Related Experiment Videos
Surgical treatment of 50 carotid dissections: indications and results
1Department of Vascular Surgery and Kidney Transplantation, the Institut of Pathology, Heinrich-Heine-University, Düsseldorf, Germany.
Insights
Surgical reconstruction effectively treats chronic carotid dissection, preventing complications like stroke when anticoagulation fails or aneurysms/stenosis persist. This approach offers a viable solution for complex cases.
Area of Science:
- Vascular Surgery
- Neurology
- Cardiovascular Medicine
Background:
- Carotid dissection can lead to serious cerebrovascular events.
- Chronic dissections pose unique management challenges.
- Surgical intervention is considered for persistent high-grade stenosis or aneurysms.
Purpose of the Study:
- To analyze the outcomes of surgical treatment for chronic carotid dissections.
- To evaluate the effectiveness of surgical reconstruction in preventing ischemic complications.
- To assess the course of patients with both chronic and acute carotid dissections.
Main Methods:
- Retrospective review of medical records and imaging studies for 49 patients.
- Histologic specimen reevaluation to determine dissection causes.
- Long-term follow-up (70 months) including Doppler ultrasound and patient questionnaires.
Main Results:
- Spontaneous dissection occurred in 70% of cases; fibromuscular dysplasia was noted in 12%.
- Surgical reconstruction achieved flow restoration in 80% of cases via vein graft.
- Complications included transient cranial nerve damage (58%) and recurrent minor strokes (10%).
Conclusions:
- Surgical reconstruction is an effective treatment for chronic carotid dissection.
- Intervention is indicated when anticoagulation fails or high-grade stenosis/aneurysms persist.
- Surgery helps prevent further thromboembolic complications in selected patients.
Purpose:
This article analyzes the course of 48 patients with 49 chronic carotid dissections (who were treated surgically at our institution after a median anticoagulation period of 9 months because of a persistent high-grade stenosis or an aneurysm) and the course of one additional patient with acute carotid dissection (who underwent early operative reconstruction 12 hours after onset because of fluctuating neurologic symptoms).
Methods:
All medical and surgical records and imaging studies were reviewed retrospectively. All histologic specimens were reevaluated by a single pathologist to assess the cause of dissection. Follow-up of 41 patients (85%) after 70 months (range, 1-190 months) consisted of an examination of the extracranial vessels in the neck by Doppler ultrasound scanning and a questionnaire about the patients' medical history and their personal appraisals of cranial nerve function.
Results:
Seventy percent of the dissections had developed spontaneously; 18% were caused by trauma; 12% of all patients (22% of the women) had a fibromuscular dysplasia. Indication for surgery was a high-grade persisting stenosis and a persisting or newly developed aneurysm. Flow restoration was achieved by resection and vein graft replacement in 40 cases (80%) and thromboendarterectomy and patch angioplasty in three cases (6%). Gradual dilatation was performed and effective in two cases (4%). Five internal carotid arteries (10%) had to be clipped because dissection extended into the skull base. One patient died of intracranial bleeding. Five patients (10%) experienced the development of a recurrent minor stroke (ipsilateral, 4 patients; contralateral, 1 patient). Cranial nerve damage could not be avoided in 29 cases (58%) but were transient in most of the cases. During follow-up, one patient died of unrelated reasons, and only one patient had experienced the development of a neurologic event of unknown cause.
Conclusion:
Chronic carotid dissection can be effectively treated by surgical reconstruction to prevent further ischemic or thromboembolic complications, if medical treatment for 6 months with anticoagulation failed or if carotid aneurysms and/or high-grade carotid stenosis persisted or have newly developed.