Extracranial Carotid and Vertebral Artery Disease

Contemporary Management

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Sachinder Singh Hans
Editor

Extracranial Carotid and

Vertebral Artery Disease
Contemporary Management
Editor
Sachinder Singh Hans
Wayne State University School of Medicine
Detroit, MI
USA

ISBN 978-3-319-91532-6    ISBN 978-3-319-91533-3 (eBook)

https://doi.org/10.1007/978-3-319-91533-3

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This book is dedicated to the memory of the late Dr. Herbert
J. Robb—a pioneering vascular surgeon who guided me
through my vascular surgery training in the late 1970s, a time
when vascular surgery was just becoming established as an
independent specialty.
Foreword

I thank my colleague Dr. Sachinder Singh Hans for inviting me to write this
foreword. It is a pleasure to welcome a book dealing with the carotid and
vertebral arteries.
In the cerebrovascular field, most of what is published today deals with the
new endovascular techniques. This makes this book timely because it reminds
us of the prominent role that surgery continues to have in the management of
these conditions. The many endovascular procedures being done in the
carotid and vertebral arteries have decreased the training we can offer to the
newer generations of vascular surgeons in the operative techniques described
here. And these are procedures that require refined technique and, indeed,
repetition if they are to be done with the levels of safety that patients deserve.
Another positive effect of this multiauthored text is to reflect the different
criteria and also the conflicting opinions that different specialties have about
how to manage the diseases that affect the supra-aortic trunks, the carotid,
and the vertebral arteries.
One view with which I disagree is the tendency to lump vertebral and
carotid disease in the neurological studies where a comparison is made
between medical and interventional/surgical treatments. My disagreement is
founded on a single fact: these two pathologies are apples and oranges that
should not be combined in clinical studies. Mixing two different pathologies
blurs the validity of any conclusion drawn from the study. The mechanism of
brain damage is different: 75% of hemispheric infarcts are embolic while
only 30% of those in the posterior brain have this mechanism. In terms of
brain infarction, those in the vertebrobasilar territory are three times more
likely to result in death.
In the carotid population the laterality of the lesion is easily inferred by the
side of the brain that has been injured. In vertebral pathology, particularly
when dealing with microembolization, the side originating the embolus can
only be presumed by some appearance of the arterial lesion. Furthermore, it
has been shown that in a large number of normal people one vertebral artery
occluded temporarily with neck rotation, leaving the other vertebral artery as
the only temporary supply to the posterior brain. There are patients in whom
this temporary occlusion of a dominant vertebral with neck rotation/exten-
sion will result in physical impairment and occasionally in severe trauma
(from severe dizziness or syncope); their outcome will not be accounted for
in the usual categories of death and stroke. Symptomatic vertebral occlusion
caused by rotation/extension of the head can only be positively identified

vii
viii Foreword

when, as we elicit the symptom in the angiogram table by rotating/extending

the head, we can see simultaneously the occlusion of the vertebral artery on
the angiography screen. This finding is a common indication for distal verte-
bral reconstruction at the level of C2 or C1. I am aware of how reluctant
angiographers are about this maneuver, but I nevertheless missed an entry for
this dynamic vertebral arteriography in the corresponding chapter.
Neurology, as a medical specialty, inherited an all-consuming interest in
the cerebral hemispheres from the revolutionary work of Hughlings Jackson
at the end of the nineteenth century. As a result, the understanding of disease
of the posterior brain has lagged two decades behind that in the anterior brain.
And in terms of their surgical treatment, the first reconstructions of the verte-
bral (proximal) artery took place in 1979, a quarter of a century after the first
carotid endarterectomy.
I enjoyed the historical summary that precedes most chapters; it enriches
our comprehension and enlightens our appreciation for the many individuals
in various specialties that contributed to what we can offer to our patients.

Ramon Berguer, MD, PhD

Emeritus Professor of Vascular Surgery
University of Michigan
Ann Arbor, MI, USA
Preface

Carotid and vertebral artery disease affects a large segment of population

with the potential of causing severe disability from a major stroke. Although
successful internal carotid surgery dates from 1954, vertebral artery surgery
has lagged behind carotid surgery by almost twenty years and this delay was
due in large part to the difficulty in establishing accurate clinical and radio-
graphic diagnosis of vertebral-basilar insufficiency. In this book emphasis is
placed on the medical, endovascular, and surgical approaches in managing
patients with extracranial carotid and vertebral artery disease following perti-
nent diagnostic studies. Besides surgical anatomy, physiology, and pathology,
strong emphasis was placed on the imaging techniques such as duplex ultra-
sound, computed tomography head, CTA neck and brain, MRI brain, MRA
neck and brain, and diagnostic arteriography. In contrast to similar book pub-
lications on this topic, this book reflects the contributions of many interre-
lated specialties: cerebrovascular physiology, pathology, neuro-radiology,
neuro-interventions, stroke neurology, and, more importantly, vascular sur-
gery whose varying perspectives have significantly enhanced our knowledge
of carotid and vertebral artery disease. It is my sincere hope that the reader
will find the scholarship of their contributions not only informative but of a
great practical value. In addition, multiple-choice questions have been added
at the end of each chapter in order to improve the comprehension of the
material.
Our intent has been to provide a comprehensive text and publish it in a
timely fashion so as to anticipate the rapid pace of progress in this field.

Warren, MI, USA Sachinder Singh Hans

ix
Acknowledgements

The editor wishes to acknowledge the contributions of all the authors who
gave up valuable time from their busy schedules to assist with this endeavor
and their help is highly appreciated. I also wish to acknowledge the unflinch-
ing support of my wife Dr. Bijoya Hans, MD-Interventional Radiologist, in
providing practical and sage advice in challenging times encountered during
publication. Last but not least, my sincere thanks and gratitude to Springer
Publishing, particularly executive editor Richard Hruska, editorial assistant
clinical medicine Lillie Mae Gaurano, and Connie Walsh, developmental edi-
tor, for providing the guidance and professional support in getting this project
completed.

xi
Contents

1 Surgical Anatomy of Carotid and Vertebral Arteries����������������    1

Sachinder Singh Hans
2 Physiology of the Cerebrovascular System����������������������������������    9
Heidi L. Lujan, Robert A. Augustyniak,
and Stephen E. DiCarlo
3 Pathology of the Extracranial Carotid
and Vertebral Arteries ������������������������������������������������������������������   21
Wendy N. Wiesend and Mitual Amin
4 History of Carotid Artery Surgery ����������������������������������������������   45
Praveen C. Balraj, Ziad Al Adas, and Alexander D. Shepard
5 History of Vertebral Artery Surgery��������������������������������������������   63
Sachinder Singh Hans
6 Noninvasive Vascular Lab Testing for Carotids, Vertebrals,
and Transcranial Doppler ������������������������������������������������������������   67
Hosam Farouk El Sayed, Nicolas J. Mouawad, and Bhagwan
Satiani
7 Cerebrovascular Imaging (CT, MRI, CTA, MRA) ��������������������   85
Brent Griffith, Brendan P. Kelley, Suresh C. Patel, and Horia
Marin
8 Carotid and Vertebral Arteriography������������������������������������������ 113
Muneer Eesa
9 Medical Therapy for Carotid and Vertebral
Artery Stenosis ������������������������������������������������������������������������������ 127
Moayd M. Alkhalifah, Paul M. Gadient,
and Seemant Chaturvedi
10 Carotid Endarterectomy �������������������������������������������������������������� 135
Sachinder Singh Hans
11 Carotid Endarterectomy for High Plaque ���������������������������������� 147
Sachinder Singh Hans

xiii
xiv Contents

12 Eversion Carotid Endarterectomy: Indications,

Techniques, Pitfalls, and Complications�������������������������������������� 151
Judith C. Lin
13 Natural History and Contemporary Management
of Recurrent Carotid Stenosis������������������������������������������������������ 159
Jeffrey R. Rubin and Yevgeniy Rits
14 Carotid Interposition Grafting ���������������������������������������������������� 167
Sachinder Singh Hans
15 Current Status of Carotid Endarterectomy
and Carotid Stenting���������������������������������������������������������������������� 171
Richard D. Fessler and Justin G. Thomas
16 Technical Aspects of Carotid Artery Stenting ���������������������������� 187
Robert G. Molnar and Nitin G. Malhotra
17 Reconstruction for Occlusive Lesions of Aortic
Arch Branches�������������������������������������������������������������������������������� 197
Mitchell R. Weaver
18 Vertebral Artery Reconstruction�������������������������������������������������� 215
Mark D. Morasch
19 Fibromuscular Dysplasia, Carotid Kinks,
and Other Rare Lesions���������������������������������������������������������������� 225
Ahmed Kayssi and Dipankar Mukherjee
20 Cervical (Carotid and Vertebral) Artery Dissection������������������ 241
Vishal B. Jani and Richard D. Fessler
21 Carotid Body Tumors�������������������������������������������������������������������� 253
Frank M. Davis, Andrea Obi, and Nicholas Osborne
22 Extracranial Carotid and Vertebral Artery Aneurysms������������ 261
Sachinder Singh Hans
23 Extracranial Cerebrovascular Trauma���������������������������������������� 267
Emily Reardon, J. Devin B. Watson, Melanie Hoehn,
and Rajabrata Sarkar
24 Stroke Rehabilitation�������������������������������������������������������������������� 279
Paola M. P. Seidel and Geoffrey K. Seidel

Index�������������������������������������������������������������������������������������������������������� 293
Contributors

Ziad Al Adas, MD Division of Vascular Surgery, Henry Ford Hospital,

Detroit, MI, USA
Surgery, Wayne State University School of Medicine, Detroit, MI, USA
Moayd M. Alkhalifah, MBBS Vascular Neurology, University of Miami
Miller School of Medicine, Miami, FL, USA
Mitual Amin, MD Department of Anatomic Pathology, Beaumont Health
System, Royal Oak, MI, USA
Robert A. Augustyniak, PhD Biomedical Sciences, Edward Via College of
Osteopathic Medicine–Carolinas Campus, Spartanburg, SC, USA
Praveen C. Balraj, MD Division of Vascular Surgery, Henry Ford Hospital,
Detroit, MI, USA
Surgery, Wayne State University School of Medicine, Detroit, MI, USA
Seemant Chaturvedi, MD, FAHA, FAAN Vice-Chair for VA Programs,
University of Miami Miller School of Medicine, Miami, FL, USA
Frank M. Davis, MD Vascular Surgery, University of Michigan, Ann Arbor,
MI, USA
Stephen E. DiCarlo, PhD Physiology, College of Osteopathic Medicine,
Michigan State University, East Lansing, MI, USA
Muneer Eesa, MBBS, MD Department of Radiology, Foothills Medical
Center, University of Calgary, Calgary, AB, Canada
Richard D. Fessler, MD Department of Surgery, St. John Hospital and
Medical Centers, Detroit, MI, USA
Paul M. Gadient, MD Vascular Neurology, University of Miami Miller
School of Medicine, Miami, FL, USA
Brent Griffith, MD Radiology, Henry Ford Health System, Detroit, MI,
USA
Sachinder Singh Hans, MD Medical Director of Vascular and Endovascular
Services, Henry Ford Macomb Hospital, Clinton Township, MI, USA
Chief of Vascular Surgery, St. John Macomb Hospital, Warren, MI, USA

xv
xvi Contributors

Department of Surgery, Wayne State University School of Medicine, Detroit,

MI, USA
Melanie Hoehn, MD Department of Surgery, Division of Vascular Surgery,
University of Maryland Medical Center, Baltimore, MD, USA
Vishal B. Jani, MD Neurology in Stroke, Department of Neurology,
Creighton University School of Medicine/CHI Health, Omaha, NE, USA
Ahmed Kayssi, MD, MSc, MPH Vascular Surgery, University of Toronto,
Toronto, ON, Canada
Brendan P. Kelley, MD, MSc Radiology, Henry Ford Health System,
Detroit, MI, USA
Judith C. Lin, MD, MBA, FACS Department of Surgery, Division of
Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
Heidi L. Lujan, PhD Physiology, College of Osteopathic Medicine,
Michigan State University, East Lansing, MI, USA
Nitin G. Malhotra, MD Division of Vascular Surgery, Michigan Vascular
Center, McLaren Regional Medical Center, Michigan State University, Flint,
MI, USA
Horia Marin, MD Radiology, Henry Ford Health System, Detroit, MI, USA
Robert G. Molnar, MD, MS Division of Vascular Surgery, Michigan
Vascular Center, McLaren Regional Medical Center, Michigan State
University, Flint, MI, USA
Mark D. Morasch, MD, FACS Division of Vascular and Endovascular
Surgery, Department of Cardiac, Thoracic and Vascular Surgery, Billings
Clinic, Billings, MT, USA
Nicolas J. Mouawad, MD, MPH, MBA, RPVI McLaren Bay Region
Hospital, Bay City, MI, USA
Dipankar Mukherjee, MD, FACS, RPVI Vascular Surgery, Inova Fairfax
Hospital, Falls Church, VA, USA
Andrea Obi, MD Vascular Surgery, University of Michigan, Ann Arbor, MI,
USA
Vascular Surgery, Ann Arbor Veterans Medical Center, Ann Arbor, MI, USA
Nicholas Osborne, MD Vascular Surgery, University of Michigan, Ann
Arbor, MI, USA
Vascular Surgery, Ann Arbor Veterans Medical Center, Ann Arbor, MI, USA
Suresh C. Patel, MD Radiology, Henry Ford Health System, Detroit, MI,
USA
Emily Reardon, MD Department of Surgery, Division of Vascular Surgery,
University of Maryland Medical Center, Baltimore, MD, USA
Contributors xvii

Yevgeniy Rits, MD Vascular Surgery, Detroit Medical Center, Detroit, MI,

USA
Jeffrey R. Rubin, MD Vascular Surgery, Detroit Medical Center, Detroit,
MI, USA
Rajabrata Sarkar, MD, PhD Department of Surgery, Division of Vascular
Surgery, University of Maryland Medical Center, Baltimore, MD, USA
Bhagwan Satiani, MD, MBA, FACS, FACHE, RPVI Department of
Surgery, Division of Vascular Surgery and Diseases, The Ohio State University
College of Medicine, Columbus, OH, USA
Hosam Farouk El Sayed, MD, PhD, FACS, RVT Department of Surgery,
Division of Vascular Surgery and Diseases, The Ohio State University College
of Medicine, Columbus, OH, USA
Paola M. P. Seidel, MD Department of Physical Medicine and Rehabilitation,
Wayne State University, Detroit, MI, USA
Geoffrey K. Seidel, MD Department of Physical Medicine and
Rehabilitation, Wayne State University, Detroit, MI, USA
Michigan State University, Lansing, MI, USA
Alexander D. Shepard, MD Division of Vascular Surgery, Henry Ford
Hospital, Detroit, MI, USA
Surgery, Wayne State University School of Medicine, Detroit, MI, USA
Justin G. Thomas, DO Section of Neurosurgery, Department of Surgery,
Providence-Providence Park Hospital, Southfield, MI, USA
J. Devin B. Watson, MD Department of Surgery, David Grant Medical
Center, Travis AFB, CA, USA
Mitchell R. Weaver, MD Wayne State University College of Medicine,
Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
Wendy N. Wiesend, MD Department of Anatomic Pathology, Beaumont
Health System, Royal Oak, MI, USA
 Surgical Anatomy of Carotid
and Vertebral Arteries 1
Sachinder Singh Hans

The Arch of Aorta Aortic Arch Anomalies

The main arteries of the head and neck supplying Anomalies of aortic arch include aberrant right
the cerebral arterial bed arise from the arch of the subclavian artery (1:200) arising lateral to left
aorta (Fig. 1.1). Three major branches arise from subclavian artery is the most common arch
superior aspect of the arch of the aorta: anomaly. Patients are usually asymptomatic, but
it may result in dysphagia lusoria when aneurys-
1. The brachiocephalic trunk (innominate) mal subclavian artery compresses the esophagus
2. Left common carotid artery posteriorly [3].
3. Left subclavian artery Other anomalies include right aortic arch with
aberrant left subclavian artery, which is its last
branch or double aortic arch.
Anatomical Variations

These three major branches may arise from the

 ommon Carotid and Internal
C
most proximal segment of the arch or distal portion
and External Carotid Arteries
of the ascending aorta, or their commencements
may be quite separate or very close as the left com-
The common carotid arteries (CCA) are variable
mon carotid artery may have a common origin with
in length and their anatomic origin. The right com-
the brachiocephalic trunk (the bovine aortic arch).
mon carotid artery originates at the bifurcation of
This variation can be present in up to 10% of indi-
the brachiocephalic trunk posterior to the right
viduals. There can be a “V-shaped origin” of both
sternoclavicular joint and continues into the neck.
common carotid arties from a single short trunk
The left CCA arises from the highest portion of
before continuing on each side of the neck [1, 2].
the arch of the aorta to the left and posterior to the
brachiocephalic trunk and can be divided into the
S. S. Hans intrathoracic portion and a cervical portion [1].
Medical Director of Vascular and Endovascular
Services, Henry Ford Macomb Hospital, The cervical portion of each common carotid
Clinton Township, MI, USA artery passes obliquely cephalad and slightly lat-
Chief of Vascular Surgery, St. John Macomb erally to the upper border of the thyroid cartilage
Hospital, Warren, MI, USA where it divides into the external and internal
Department of Surgery, Wayne State University carotid arteries. The common carotid arteries
School of Medicine, Detroit, MI, USA with the internal jugular vein and vagus nerve are

© The Editor(s) (if applicable) and The Author(s) 2018 1

S. S. Hans (ed.), Extracranial Carotid and Vertebral Artery Disease,
https://doi.org/10.1007/978-3-319-91533-3_1
2 S. S. Hans

Fig. 1.1 Heart and great Left

vessels with supra-aortic Brachiocephalic Left subclavian
trunks trunk CCA artery

contained in the carotid sheath, the vein cours- joint. It may arise separately from the arch of the
ing lateral to the artery and the vagus nerve lying aorta, or both common carotid arteries could arise
between the artery and the vein (Fig. 1.2). The as a common trunk from the arch of the aorta. It
upper border of the thyroid cartilage (carotid is extremely uncommon for the common carotid
bifurcation) is usually at the level of the fourth artery to ascend into the neck without its division.
cervical vertebral body. The carotid bifurcation is Rarely there is agenesis of the common carotid
variable, and bifurcation can be as low as the level artery on the right side. In persons with agene-
of cervical fifth or even cervical sixth vertebral sis of the right common carotid artery, the right
body (48%) or high at the level of cervical third external carotid artery usually arises proximally
vertebral body (34%). At the point of division of from the brachiocephalic artery, and internal
the common carotid artery, internal carotid artery carotid artery arises distally from the subclavian
(ICA) is slightly dilated into carotid sinus [1, 2]. artery proximal to the origin of the vertebral
The adventitial layer of the internal carotid artery artery. When agenesis of the CCA occurs on the
is thicker in the carotid sinus and contains numer- left side, both the ECA and ICA arise from the
ous sensory fibers arising from glossopharyngeal aortic arch, with ECA arising proximal to the ori-
nerve [1]. These nerve fibers respond to changes gin of ICA [1, 2].
in the arterial blood pressure reflexly. The carotid
body, which lies behind the point of division of
the common carotid artery, is a small brownish The External Carotid Artery
red structure which acts as a chemoreceptor.
In majority of patients (80%), the internal The external carotid artery (ECA) begins oppo-
carotid artery is posterior or posterolateral to the site to the upper border of the thyroid cartilage
external carotid artery. between the third and fourth cervical vertebrae
and continues cephalad and anteriorly behind the
angle of the mandible between the tip of the mas-
Anatomic Variations toid process and the angle of the jaw and divides
into superficial temporal artery and maxillary
In about 10–12% of patients, the right common arteries in the parotid gland. The external carotid
carotid artery arises cephalad to sternoclavicular artery branches in order are superior thyroid
1 Surgical Anatomy of Carotid and Vertebral Arteries 3

XI Nerve ICA

ECA
Vagus (X) nerve
IX Nerve

Stylopharyngeus

Post belly digastric

Occipital artery

XII Nerve

Sternocleidomastoid
branch of occipital artery

Ansa cervicalis

Omo hyoid

Fig. 1.2 Relations between carotid arteries and internal jugular vein and nerves of the neck

(which may arise from distal CCA), ascending tive hypoglossal artery (HA) has been reported in
pharyngeal (which may arise from internal carotid 0.03–0.26% on cerebral arteriography. Persistent
artery), lingual, facial, occipital, posterior auricu- HA arises from the ICA between c1 and c2 verte-
lar, superficial temporal, and maxillary artery [1]. bral levels and traverses through the hypoglossal
canal to join the vertebrobasilar circulation [3].

Anatomic Variations
The Internal Carotid Artery
Occasionally, external carotid artery may be
absent on one or both sides. Carotid basilar anas- The internal carotid artery (ICA) is the primary
tomoses are rare arterial anomalies in which source of oxygenated blood to anterior portion of
embryonic connections between carotid and ver- the brain and the orbits. The ICA is divided into the
tebral arterial system persists (Fig. 1.3) [3]. following seven segments: cervical (c1), petrous
The persistent trigeminal artery is the most (c2), lacerum (c3), cavernous (c4), clinoid (c5),
common and most cephalad-located embryologi- ophthalmic (c6), and communicating (c7). ICA
cal anastomosis between the developing carotid ascends into the skull base and becomes intracra-
artery and vertebrobasilar system to persist into nial through the carotid canal of temporal bone. It
adulthood. Its incidence ranges from 0.1% to 0.6% continues anteriorly through the cavernous sinus
by MRA and DSA imaging. The persistent primi- and divides into anterior and middle cerebral artery.