DIFFICULT LESIONS OF THE CAROTID ARTERIES AND THEIR SURGICAL MANAGEMENT JOSHUA T. SALVADOR, M.D., F.A.C.A, JOSEPH TARNOFF, M.D., F.A.C.A., EMANUEL FEINHANDLER, M.D. Chicago, Illinois
AND
INTRODUCTION
About a quarter of a million persons die every year in the United States from strokes. It is only in the last two decades that extracranial carotid disease became known as a major cause for strokes and came under the attack of surgeons, who thus prevent strokes before they occur and thereby alter the natural history of this disease. The usual carotid lesion lies at the bifurcation and occludes over 70% of the lumen of the internal carotid artery. With advances in technique and proper selection of patients, surgery can be performed on this group of patients with a mortality and morbidity of about 1-2%. They comprise about 90 to 95% of all carotid lesions that can lead to a stroke. The remaining lesions are uncommon and more difficult to manage. They include the higher occlusions close to the base of the skull, the tortuous and kinked internal carotid arteries, the nonobstructive but ulcerated lesions, aneurysms of the internal carotid arteries, whether arteriosclerotic or traumatic, and lastly, the carotid body tumors. The purpose of this paper is to present those unusual lesions, and to discuss the difficulties in their management and the surgical techniques for dealing with them. Because some of those lesions are rare and others do not come to surgery often, only illustrative examples of patients suffering from such lesions will be presented, and not a series of each. 1.
HIGH LESIONS
High lesions are difficult to manage because of their proximity to the base of the skull, making distal control difficult and limiting the exposure to a narrow triangle formed by the mandible, the mastoid process, and the
hypoglossal
nerve.
in these cases to extend the arteriotomy beyond the occlusive lesion to make sure that it is resected completely. The commonest complication is to leave part of the plaque broken into the artery thus order to predisposing to postoperative thrombosis of the artery. These lesions cannot be removed by a shunt; it will invariably be in the way. Distal control can be achieved either by a small angled renal-type vascular clamp, or by occlusion with a small Fogarty balloon catheter. The patient whose X-rays are illustrated in Figure 1 is a 56-year-old It is very
important
From Mount Sinai Hospital, Chicago, Illinois. Presented at the Twenty-Second Annual Meeting of the American Springs, California.
College
500
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
of
Angiology, Palm
501
F~c. lA. Lesion above bifurcation
on
right
side.
Three weeks before surgery he suffered a minor stroke which caused transient right hemiplegia that lasted about 24 hours. Two days later carotid arteriograms were performed by means of direct carotid arterial stick. The patient was given 3 weeks to stabilize, then the right side (which man.
a
F~c. 1 B.
Higher
lesion
on
left side.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
502
side) was operated first. A week later, the left side was Carotid occlusion time was 10 minutes on the right side and 35 minutes on the left side, where the lesion was much higher, the arteriotomy longer, and more difficult to close. The plaque that was completely excised from this side is shown in Figure 2. Recovery from both operations was uneventful and the patient left the hospital without any neurologic deficit a week after his second operation. was
the
worse
operated.
2.
ULCERATIVE LESIONS
In the last 5 to 6 years, embolism from ulcerative lesions became known of transient ischemic attacks and temporary loss of vision (amaurosis fugax), rather than obstruction to the flow of blood by occlusive lesion. Such lesions are not uncommon but they are presented because they pose controversies in diagnosis and management. The trouble is that the radiologic criteria for ulceration are by no means conclusive, and it is difficult to know which of those minor lesions is ulcerated and which is as a cause
not.
To help establish such criteria, Blaisdell and Gootman studied ulceration in the carotid arteries in 50 consecutive patients. Patients were subjected to arteriographic evaluation, the radiologist gave his impression, the patients were operated and photographs of the gross specimens at operation were taken and the impression from the gross examination was confirmed by microscopic examination. They concluded that half the lesions that are less than 30% occlusive were ulcerated. When the lesions were over 30% occlusive, 75% of them were found to be ulcerated. Irregularity of the surface on arteriograms, retension of the dye in a certain area
FIG. 2.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
503
after flow of the rest, and double densities were found to be significant signs of ulceration. The question arises whether all such patients with minor lesions should be subjected to surgery if they have corresponding neurologic deficits. This subject remains controversial. Figure 3 shows the appearance of a typical ulcerated lesion and Figure 4 shows the type of filling deficit that may be encountered in practice; it was diagnosed as a minor lesion by the radiologist and found to be ulcerated in surgery. The patient suffered from attacks of transient blindness, which were relieved by surgical removal of the plaque. 3.
TORTUOUS
KINKED
CAROTID ARTERIES
Tortuosity by itself may not lead to transient ischemic attacks or strokes. It is only when a tortuous artery becomes kinked that the flow of blood to the brain is obstructed and such symptoms appear. Tortuosity of the internal carotid artery may be congenital in children but usually does not give rise to symptoms. In the aged it is usually accompanied by arteriosclerosis. Whether all tortuous arteries are going to become kinked at one time or
FIG. 3.
Typical
appearance of
an
ulcerated lesion.
Though
not
occlusive, it
can cause
symptoms by embolization.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
cerebral
504
an
FIG. 4. An ulcerative lesion ulcerated plaque.
(arrow) presenting
as an
ulcer niche and
proved in surgery to
be
another is not known. In the past these lesions were treated by repositionthe artery in a way that smooths its tortuosity into a curve. Recently the atheromatous portion of the internal carotid artery was resected and
ing
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
505
FIG. 5. A kinked occluded internal carotid
ar-
tery.
the
remaining portion
was
implanted proximally in the common carotid was straightened. This procedure
artery; thus the internal carotid artery
be done with or without a shunt. The characteristic findings in these patients is that the transient ischemic attack occurs when they move their necks in a certain direction. The first patient whose arteriograms are illustrated (Figure 5) was a 67-
can
FIG. 6 Tortuous internal carotid artery with occlusion near its origin that does not show well in this view but is clear in the A-P view. Hence the importance of making arteriograms in two views is demonstrated. severe
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
506
year-old lady. She was leaving the bank when the teller called her back to take some change which she had forgotten. When she turned her head toward the teller, she fainted. The second patient, in addition to his tortuosity, had a 95% occlusion of his internal carotid artery near its origin. He suffered a minor stroke 3 weeks before surgery. His arteriograms are illustrated. The occlusive lesion does not show well in the lateral view (Figure 6), but it shows better in the A-P view (Figure 7). Hence the importance of making arteriograms in more than one plane is demonstrated. His stenotic segment was excised, and the internal carotid artery was reimplanted distally in a straight line. Similar surgery was performed on the first patient, and both had uneventful recoveries. 4.
ANEURYSMS OF THE INTERNAL CAROTID ARTERIES
These aneurysms are either arteriosclerotic or traumatic. An illustrative example of each is presented. The first patient was referred from an ear, nose, and throat clinic because of a pulsating swelling in his right neck which was diagnosed as a carotid body tumor. The patient received irradiation without improvement of his symptoms. The arteriograms were diagnosed by the radiolgist as &dquo;dilatation&dquo; of his internal carotid artery, with widening of the bifurcation. It lacked the vascularity, which is characteristic of carotid body tumors, but this peculiarity was attributed to the irradiation. In view of his symptoms, the neck was explored, but no carotid body tumor was found. Instead an aneurysm of the internal carotid artery was discovered (Figure 8). The artery felt very soft at the region of the aneurysm, and we thought of treating it by wrapping it with a dacron patch to avoid future rupture. However, as soon as the patient woke up from the anesthesia we found that he was not moving his contralateral side. Hence he was taken back to surgery immediately. The aneurysm was opened and it was found to be full of clot. Embolectomy was performed with a No. 1 Fogarty catheter, and back-flow and suction were allowed. The walls of the aneurysm were partially excised and the remaining portion closed over a stent, i.e. aneurysmorrhaphy was performed. His neurologic deficit recovered gradually over 10 days and he left the hospital with full motor power. The second case is that of a traumatic aneurysm in a 12-year-old girl who was involved in a car accident, after which she was in a coma for 3 weeks. While she was in coma it was noticed that she was not moving her left side. Hence carotid arteriograms, which are illustrated in Figure 9, were performed. They revealed a false aneurysm which extended to the base of the skull. In view of the danger of rupture and fatal hemorrhage, it was decided to explore her neck with the possibility of having to ligate the internal carotid artery, if distal control could not be achieved. This procedure is accompanied by a 20% risk of a permanent stroke, but it might have been necessary to save her life. However during surgery the aneurysm
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
507
Fic. 7. An occlusive lesion near the origin of a tortuous internal carotid artery that did not show in the previous view. It was treated by resecting the stenotic segment and reimplanting the internal carotid artery more proximally in the common carotid. Recovery
was
good.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
508
FIG. 8.
could be completely exposed, and distal control was possible. A saphenous vein graft was mounted over a Javid shunt and anastomosed first distally, then proximally, while the shunt carried out the circulation to the brain (Figure 10). The recovery was uneventful. 5.
CAROTID BODY TUMORS
(CHEMODECTOMAS)
Chemodectomas are very vascular tumors that arise from the undersurface of the carotid bifurcation, and remain closely adherent to the vessel wall as they expand and cause widening of the carotid bifurcation. They present as a pulsating mass in the side of the neck. They are derived from the neuroepithelial elements (chemoreceptors) in the carotid body, and their structure is similar to that of an endocrine gland. Fifty percent could become malignant and develop metastases if left untreated. In some series there was an incidence of vocal cord paralysis as high as 25% caused by local invasion of the vagus nerve. Carotid body tumors can give rise to
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
509
FIG. 9. Arteriogram of a traumatic aneurysm in a 12-year-old girl involved in a car accident.
hypertension and cause pressure on the larynx or esophagus. A strong familial incidence has been recorded. They are usually treated by tedious and meticulous ligation of the numerous feeding arteries and excision from the carotid arteries. The biggest hazard of this surgery is uncontrollable hemorrhage, which could necessitate ligation of the carotids with the probability of hemiplegia. This fearful combination of accidents carried a mortality of about 30%. In addition, there was the risk of damage to surrounding structure, particularly the cranial nerves. The patient whose arteriograms are illustrated in Figure 11 was referred to us after an attempt to excise his tumor in another hospital. However the procedure had to be abandoned because of massive hemorrhage after tranfusing about 7 units of blood. In view of the patient’s symptoms he was reexplored by us, and attempts to dissect the tumor from the carotid arteries proved to very time-consuming because of the dense adhesions and the almost uncontrollable bleeding. Hence we had either to abandon the operation once again and declare this tumor inoperable, or use a technique which later became our standard procedure for resection of all carotid body tumors, and which is described below. Once again a shunt was used between the common carotid artery and the distal internal carotid artery, and the tumor was excised, this time
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
510
FIG. 10.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
511
FIG. 11. Arteriograms of the carotid body tumor. Notice the bifurcation and the network of blood vessels feeding the tumor.
widening
of the carotid
with the internal carotid artery. A saphenous vein graft was anastomosed first distally and then proximally to the stump of the internal carotid artery, while the shunt carried the circulation to the brain. This procedure cuts down the hemorrhage, operative time, and operative risk tremendously. The tumor and operative technique are illustrated in Figures 12 and 13.
together
SUMMARY
-I-
We have discussed five lesions that are encbunted less commonly than the usual occlusive carotid lesion that occurs at the carotid bifurcation,
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
512
F~c. 12.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
513
Fm. 13. The end result of vein graft.
resuming continuity
of the internal carotid artery
by
a
long saphenous
ulcerative plaques, tortuous carotids, carotid and carotid aneurysms, body tumors. Illustrative cases of these lesions were presented. The diagnostic difficulties related to some of them and the technical aspects of their surgical management were discussed. New techniques for resecting internal carotid aneurysms and carotid body tumors by using autogenous saphenous vein grafts and a shunt were described and illustrated.
namely, high lesions,
Joshua D. Salvador, M.D., F.A.C.A. Bellwood Clinic 4420 St. Charles Road Bellwood, Illinois 60104 BIBLIOGRAPHY 1. Blaisdell, W. F.: Personal communication. 2. Weibel, W. F., Jr.: Occlusive disease of the extracranial arteries, Atlas of Arteriography in Occlusive Cerebrovascular Disease. Philadelphia, Saunders, 1969. 3. Feldtman, R. W., Mozersky, D. J., Hagood, C.O.: Surgical correction of a kinked carotid artery in an asymptomatic child. Vasc. Surg., 9: 73, 1975. 4. Najafi, H., Dye, N.S., Hunter, J. A., et al.: The kinked internal carotid artery: Clinical evaluation and surgical correction. Arch. Surg., 89: 134-143, 1964. 5. Moore, W.: Personal communication. 6. Hershey, F. G., Colmon, C. H.: Cerebral arterial insufficiency, Arterial Surgery. St. Louis, Mosby, 1973.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
514 7. Eastcott, H. H.: Carotid body tumors and carotid vertebral insufficiency, Arterial Surgery. Second edition. Philadelphia, Lippincott, 1973. 8. Hershey, F. B.: Operations for aneurysm of the internal carotid artery high in the neck. Angiology, 25: 24-30, 1974. 9. Bladin, P. F.: Dissecting aneurysm of carotid and vertebral arteries: A study of four cases. Vasc. Surg., 8: 203, 1974. 10. Sohia, Y., Katsumoto, E., Iamamura, H., et al.: An axillary-carotid shunt for excision and replacement of aneurysm of the carotid artery. J. Cardiovasc. Surg., 15: 595, 1974.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
AND
INTRODUCTION
About a quarter of a million persons die every year in the United States from strokes. It is only in the last two decades that extracranial carotid disease became known as a major cause for strokes and came under the attack of surgeons, who thus prevent strokes before they occur and thereby alter the natural history of this disease. The usual carotid lesion lies at the bifurcation and occludes over 70% of the lumen of the internal carotid artery. With advances in technique and proper selection of patients, surgery can be performed on this group of patients with a mortality and morbidity of about 1-2%. They comprise about 90 to 95% of all carotid lesions that can lead to a stroke. The remaining lesions are uncommon and more difficult to manage. They include the higher occlusions close to the base of the skull, the tortuous and kinked internal carotid arteries, the nonobstructive but ulcerated lesions, aneurysms of the internal carotid arteries, whether arteriosclerotic or traumatic, and lastly, the carotid body tumors. The purpose of this paper is to present those unusual lesions, and to discuss the difficulties in their management and the surgical techniques for dealing with them. Because some of those lesions are rare and others do not come to surgery often, only illustrative examples of patients suffering from such lesions will be presented, and not a series of each. 1.
HIGH LESIONS
High lesions are difficult to manage because of their proximity to the base of the skull, making distal control difficult and limiting the exposure to a narrow triangle formed by the mandible, the mastoid process, and the
hypoglossal
nerve.
in these cases to extend the arteriotomy beyond the occlusive lesion to make sure that it is resected completely. The commonest complication is to leave part of the plaque broken into the artery thus order to predisposing to postoperative thrombosis of the artery. These lesions cannot be removed by a shunt; it will invariably be in the way. Distal control can be achieved either by a small angled renal-type vascular clamp, or by occlusion with a small Fogarty balloon catheter. The patient whose X-rays are illustrated in Figure 1 is a 56-year-old It is very
important
From Mount Sinai Hospital, Chicago, Illinois. Presented at the Twenty-Second Annual Meeting of the American Springs, California.
College
500
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
of
Angiology, Palm
501
F~c. lA. Lesion above bifurcation
on
right
side.
Three weeks before surgery he suffered a minor stroke which caused transient right hemiplegia that lasted about 24 hours. Two days later carotid arteriograms were performed by means of direct carotid arterial stick. The patient was given 3 weeks to stabilize, then the right side (which man.
a
F~c. 1 B.
Higher
lesion
on
left side.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
502
side) was operated first. A week later, the left side was Carotid occlusion time was 10 minutes on the right side and 35 minutes on the left side, where the lesion was much higher, the arteriotomy longer, and more difficult to close. The plaque that was completely excised from this side is shown in Figure 2. Recovery from both operations was uneventful and the patient left the hospital without any neurologic deficit a week after his second operation. was
the
worse
operated.
2.
ULCERATIVE LESIONS
In the last 5 to 6 years, embolism from ulcerative lesions became known of transient ischemic attacks and temporary loss of vision (amaurosis fugax), rather than obstruction to the flow of blood by occlusive lesion. Such lesions are not uncommon but they are presented because they pose controversies in diagnosis and management. The trouble is that the radiologic criteria for ulceration are by no means conclusive, and it is difficult to know which of those minor lesions is ulcerated and which is as a cause
not.
To help establish such criteria, Blaisdell and Gootman studied ulceration in the carotid arteries in 50 consecutive patients. Patients were subjected to arteriographic evaluation, the radiologist gave his impression, the patients were operated and photographs of the gross specimens at operation were taken and the impression from the gross examination was confirmed by microscopic examination. They concluded that half the lesions that are less than 30% occlusive were ulcerated. When the lesions were over 30% occlusive, 75% of them were found to be ulcerated. Irregularity of the surface on arteriograms, retension of the dye in a certain area
FIG. 2.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
503
after flow of the rest, and double densities were found to be significant signs of ulceration. The question arises whether all such patients with minor lesions should be subjected to surgery if they have corresponding neurologic deficits. This subject remains controversial. Figure 3 shows the appearance of a typical ulcerated lesion and Figure 4 shows the type of filling deficit that may be encountered in practice; it was diagnosed as a minor lesion by the radiologist and found to be ulcerated in surgery. The patient suffered from attacks of transient blindness, which were relieved by surgical removal of the plaque. 3.
TORTUOUS
KINKED
CAROTID ARTERIES
Tortuosity by itself may not lead to transient ischemic attacks or strokes. It is only when a tortuous artery becomes kinked that the flow of blood to the brain is obstructed and such symptoms appear. Tortuosity of the internal carotid artery may be congenital in children but usually does not give rise to symptoms. In the aged it is usually accompanied by arteriosclerosis. Whether all tortuous arteries are going to become kinked at one time or
FIG. 3.
Typical
appearance of
an
ulcerated lesion.
Though
not
occlusive, it
can cause
symptoms by embolization.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
cerebral
504
an
FIG. 4. An ulcerative lesion ulcerated plaque.
(arrow) presenting
as an
ulcer niche and
proved in surgery to
be
another is not known. In the past these lesions were treated by repositionthe artery in a way that smooths its tortuosity into a curve. Recently the atheromatous portion of the internal carotid artery was resected and
ing
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
505
FIG. 5. A kinked occluded internal carotid
ar-
tery.
the
remaining portion
was
implanted proximally in the common carotid was straightened. This procedure
artery; thus the internal carotid artery
be done with or without a shunt. The characteristic findings in these patients is that the transient ischemic attack occurs when they move their necks in a certain direction. The first patient whose arteriograms are illustrated (Figure 5) was a 67-
can
FIG. 6 Tortuous internal carotid artery with occlusion near its origin that does not show well in this view but is clear in the A-P view. Hence the importance of making arteriograms in two views is demonstrated. severe
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
506
year-old lady. She was leaving the bank when the teller called her back to take some change which she had forgotten. When she turned her head toward the teller, she fainted. The second patient, in addition to his tortuosity, had a 95% occlusion of his internal carotid artery near its origin. He suffered a minor stroke 3 weeks before surgery. His arteriograms are illustrated. The occlusive lesion does not show well in the lateral view (Figure 6), but it shows better in the A-P view (Figure 7). Hence the importance of making arteriograms in more than one plane is demonstrated. His stenotic segment was excised, and the internal carotid artery was reimplanted distally in a straight line. Similar surgery was performed on the first patient, and both had uneventful recoveries. 4.
ANEURYSMS OF THE INTERNAL CAROTID ARTERIES
These aneurysms are either arteriosclerotic or traumatic. An illustrative example of each is presented. The first patient was referred from an ear, nose, and throat clinic because of a pulsating swelling in his right neck which was diagnosed as a carotid body tumor. The patient received irradiation without improvement of his symptoms. The arteriograms were diagnosed by the radiolgist as &dquo;dilatation&dquo; of his internal carotid artery, with widening of the bifurcation. It lacked the vascularity, which is characteristic of carotid body tumors, but this peculiarity was attributed to the irradiation. In view of his symptoms, the neck was explored, but no carotid body tumor was found. Instead an aneurysm of the internal carotid artery was discovered (Figure 8). The artery felt very soft at the region of the aneurysm, and we thought of treating it by wrapping it with a dacron patch to avoid future rupture. However, as soon as the patient woke up from the anesthesia we found that he was not moving his contralateral side. Hence he was taken back to surgery immediately. The aneurysm was opened and it was found to be full of clot. Embolectomy was performed with a No. 1 Fogarty catheter, and back-flow and suction were allowed. The walls of the aneurysm were partially excised and the remaining portion closed over a stent, i.e. aneurysmorrhaphy was performed. His neurologic deficit recovered gradually over 10 days and he left the hospital with full motor power. The second case is that of a traumatic aneurysm in a 12-year-old girl who was involved in a car accident, after which she was in a coma for 3 weeks. While she was in coma it was noticed that she was not moving her left side. Hence carotid arteriograms, which are illustrated in Figure 9, were performed. They revealed a false aneurysm which extended to the base of the skull. In view of the danger of rupture and fatal hemorrhage, it was decided to explore her neck with the possibility of having to ligate the internal carotid artery, if distal control could not be achieved. This procedure is accompanied by a 20% risk of a permanent stroke, but it might have been necessary to save her life. However during surgery the aneurysm
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
507
Fic. 7. An occlusive lesion near the origin of a tortuous internal carotid artery that did not show in the previous view. It was treated by resecting the stenotic segment and reimplanting the internal carotid artery more proximally in the common carotid. Recovery
was
good.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
508
FIG. 8.
could be completely exposed, and distal control was possible. A saphenous vein graft was mounted over a Javid shunt and anastomosed first distally, then proximally, while the shunt carried out the circulation to the brain (Figure 10). The recovery was uneventful. 5.
CAROTID BODY TUMORS
(CHEMODECTOMAS)
Chemodectomas are very vascular tumors that arise from the undersurface of the carotid bifurcation, and remain closely adherent to the vessel wall as they expand and cause widening of the carotid bifurcation. They present as a pulsating mass in the side of the neck. They are derived from the neuroepithelial elements (chemoreceptors) in the carotid body, and their structure is similar to that of an endocrine gland. Fifty percent could become malignant and develop metastases if left untreated. In some series there was an incidence of vocal cord paralysis as high as 25% caused by local invasion of the vagus nerve. Carotid body tumors can give rise to
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
509
FIG. 9. Arteriogram of a traumatic aneurysm in a 12-year-old girl involved in a car accident.
hypertension and cause pressure on the larynx or esophagus. A strong familial incidence has been recorded. They are usually treated by tedious and meticulous ligation of the numerous feeding arteries and excision from the carotid arteries. The biggest hazard of this surgery is uncontrollable hemorrhage, which could necessitate ligation of the carotids with the probability of hemiplegia. This fearful combination of accidents carried a mortality of about 30%. In addition, there was the risk of damage to surrounding structure, particularly the cranial nerves. The patient whose arteriograms are illustrated in Figure 11 was referred to us after an attempt to excise his tumor in another hospital. However the procedure had to be abandoned because of massive hemorrhage after tranfusing about 7 units of blood. In view of the patient’s symptoms he was reexplored by us, and attempts to dissect the tumor from the carotid arteries proved to very time-consuming because of the dense adhesions and the almost uncontrollable bleeding. Hence we had either to abandon the operation once again and declare this tumor inoperable, or use a technique which later became our standard procedure for resection of all carotid body tumors, and which is described below. Once again a shunt was used between the common carotid artery and the distal internal carotid artery, and the tumor was excised, this time
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
510
FIG. 10.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
511
FIG. 11. Arteriograms of the carotid body tumor. Notice the bifurcation and the network of blood vessels feeding the tumor.
widening
of the carotid
with the internal carotid artery. A saphenous vein graft was anastomosed first distally and then proximally to the stump of the internal carotid artery, while the shunt carried the circulation to the brain. This procedure cuts down the hemorrhage, operative time, and operative risk tremendously. The tumor and operative technique are illustrated in Figures 12 and 13.
together
SUMMARY
-I-
We have discussed five lesions that are encbunted less commonly than the usual occlusive carotid lesion that occurs at the carotid bifurcation,
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
512
F~c. 12.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
513
Fm. 13. The end result of vein graft.
resuming continuity
of the internal carotid artery
by
a
long saphenous
ulcerative plaques, tortuous carotids, carotid and carotid aneurysms, body tumors. Illustrative cases of these lesions were presented. The diagnostic difficulties related to some of them and the technical aspects of their surgical management were discussed. New techniques for resecting internal carotid aneurysms and carotid body tumors by using autogenous saphenous vein grafts and a shunt were described and illustrated.
namely, high lesions,
Joshua D. Salvador, M.D., F.A.C.A. Bellwood Clinic 4420 St. Charles Road Bellwood, Illinois 60104 BIBLIOGRAPHY 1. Blaisdell, W. F.: Personal communication. 2. Weibel, W. F., Jr.: Occlusive disease of the extracranial arteries, Atlas of Arteriography in Occlusive Cerebrovascular Disease. Philadelphia, Saunders, 1969. 3. Feldtman, R. W., Mozersky, D. J., Hagood, C.O.: Surgical correction of a kinked carotid artery in an asymptomatic child. Vasc. Surg., 9: 73, 1975. 4. Najafi, H., Dye, N.S., Hunter, J. A., et al.: The kinked internal carotid artery: Clinical evaluation and surgical correction. Arch. Surg., 89: 134-143, 1964. 5. Moore, W.: Personal communication. 6. Hershey, F. G., Colmon, C. H.: Cerebral arterial insufficiency, Arterial Surgery. St. Louis, Mosby, 1973.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
514 7. Eastcott, H. H.: Carotid body tumors and carotid vertebral insufficiency, Arterial Surgery. Second edition. Philadelphia, Lippincott, 1973. 8. Hershey, F. B.: Operations for aneurysm of the internal carotid artery high in the neck. Angiology, 25: 24-30, 1974. 9. Bladin, P. F.: Dissecting aneurysm of carotid and vertebral arteries: A study of four cases. Vasc. Surg., 8: 203, 1974. 10. Sohia, Y., Katsumoto, E., Iamamura, H., et al.: An axillary-carotid shunt for excision and replacement of aneurysm of the carotid artery. J. Cardiovasc. Surg., 15: 595, 1974.
Downloaded from ang.sagepub.com at University of Sussex Library on August 20, 2015
