Minimally invasive surgical treatment of a patient with pathological tortuosity of the carotid artery using endoscopic assistance

The study objective is to describe a clinical case of surgical treatment of a patient with pathological distal tortuosity of the left internal carotid artery (ICA) and present a comprehensive description of a proposed surgical technique, as well as compare advantages and disadvantages of the chosen and alternative surgery types.

Materials and methods. At the 1st stage, we performed computed angiography and triplex scanning of the main head arteries and modelled operative approach. At the 2nd stage, we mapped the ICA approach, redressing and resection. At the 3rd stage, using endoscopic assistance we separated the ICA along its entire length, found its pathological kink, performed ICA redressing and resection with subsequent reanastomosis with high accuracy and minimal injury.

Results. ICA blood flow was 320 ml/min (prior to surgery: 140 ml/min). In the postoperative period, positive dynamics of the patient’s neurological status were observed. Computed angiography and triplex scanning confirmed removal of pathological tortuosity. Compared to the proposed technique, other surgery types (open access) are characterized by high risk of injury of the cranial nerve branches, submandibular and parotid glands, necessity of dissection of the digastric, stylohyoid muscles, subluxation of the mandibula, etc.

Conclusion. The method of allocation of hard to reach tortuosities of the carotid artery developed based on previously known endoscopic manipulations on the vessels of the extremities using endoscopic assistance allows to decrease injury during the intervention and achieve maximal technical and clinical effect.

1. Ballotta E., Da Giau G., Baracchini C., Manara R. Carotid eversion endarterectomy: perioperative outcome and restenosis incidence. Ann Vasc Surg 2002;16(4):422–9. DOI: 10.1007/s10016-001-0114-8. PMID: 12244433.

2. Markovic D.M., Davidovic L.B., Cvetkovic D.D. et al. Single-center prospective, randomized analysis of conventional and eversion carotid endarterectomy. J Cardiovasc Surg (Torino) 2008;49(5):619–25. PMID: 18670379.

3. Partsakhashvili J., Rtveliashvili N., Philishvili O. et al. Correlating the length of internal carotid artery stenosis to the technique of endarterectomy and anesthesia used. Georgian Med News 2014;(234):7–11. PMID: 25341231.

4. Clinical angiology: a guide. Ed. by A.V. Pokrovsky. In 2 vol. Moscow: Meditsina, 2004. 808 p. (In Russ.).

5. Knight F.W., Yeager R.M., Morris D.M. Cranial nerve injuries during carotid endoarterectomy. Am J Surg 1987;154(5)529–32. PMID: 3674303.

6. DePalma R.G. Optimal exposure of the internal carotid artery for endarterectomy. Surg Gynecol Obstet 1977;144(2):249–50. PMID: 835067.

7. Barkauskas E.M., Paulukas E.M. Some aspects of the methods and techniques of operations on brachiocephalic arteries. In: Topical issues of prevention and surgical treatment of vascular diseases: abstracts. Moscow, 1985. Pp. 7–8. (In Russ.).

8. Shaha A., Phillips T., Scolea T. et al. Exposure of the internal carotid artery near the skull base: the posterolateral anatomic approach. J Vasc Surg 1988;8(5):618–22. PMID: 3184316.

9. Pearce W.H., Whitehill T.A. Carotid and vertebral arterial injuries. Surg Clin North Am 1988;68(4):705–23. PMID: 3046001.

10. Greenstein A.J., Chassin M.R., Wang J. et al. Association between minor and major surgical complications after carotid endarterectomy: results of the New York Carotid Artery Surgery study. J Vasc Surg 2007;46(6):1138–46. DOI: 10.1016/j.jvs.2007.08.026. PMID: 18154989.

11. Hye R.J., MD, Mackey A., Hill M.D. et al. Incidence, outcomes and effect on quality of life of cranial nerve injury(CNI) in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). J Vasc Surg 2015;61(5):1208–14. DOI: 10.1016/j.jvs.2014.12.039. PMID: 25770984.

12. Schauber M.D., Fontanelle L.J., Solomon J.W., Hanson T.L. Cranial/ cervical nerve dysfunction after carotid endoarterectomy. J Vasc Surg 1997;25(3):481–7. PMID: 9081129.

13. Pokrovsky A.V., Beloyartsev D.F., Kolosov R.V. What influences the standards of “quality” of carotid endarterectomy? Angiologiya i sosudistaya khirurgiya = Angiology and Vascular Surgery 2003;9(3):80–7. (In Russ.).

14. Khorev N.G., Beller A.V., Shoykhet I.N., Kulikov V.P. Surgical treatment of pathological tortuosity of the internal carotid artery in children. Barnaul: Azbuka, 2004. 147 p. (In Russ.).

15. Shoykhet Ya.N., Khorev N.G., Kulikov V.P. Pathological tortuosity of the internal carotid artery and its surgical treatment. Problemy klinicheskoy meditsiny = Problems of Clinical Medicine 2005;(1):80–90. (In Russ.).

16. Dalibaldyan V.A., Luk’yanchikov V. A., Shalumov A.Z. et al. The temporary mandible subluxation during surgical treatment of high-level atherosclerotic damages of extracranial part of internal carotid artery. Neyrokhirurgiya = Russian Journal of Neurosurgery 2016;(1):60–7. (In Russ.).

17. Carranza C.L., Ballegaard M., Werner M.U. et al. Endoscopic versus open radial artery harvest and mammario-radial versus aortoradial grafting in patients undergoing coronary artery bypass surgery: protocol for the 2 × 2 factorial designed randomised NEO trial. Trials 2014;15:135. DOI: 10.1186/1745-6215-15-135. PMID: 24754891.