Vaskulárna medicína 2/2019

Kinking of the carotid artery

Objective: General aim of all carotid arteries interventions is prevention of ischaemic attacks originating in carotid bifurcation. Deformations of carotid artery are relatively frequent. Recently there have been published a lot of works dealing with benefits of surgical treatment of the elongation, tortuosity, kinking and coiling of the carotid arteries. But, however, many unclair questions are still persisting (etiopathogenesis, natural history, clinical significance and optimal management). Methods: This paper deals with the contemporary state of knowledge researching selected scientific works published in English language since 60-ties years to present time. We have been focused on the classification, natural history, and clinical significance of the entity from the point of view of cerebral ischaemia, diagnostic practices and choice of optimal treatment methods in indicated cases, as well. We have compared these knowledge with our own experience and results of surgical correction of carotid artery kinking during the course of five years (2012 – 2016). Results: Contemporary, there is generally aaccepted the classification proposed by Metz and Weibel with Fields in early 60. years because of its simple clinical use. The prevalence of the ICA deformities in general population has been indicated 1,3 %. The prevalence is higher in the population of patients evaluated because of signs of cerebral ischaemia: 16 to 26 %. Pellegrino et al. (1998) have found this entity even in 25,9 %. There is no difference between genders in patients of age up to 60 years. In older patients there is higher prevalence in females. In older patients we can suppose influence of aging process on vascular wall. On the opposite, in children and younger persons up to 40 years it is possible to suppose congenital origin of deformations. Symptoms of the disease including TIA and brain infarction may arise without any atherosclrotic changes of the carotic artery wall. As concerns the pathophysiologic mechanism of ischaemia many authors accept also the possibility of thromboembolism. But, however, haemodynamic mechanism seems to be more acceptable (severe reduction of the blood flow in transitory hypotension, asleep or in rotation of head and neck). Signs of ischaemia may be haemispheral, nonhaemispheral or ocular. Imaging methods especially colour coded Doppler ultrasound and CT angiography play a dominant role in diagnostics. Endovascular treatment of carotid artery kinking is practically impossible. Indication for open surgical reconstruction represent particularly haemispheral symptomatology (TIA, stroke), heavy kinks in nonhaemispheral signs. Correction of deformities in asymptomatic patients is acceptable only in cases of high grade of deformity or in patients with contralateral occlusion of the ICA. Published proportion of kinking correction in the global carotic surgery in major centres is 10 – 12 %. In our material it was 11,7 %. Published results of surgical corrections, morbidity and mortality and long-term patency and our own results are excellent. Conclusion: In spite of great extent of recently published works on the problems of carotis artery kinking still persist many unclair questions. For their clear solution there is lack of multicentric randomised studies and guidelines.

Keywords: carotid artery carotis, kinking, management