0]. In our series, pathology reports of the specimen did not show any evidence in favor of dissection. Dissecting aneurysms can either regress or stabilize [22,25] and, as aneurysms of fibromuscular dysplasia origin, they can also increase in size and lead to the same thromboembolic complications that justify their surgical treatment [26-28]. On the other hand, better knowledge of the natural history of small, asymptomatic aneurysms should allow definition of the therapeutic indications of these lesions when they are located at the base of the skull.
REFERENCES 1. PALUBINSKAS AJ, RIPLEY HR. Fibromuscular hyperplasia in extrarenal arteries. Radiology 1964;82:451--455. 2. H E F F E L F I N G E R M J, HOLLEY KE, HARRISON EG Jr, et al. Arterial fibromuscular dysplasia studied at autopsy (abstract). Am J Clin Pathol 1970;54:274. 3. CORRIN LS, SANDOK BA, HOUSER OW. Cerebral ischemic events in patients with carotid artery fibromuscular dysplasia. Arch Neurol 1981;38:616--618. 4. OSBORN AG, ANDERSON RE. Angiographic spectrum of cervical and intra-cranial fibromuscular dysplasia. Stroke 1977;8:617-626. 5. HOUSER OW, BAKER HL, SANDOK BA, et al. Cephalic arterial fibromuscular dysplasia. Radiology 1971;101:605611. 6. MC CORMACK LJ, POUTASSE EF, MEANEY TF, et al. A pathologic arteriographic correlation of renal arterial disease. Am Heart J 1966;72:188--198. 7. SO EL, TOOLE J, DALAL P, et al. Cephalic fibromuscular dysplasia in 32 patients (clinical findings and radiologic features). Arch Neurol 1981;38:619-622. 8. HARRISON EG Jr, MC CORMACK LJ. Pathologic classification of renal arterial disease in renovascular hypertension. Mayo Clin Proc 1971;46:161-167. 9. STANLEY JC, GEWERTZ BL, BOVE EL, et al. Arterial fibrodysplasia. Arch Surg 1975;110:561-566. 10. M A N E L F E C, CLARISSE J, FREDY D, et al. Dysplasies
208
11.
12. 13. 14.
15. 16. 17. 18. 19.
A N E U R Y S M S OF THE E X T R A C R A N I A L ICA
fibromusculaires des art~.res cervico-crphaliques. (A propos de 70 cas). J Neuroradiol 1974;1:149-231. KINCAID OW, DAVIS GD, H A L L E R M A N N FJ, et al. Fibromuscular dysplasia of the renal arteries: arteriographic features, classifcation, and observations on natural history of the disease. A m J Roentgenol 1968;104:271-282. METTINGER K, ERICSON K. Fibromuscular dysplasia and the brain observations on angiographic, clinical and genetic characteristics. Stroke 1982;13:46-52. SANDMANN W, HENNERICI M, AULICH A, et al. Progress in carotid artery surgery at the base of the skull. J Vasc Surg 1984;1:734--743. E H R E N F E L D WK. Dysplasie fibromusculaire de la carotide: indications chirurgicales et rrsultats. In: KIEFFER E, BOUSSER MG (eds). Indications et R~sultats de la Chirurgie Carotidienne. Paris: AERCV, 1988, pp. 241-244. E F F E N E Y DJ, E H R E N F E L D WK, STONEY ILl, et al. Why operate on carotid fibromuscular dysplasia? Arch Surg 1980;115:1261-1263. STEWART MT, MORITZ MW, SMITH RB, et al. The natural history of carotid fibromuscular dysplasia. J Vasc Surg 1986;3:305-310. PAINTER TA, HERTZER N, BEVEN EG, et al. Extracranial carotid aneurysms report of six cases and review of the literature. J Vasc Surg 1985;2:312-318. M O R G E N L A N D E R JC, GOLDSTEIN LB. Recurrent transient ischemic attacks and stroke in association with an internal carotid web. Stroke 1991 ;22:94--98. MERCIER C, TOURNIGAND P, PIQUET P, et al. Chirurgie de l'art~.re carotide interne juxta-cr~nienne. In: KIEFFER E, NATALI J (eds). Aspects Techniques de la Chirurgie Carotidienne. Paris: AERCV, 1987, pp. 241-248.
nun
ANNALS OF VASCULAR SURGERY
20. E H R E N F E L D WK, STONEY RJ, WYLIE EJ. Relation of carotid stump pressure to safety of carotid artery ligation. Surgery 1983;93:299-305. 21. NORDESTGAARD AG, WHITE GH, COBB S, et al. Blunt traumatic dissection of the internal carotid artery treated by balloon occlusion. Ann Vasc Surg 1987;1:610-615. 22. D'ANGLEJAN-CHATILLON J, RIBEIRO V, MAS JL, et al. Dissection de l'art~re carotide interne extracr~nienne. Presse Med 1990;19:661--667. 23. MOKRI B, STANSON AW, HOUSER OW. Spontaneous dissections of the renal arteries in a patient with previous spontaneous dissections of the internal carotid arteries. Stroke 1985;16:959-963. 24. WELLING RE, TAHA A, GOEL T, et al. Extracranial carotid artery aneurysms. Surgery 1983;93:319-323. 25. SELLIER N, CHIRAS J, BENHAMOU M, et al. Dissections spontan~es de la carotide interne: aspects cliniques, radiologiques et ~volutifs. (Apropos de 46 cas). J Neuroradiol 1983;10:243-259. 26. HOUSER OW, MOKRI B, SUNDT TM Jr, et al. Spontaneous cervical cephalic arterial dissection and its residuum: angiographic spectrum. A J N R 1984;5:27-34. 27. RUOTOLO C, KIEFFER E. An~vrysmes dissrquants chroniques de la carotide interne: place du traitement chirurgical. In: KIEFFER E, BOUSSER MG (eds). Indications et R(sultats de la Chirurgie Carotidienne. Paris: AERCV, 1988, pp. 253-258. 28. PETRO GR, WlTWER GA, CACAYORIN ED, et al. Spontaneous dissection of the cervical internal carotid artery: correlation of arteriography, CT, and pathology. A JR 1987;148:393-398.
