Surgical approach to kinking and coiling of the internal carotid artery

Whether kinking or coiling of the internal carotid artery (ICA) simply represents a morphological variation without clinical relevance still remains an object of debate. While most patients are incidentally diagnosed in an asymptomatic state due to the broad use of non-invasive investigations (like colour coded Doppler sonography), associated neurological deficits are often unspecific and might be related to coexisting proximal stenotic lesions. Its etiology is unclear. Beside artherosclerotic genesis, a persistent embryological condition or underlying fibromuscular dysplasia is discussed. Moreover, in contrast to precise recommendations concerning the indication for endarteriectomy in carotid artery stenosis, general guidelines for surgical intervention in case of kinking or coiling are not yet established.

The characteristics of 16 patients who underwent a total of 21 reconstructive operations for isolated kinking or coiling of the ICA during 5 years of observation were retrospectively analyzed.

In 10 out of 14 kinkings and 5 out of 7 coilings central nervous symptoms were noted including unspecific vertigo, syncope, tinnitus synchronous to pulse, transient ischemic attacks and manifest cerebral infarction. All these individual complaints disappeared postoperatively. In 1 patient presenting with an ICA coiling histological examination revealed signs of fibromuscular dysplasia. The other specimens showed typical changes of artherosclerotic disease.

By precluding significant proximal stenosis and effective elimination of symptoms after surgical correction, a causal connection between cerebral dysfunction and severe ICA kinking or coiling can be supposed. An actual abnormality of the arterial wall structure only exists in exceptional cases. Rather, a sequential development from kinking to coiling was noticed.