Rationale of the surgical treatment of carotid kinking

Elongation and tortuosity of the internal carotid artery (ICAET) is a common angiographic, angioMR or Duplex scanning finding: it can be "pure" and, in a great majority of cases, it is not correlated to neurological symptoms. It can be associated with atherosclerotic bifurcation plaque, therefore in this case, indications to surgery follow that of carotid stenosis. On the other hand in some patients ICAET seems potentially correlated to hemispheric or non hemispheric symptoms: ICAET may show as kinking with a wide or narrow acute angle, single (< shaped) or double (Z shaped), or less frequently as a coiling (S,U, or C shaped). Surgical indications are controversial. In the author's opinion, surgery may represent the safest tool in the prevention of a stroke due to carotid occlusion, in selected patients. The aim of this study is to describe the author's experience in the surgical treatment of carotid kinking not associated with significant atherosclerotic lesions.

From March 1994 to March 2001, 29 patients (11 male, 18 female) with a pure ICAET underwent surgery. Patients presented hemispheric symptoms (24.13%), non hemispheric symptoms (41.3%) or both (27.5 %). Two asymptomatic patients (6.9%) underwent surgery because of contralateral carotid occlusion.

The postoperative (within 30 days from operation) results, no mortality was observed, 1 patient presented a stroke (3.4%), and 1 patient had a TIA at awakening (negative cerebral CT scan). All patients with hemispheric symptoms (15 patients) had complete remission, whereas only 6 out of 12 patients (50%) presenting non-hemispheric symptoms had remission (1 patient underwent a controlateral ICAET correction).

The natural history of symptomatic and asymptomatic ICAET is practically unknown, but in some cases selected indication to surgery is justified. Surgery was indicated for patients with transient ischaemic attacks ( hemispheric symptoms); in asymptomatic patients presenting a kinking with an angle inferior to 30 degrees, and a contralateral carotid artery occlusion; in patients with non hemispheric symptoms, after a screening to exclude all other possible neurological or non-neurological causes with duplex scan positive for significant increase of flow velocity in ICA and positive cerebral CT scan or MR scan for ischaemic lesions in the homolateral hemisphere, and/or a flow inversion in anterior cerebral artery or flow reduction in the middle cerebral artery, according to different head positions (rotation and flex-extension).