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Extracranial Carotid
and Vertebral Artery
Disease
Contemporary Management
Sachinder Singh Hans
Editor
123
Extracranial Carotid and Vertebral Artery
Disease
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
Library of Congress Control Number: 2018950454
© The Editor(s) (if applicable) and The Author(s) 2018
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional afliations.
Printed on acid-free paper
This Springer imprint is published by the registered company Springer International Publishing
AG part of Springer Nature
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
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 eld, 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 rened 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 reect the different
criteria and also the conicting 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/extension 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 identied
vii
viii
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 nding is a common indication for distal vertebral 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 rst reconstructions of the vertebral (proximal) artery took place in 1979, a quarter of a century after the rst
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.
RamonBerguer, MD, PhD
Emeritus Professor of Vascular Surgery
University of Michigan
Ann Arbor, MI, USA
Foreword
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 difculty in establishing accurate clinical and radiographic diagnosis of vertebral-basilar insufciency. In this book emphasis is
placed on the medical, endovascular, and surgical approaches in managing
patients with extracranial carotid and vertebral artery disease following pertinent diagnostic studies. Besides surgical anatomy, physiology, and pathology,
strong emphasis was placed on the imaging techniques such as duplex ultrasound, computed tomography head, CTA neck and brain, MRI brain, MRA
neck and brain, and diagnostic arteriography. In contrast to similar book publications on this topic, this book reects the contributions of many interrelated specialties: cerebrovascular physiology, pathology, neuro-radiology,
neuro-interventions, stroke neurology, and, more importantly, vascular surgery whose varying perspectives have signicantly enhanced our knowledge
of carotid and vertebral artery disease. It is my sincere hope that the reader
will nd 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 eld.
Warren, MI, USA SachinderSinghHans
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 uninching 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 editor, for providing the guidance and professional support in getting this project
completed.
xi
Contents
1 Surgical Anatomy ofCarotid andVertebral Arteries . . . . . . . . 1
Sachinder Singh Hans
2 Physiology oftheCerebrovascular System . . . . . . . . . . . . . . . . . 9
Heidi L. Lujan, Robert A. Augustyniak,
and Stephen E. DiCarlo
3 Pathology oftheExtracranial Carotid
andVertebral Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Wendy N. Wiesend and Mitual Amin
4 History ofCarotid Artery Surgery . . . . . . . . . . . . . . . . . . . . . . . 45
Praveen C. Balraj, Ziad Al Adas, and Alexander D. Shepard
5 History ofVertebral Artery Surgery . . . . . . . . . . . . . . . . . . . . . . 63
Sachinder Singh Hans
6 Noninvasive Vascular Lab Testing forCarotids, Vertebrals,
andTranscranial Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Hosam Farouk El Sayed, Nicolas J. Mouawad, and Bhagwan
Satiani
7 Cerebrovascular Imaging (CT, MRI, CTA, MRA) . . . . . . . . . . 85
Brent Grifth, Brendan P. Kelley, Suresh C. Patel, and Horia
Marin
8 Carotid andVertebral Arteriography . . . . . . . . . . . . . . . . . . . . . 113
Muneer Eesa
9 Medical Therapy forCarotid andVertebral
Artery Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Moayd M. Alkhalifah, Paul M. Gadient,
and Seemant Chaturvedi
10 Carotid Endarterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Sachinder Singh Hans
11 Carotid Endarterectomy forHighPlaque . . . . . . . . . . . . . . . . . 147
Sachinder Singh Hans
xiii
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