Letter to the Editor
Eversion endarterectomy and re-implantation in carotid stenosis and distal kink
Endarterectomía por eversión y reimplante en una estenosis carotídea y un bucle distal
B. López de La Franca Beltrán
, P. Pérez Ramírez, C. Esteban Gracia, S. Llagostera Pujol
Corresponding author
Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
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López de La Franca Beltrán, P. Pérez Ramírez, C. Esteban Gracia, S. Llagostera Pujol" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "López de La Franca Beltrán" "email" => array:1 [ 0 => "lopezdelafrancabeltran@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Pérez Ramírez" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Esteban Gracia" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Llagostera Pujol" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Endarterectomía por eversión y reimplante en una estenosis carotídea y un bucle distal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1164 "Ancho" => 950 "Tamanyo" => 113561 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cranial CT scan showing necrotic lesion on the right superior parietal area.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Kinking and coiling of the arteries are rare morphological alterations of the internal carotid artery (ICA) described as the most frequent sole cause of cerebrovascular insufficiency (CI), or as a combined cause together with carotid atherosclerosis. Although incidence of kinking and coiling of the ICA has been estimated to range from 10% to 16% in the general population, only 4% to 16% of these features cause symptomatic CI.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> Their natural course seems to be benign, and these alterations are asymptomatic in most cases. Morphological diagnosis is easy to determine with the help of current imaging techniques, but it is essential to determine, by means of a neurological examination and transcranial Doppler ultrasound, whether the anomaly is causing cerebral ischaemia.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This letter presents the case of a patient with carotid stenosis and distal kink.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient is an 80-year-old man, a former smoker of one packet a day during 60 years with a medical history of arterial hypertension treated with 2 antihypertensive drugs (losartan and hydrochlorothiazide); he was also fitted with a cochlear implant. The patient visited the emergency department due to an episode of left-sided hemiparesia, plegic left arm, dysarthria, and amaurosis fugax of the right eye; symptoms had been present for several hours without remitting fully. Physical examination revealed left supranuclear facial paresis, distal brachial paresis with a tendency to pronation of the left forearm, and crural paresis with slow claudication after 10<span class="elsevierStyleHsp" style=""></span>seconds. Right flexor plantar reflex was observed.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A Doppler ultrasound of the supra-aortic trunks revealed a heterogeneous and irregular plaque in the right carotid bifurcation, preocclusive stenosis (70%-99%) of the right internal carotid (RIC), and homogeneous plaque with moderate stenosis in the left internal carotid (LIC). Transcranial Doppler ultrasound showed the right middle cerebral artery (MCA) to be less curved than the left one. Head CT showed necrosis on the right superior parietal postrolandic area, and signs of diffuse brain atrophy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A subsequent computed axial tomography angiography of the brain and neck revealed a fibrolipid atheromatous plaque on the proximal third of the RIC causing critical stenosis (90% approximately) and coiling of the distal third of the RIC. Intracranial images showed a total occlusion of the M3 segment of the MCA. The LIC showed an atheromatous plaque causing moderate stenosis (50%-70%).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient started treatment with antiplatelet drugs (ASA 300<span class="elsevierStyleHsp" style=""></span>mg) and statins (atorvastatin 80<span class="elsevierStyleHsp" style=""></span>mg). Twenty-four hours after the patient was admitted, his motor symptoms on the left side improved with only the tendency towards left forearm pronation persisting. Six days later, after the presurgical evaluation and brain reserve test had been carried out, the surgery was performed with the patient under general anaesthesia (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Surgery involved complete resection of the right ICA, eversion endarterectomy (TEA) and reimplantation of the ICA (by lateroterminal anastomosis) on the common carotid to remove the kink. The post-operative period was uneventful, with no neurological focal signs or other complications.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Since that period, and also during long-term follow-up, the patient has remained asymptomatic and no new symptoms have been detected. Yearly follow-up Doppler ultrasounds of the supra-aortic trunks show adequate permeability of the right ICA and stable stenosis of the LIC.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Some of these malformations can be due to an insufficiently descended heart or a persistent embryonic configuration.</p><p id="par0040" class="elsevierStylePara elsevierViewall">However, embryological development is not the only aetiology, since the appearance of kinking has also been related to abnormalities on vascular walls that are secondary to atherosclerotic changes or modifications to the internal elastic lamina. Coiling clearly seems to be congenital, while kinking is secondary to atherosclerotic disease or abnormalities on vascular walls that may in turn be affected or exacerbated by haemodynamic changes.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Clinical manifestations are more frequently associated with carotid artery kinking than coiling, and they are more frequent when atherosclerosis is also present. It remains uncertain whether elongation due to a congenital malformation is the primary condition, and if turbulences then cause formation of atherosclerotic plaque; or if atherosclerosis and other problems such as hypertension primarily weaken vascular walls, thereby leading to a secondary kinking of the carotid.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Considering that numerous carotid kinks and coils are asymptomatic, merely describing the lesion is not sufficient. Instead, we should determine whether the lesion causes vessel stenosis, the degree of stenosis, and if it causes CI.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In addition to the neurological examination, studies used to assess whether a kink or coil is causing CI include oculoplethysmography, transcranial Doppler ultrasound, cerebral parenchyma studies based on CT or MRI scans, colour Doppler ultrasound, arteriography, computed axial tomography angiography, and magnetic resonance angiography.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In adult patients with cerebrovascular ischaemic symptoms, kinks of the internal carotid are frequently associated with atheromatosis of the carotid bifurcation. When these two lesions coexist in symptomatic patients, surgical treatment is indicated. This procedure involves endarterectomy of the atheromatous plaque and correction of the kinks.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The main indication for surgical treatment to repair kinks and coils of the ICA, with no coexistence of atherosclerotic lesions, is presence of neurological symptoms. However, establishing the relationship between the carotid tortuosity and the patient's symptoms is difficult in these cases.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Another important step is ruling out other diseases that are able to provoke neurological deficit.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Surgery is contraindicated in cases of neurological instability, cerebral infarct with severe sequelae, severe intracerebral atheromatosis, and post-stroke cerebral oedema visible on a CT or MRI scan.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The aim of surgical treatment for kinks and coils is to prevent carotid thrombosis and cerebrovascular infarct, as well as to maintain cerebral perfusion. Therefore, treatment should offer a better outcome than the natural progression of the disease.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López de La Franca Beltrán B, Pérez Ramírez P, Esteban Gracia C, Llagostera Pujol S. Endarterectomía por eversión y reimplante en una estenosis carotídea y un bucle distal. Neurología. 2015;30:524–525.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1164 "Ancho" => 950 "Tamanyo" => 113561 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cranial CT scan showing necrotic lesion on the right superior parietal area.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 832 "Ancho" => 950 "Tamanyo" => 180079 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Coil in the right internal carotid.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Kinking and coiling of internal carotid artery with and without associated stenosis. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 9 | 11 | 20 |
| 2024 September | 24 | 16 | 40 |
| 2024 August | 24 | 14 | 38 |
| 2024 July | 25 | 8 | 33 |
| 2024 June | 21 | 10 | 31 |
| 2024 May | 24 | 3 | 27 |
| 2024 April | 22 | 35 | 57 |
| 2024 March | 31 | 2 | 33 |
| 2024 February | 11 | 3 | 14 |
| 2024 January | 34 | 4 | 38 |
| 2023 December | 20 | 10 | 30 |
| 2023 November | 42 | 10 | 52 |
| 2023 October | 35 | 18 | 53 |
| 2023 September | 17 | 4 | 21 |
| 2023 August | 16 | 7 | 23 |
| 2023 July | 26 | 10 | 36 |
| 2023 June | 35 | 9 | 44 |
| 2023 May | 48 | 3 | 51 |
| 2023 April | 49 | 5 | 54 |
| 2023 March | 31 | 4 | 35 |
| 2023 February | 28 | 12 | 40 |
| 2023 January | 14 | 9 | 23 |
| 2022 December | 23 | 3 | 26 |
| 2022 November | 20 | 8 | 28 |
| 2022 October | 18 | 12 | 30 |
| 2022 September | 33 | 25 | 58 |
| 2022 August | 33 | 14 | 47 |
| 2022 July | 16 | 13 | 29 |
| 2022 June | 17 | 8 | 25 |
| 2022 May | 19 | 10 | 29 |
| 2022 April | 25 | 8 | 33 |
| 2022 March | 15 | 6 | 21 |
| 2022 February | 12 | 7 | 19 |
| 2022 January | 12 | 7 | 19 |
| 2021 December | 14 | 9 | 23 |
| 2021 November | 14 | 11 | 25 |
| 2021 October | 28 | 11 | 39 |
| 2021 September | 31 | 10 | 41 |
| 2021 August | 24 | 9 | 33 |
| 2021 July | 11 | 7 | 18 |
| 2021 June | 31 | 6 | 37 |
| 2021 May | 23 | 8 | 31 |
| 2021 April | 31 | 14 | 45 |
| 2021 March | 30 | 10 | 40 |
| 2021 February | 36 | 8 | 44 |
| 2021 January | 15 | 17 | 32 |
| 2020 December | 25 | 13 | 38 |
| 2020 November | 14 | 19 | 33 |
| 2020 October | 14 | 7 | 21 |
| 2020 September | 14 | 15 | 29 |
| 2020 August | 24 | 8 | 32 |
| 2020 July | 9 | 9 | 18 |
| 2020 June | 12 | 11 | 23 |
| 2020 May | 16 | 8 | 24 |
| 2020 April | 19 | 7 | 26 |
| 2020 March | 20 | 8 | 28 |
| 2020 February | 26 | 6 | 32 |
| 2020 January | 25 | 15 | 40 |
| 2019 December | 23 | 5 | 28 |
| 2019 November | 19 | 10 | 29 |
| 2019 October | 16 | 5 | 21 |
| 2019 September | 20 | 9 | 29 |
| 2019 August | 14 | 4 | 18 |
| 2019 July | 27 | 13 | 40 |
| 2019 June | 46 | 38 | 84 |
| 2019 May | 124 | 74 | 198 |
| 2019 April | 66 | 49 | 115 |
| 2019 March | 17 | 7 | 24 |
| 2019 February | 8 | 14 | 22 |
| 2019 January | 16 | 9 | 25 |
| 2018 December | 16 | 14 | 30 |
| 2018 November | 16 | 6 | 22 |
| 2018 October | 18 | 15 | 33 |
| 2018 September | 9 | 1 | 10 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 8 | 2 | 10 |
| 2018 June | 5 | 2 | 7 |
| 2018 May | 6 | 4 | 10 |
| 2018 April | 11 | 1 | 12 |
| 2018 March | 11 | 3 | 14 |
| 2018 February | 5 | 1 | 6 |
| 2018 January | 2 | 0 | 2 |
| 2017 December | 16 | 1 | 17 |
| 2017 November | 10 | 3 | 13 |
| 2017 October | 12 | 2 | 14 |
| 2017 September | 12 | 5 | 17 |
| 2017 August | 16 | 2 | 18 |
| 2017 July | 10 | 2 | 12 |
| 2017 June | 22 | 3 | 25 |
| 2017 May | 21 | 9 | 30 |
| 2017 April | 13 | 4 | 17 |
| 2017 March | 13 | 30 | 43 |
| 2017 February | 23 | 6 | 29 |
| 2017 January | 12 | 5 | 17 |
| 2016 December | 16 | 10 | 26 |
| 2016 November | 21 | 9 | 30 |
| 2016 October | 29 | 5 | 34 |
| 2016 September | 27 | 5 | 32 |
| 2016 August | 39 | 4 | 43 |
| 2016 July | 16 | 1 | 17 |
| 2016 June | 28 | 16 | 44 |
| 2016 May | 24 | 20 | 44 |
| 2016 April | 39 | 17 | 56 |
| 2016 March | 41 | 28 | 69 |
| 2016 February | 50 | 22 | 72 |
| 2016 January | 41 | 13 | 54 |
| 2015 December | 43 | 17 | 60 |
| 2015 November | 39 | 19 | 58 |
| 2015 October | 67 | 31 | 98 |
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