In a groundbreaking surgical intervention, a team of neurosurgeons at Sasebo City General Hospital accomplished a rare feat by carrying out an effective Carotid Endarterectomy (CEA) on a 75-year-old female patient with a complicated case of Internal Carotid Artery (ICA) stenosis. This intricate procedure, required to resolve a condition associated with a twisted ICA, is reported in depth in the April 2019 issue of “No Shinkei Geka. Neurological surgery” (Japanese Journal of Neurosurgery). The patient’s condition was marked by the abnormal medial positioning of the ICA relative to the external carotid artery (ECA), leading to significant health risks including cerebral infarction.
The patient was admitted to the hospital presenting with left-sided hemiparesis—a partial weakness affecting one side of the body. An MRI diffusion-weighted imaging scan revealed the occurrence of right frontal lobe infarction caused by severe stenosis at the origin of the right ICA—the blood vessel responsible for supplying oxygenated blood to the brain. In this particular case, the twisted anatomy of the patient’s ICA, where it was positioned inside in relation to the ECA, posed an additional challenge to the surgical team.
The surgical team, led by Dr. Hayashi Kentaro and including neurosurgeons Matsunaga Yuki, Hayashi Yukishige, Shirakawa Kiyoshi, and Iwanaga Mitsuto, described the meticulous planning and execution of the CEA. They emphasized the importance of accurately identifying the ICA before and during the operation to avoid damaging adjacent structures and to ensure the complete removal of the plaque causing the stenosis.
The operation involved general anesthesia followed by a detailed exposure of the bifurcation of the right common carotid artery. The twisted positioning of the ICA was fully evaluated with the superior thyroid artery, a branch of the ECA, coursing in front of the ICA. After making an arteriotomy, or incision into the artery, internal shunting was performed to maintain the blood flow to the brain throughout the procedure. Subsequently, the plaque was carefully removed in one piece, and the arteriotomy was sutured closed.
The report hailed the operation as a success, with the patient experiencing an uneventful postoperative course and imaging studies confirming the resolution of the stenosis. Such outcomes underscore the vital nature of precise imaging and surgical planning in cases of twisted ICA anatomy. The report suggests that congenital or acquired factors can lead to twisted ICAs and recommends thorough preparation and the implementation of specific surgical techniques to mitigate risks.
The key to achieving a favorable result in this challenging scenario was a combination of factors, from adept diagnosis and careful surgical planning to precision in execution and vigilant postoperative care. The publication of this case not only illuminates the complexities surrounding CEA in atypical presentations of carotid artery pathologies but also serves as a beacon guiding future surgeries of a similar nature.
Keywords
1. Carotid Endarterectomy Success
2. Twisted Internal Carotid Artery
3. ICA Stenosis Treatment
4. Complex Carotid Surgery
5. Cerebral Infarction Intervention
References
1. Hayashi, K., Matsunaga, Y., Hayashi, Y., Shirakawa, K., & Iwanaga, M. (2019). A Case of Carotid Endarterectomy for the Internal Carotid Artery Stenosis Associated with Twisted Internal Carotid Artery. No Shinkei Geka. Neurological Surgery, 47(4), 455-460. DOI: 10.11477/mf.1436203962
2. Barnett, H. J., Taylor, D. W., Haynes, R. B., Sackett, D. L., Peerless, S. J., Ferguson, G. G., Fox, A. J., Rankin, R. N., Clagett, G. P., Hachinski, V. C., Wiebers, D. O., and Eliasziw, M. (1998). Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. The New England Journal of Medicine, 339(7), 1415-1425. DOI: 10.1056/NEJM199809033391007
3. AbuRahma, A. F., & Srivastava, M. (2019). Advances in Carotid Stenosis Management. In R. W. Hobson II, F. A. Veith, & M. L. Marin (Eds.), Vascular Surgery: A Comprehensive Review (pp. 254-271). Elsevier.
4. Liapis, C. D., Bell, P. R. F., Mikhailidis, D., Sivenius, J., Nicolaides, A., Fernandes e Fernandes, J., Biasi, G., & Norgren, L. (2009). ESVS Guidelines: Invasive Treatment for Carotid Stenosis: Indications, Techniques. European Journal of Vascular and Endovascular Surgery, 37(4 SUPPL.), 1-19. DOI: 10.1016/j.ejvs.2009.01.006
5. Carnes, A. W., & de Tribolet, N. (1999). Manual of Cerebrovascular Surgery. Vol. 1, Endarterectomy and Extracranial-Intracranial Bypass, Techniques and Results. Journal of Neurology, Neurosurgery, and Psychiatry, 67(3), 413. DOI: 10.1136/jnnp.67.3.413
The publication of this case report not only advances the medical community’s understanding of twisted ICA and its implications but also reassures patients suffering from complex carotid artery pathologies that there are viable solutions available. Through continued research, experience-sharing, and advancements in surgical techniques, the management of carotid artery diseases will continue to improve, offering hope and better outcomes for those affected.