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Simple classification of carotid bifurcation: is it possible to predict twisted carotid artery during carotid endarterectomy?

  • Original Article - Vascular
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Abstract

Background

The internal carotid artery (ICA) usually runs posterolaterally to the external carotid artery (ECA), but occasionally we encounter the twisted carotid bifurcation, a variant in which the ICA courses medially to the ECA during carotid endarterectomy (CEA). Prediction of this anomaly in the preoperative evaluation is mandatory, although descriptions in the literature are limited. We reviewed the clinical features of patients who underwent CEA and analyzed preoperative cerebral angiography, especially the anteroposterior (AP) view to determine whether it could be a predictive modality.

Methods

In 58 consecutive CEA cases, we simply classified them into three groups; type 1 (the ICA runs laterally and the ECA runs medially), type 2 (the ICA and ECA run to overlap each other), and type 3 (the ICA runs medially and the ECA runs laterally), based on the findings of AP view of cerebral angiography. We compared the clinical features and intraoperative findings of these groups.

Results

Of 58 cases, types 1–3 were 24, 30, and four cases, respectively. Twisted carotid bifurcations were recognized in seven cases (12.4 %), including three cases in type 2 and four in type 3, and all twisted cases were found on the right side. Twisted carotids and right-sided lesion were significantly frequent in type 3, but no statistical differences of coexisting diseases were recognized among the three groups. CEAs of twisted carotid bifurcations were performed successfully with correction of the carotid position in three and as it was in four cases.

Conclusions

Twisted carotid bifurcations were observed during operation in 10 % in type 2 and 100 % in type 3. CEA of twisted carotid bifurcations can be performed safely with or without correction of the carotid position. AP view of cerebral angiography could be useful for preoperative evaluation.

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Authors and Affiliations

  1. Department of Neurosurgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan

    Tomoya Kamide & Mitsutoshi Nakada

  2. Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, 247-8581, Japan

    Tomoya Kamide, Motohiro Nomura, Akira Tamase, Kentaro Mori, Shunsuke Seki & Yoshihisa Kitamura

  3. Department of Neurosurgery, Kanto Rosai Hospital, Kawasaki, 211-8510, Japan

    Motohiro Nomura

Authors
  1. Tomoya Kamide
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  2. Motohiro Nomura
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  3. Akira Tamase
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  4. Kentaro Mori
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  5. Shunsuke Seki
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  6. Yoshihisa Kitamura
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  7. Mitsutoshi Nakada
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Corresponding author

Correspondence to Tomoya Kamide.

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Funding

No funding was received for this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Comments

It is critically important to understand the relationship between the ICA and ECA when planning a successful carotid reconstruction. As I have pointed out previously, if the twisted carotid variant is not discerned preoperatively, an inexperienced surgeon might mistake the ECA for the ICA in the dissection, and work medial to it, damaging the recurrent laryngeal nerve and other medial structures that are usually left untouched.

Fortunately, once one understands the anatomy, a twisted carotid is easily recognized on the AP and lateral angiograms, and it can also be easily discerned from the reconstructed CTA images. There should be no doubt and no ambiguity about the ECA/ICA relationship if the surgeon studies the films carefully. The radiography and anatomy are well illustrated in Figure 2-3 and 3-26 of reference 1 (1).

These authors deal with twisted anatomy either by restoring it to normal (as I always do) or by in some cases operating up the medial rather than the lateral side of the carotid tree. I have never done this, for two reasons. First, it would leave the completed suture line repair on the back side, away from me and out of view, making hemostasis potentially more difficult. Second, if the anatomy is not corrected in the dissection (by pulling the ICA back out into a normal position), the ECA and ICA remain “twisted” distally, potentially limiting the surgeon’s ability to secure a high distal ICA exposure.

This anomaly has been described by myself, as mentioned, and by Katano and Yamada in Nagoya, and now elegantly and eloquently by these authors. This is an important contribution, and all carotid surgeons should understand this anomaly and how it should be dealt with at surgery.

Christopher Loftus

Illinois, USA

1. Loftus CM: Carotid Artery Surgery: Principles and Technique. 2nd edition. New York, Informa Publishing 2006.

A concise paper addressing a useful method to preoperatively identify the position of the ICA during endarterectomy. I believe it is a useful addition to the knowledge base of surgeons who perform this surgery.

F. Charbel

Illinois, USA

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Kamide, T., Nomura, M., Tamase, A. et al. Simple classification of carotid bifurcation: is it possible to predict twisted carotid artery during carotid endarterectomy?. Acta Neurochir 158, 2393–2397 (2016). https://doi.org/10.1007/s00701-016-2948-4

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  • DOI: https://doi.org/10.1007/s00701-016-2948-4

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