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xiv

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

Contents

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 Grifth, 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

xvi

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

Contributors

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, Southeld, 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

SachinderSinghHans

The Arch ofAorta

The main arteries of the head and neck supplying the cerebral arterial bed arise from the arch of the aorta (Fig.1.1). Three major branches arise from superior aspect of the arch of the aorta:

1. The brachiocephalic trunk (innominate)

2. Left common carotid artery

3. Left subclavian artery

Anatomical Variations

These three major branches may arise from the most proximal segment of the arch or distal portion of the ascending aorta, or their commencements may be quite separate or very close as the left common carotid artery may have a common origin with the brachiocephalic trunk (the bovine aortic arch). This variation can be present in up to 10% of individuals. There can be a “V-shaped origin” of both common carotid arties from a single short trunk before continuing on each side of the neck [1, 2].

S. S. Hans 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

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

Aortic Arch Anomalies

Anomalies of aortic arch include aberrant right subclavian artery (1:200) arising lateral to left subclavian artery is the most common arch anomaly. Patients are usually asymptomatic, but it may result in dysphagia lusoria when aneurysmal subclavian artery compresses the esophagus posteriorly [3].

Other anomalies include right aortic arch with aberrant left subclavian artery, which is its last branch or double aortic arch.

Common Carotid and Internal andExternal Carotid Arteries

The common carotid arteries (CCA) are variable in length and their anatomic origin. The right common carotid artery originates at the bifurcation of the brachiocephalic trunk posterior to the right sternoclavicular joint and continues into the neck. The left CCA arises from the highest portion of the arch of the aorta to the left and posterior to the brachiocephalic trunk and can be divided into the intrathoracic portion and a cervical portion [1].

The cervical portion of each common carotid artery passes obliquely cephalad and slightly laterally to the upper border of the thyroid cartilage where it divides into the external and internal carotid arteries. The common carotid arteries with the internal jugular vein and vagus nerve are

https://doi.org/10.1007/978-3-319-91533-3_1

Left

S. S. Hans

Fig. 1.1 Heart and great vessels with supra-aortic trunks

Brachiocephalic

contained in the carotid sheath, the vein coursing lateral to the artery and the vagus nerve lying between the artery and the vein (Fig.1.2). The upper border of the thyroid cartilage (carotid bifurcation) is usually at the level of the fourth cervical vertebral body. The carotid bifurcation is variable, and bifurcation can be as low as the level of cervical fth or even cervical sixth vertebral body (48%) or high at the level of cervical third vertebral body (34%). At the point of division of the common carotid artery, internal carotid artery (ICA) is slightly dilated into carotid sinus [1, 2]. The adventitial layer of the internal carotid artery is thicker in the carotid sinus and contains numerous sensory bers arising from glossopharyngeal nerve [1]. These nerve bers respond to changes in the arterial blood pressure reexly. The carotid body, which lies behind the point of division of the common carotid artery, is a small brownish red structure which acts as a chemoreceptor.

In majority of patients (80%), the internal carotid artery is posterior or posterolateral to the external carotid artery.

Anatomic Variations

In about 10–12% of patients, the right common carotid artery arises cephalad to sternoclavicular

Left

trunk

CCA

subclavian

artery

joint. It may arise separately from the arch of the aorta, or both common carotid arteries could arise as a common trunk from the arch of the aorta. It is extremely uncommon for the common carotid artery to ascend into the neck without its division. Rarely there is agenesis of the common carotid artery on the right side. In persons with agenesis of the right common carotid artery, the right external carotid artery usually arises proximally from the brachiocephalic artery, and internal carotid artery arises distally from the subclavian artery proximal to the origin of the vertebral artery. When agenesis of the CCA occurs on the left side, both the ECA and ICA arise from the aortic arch, with ECA arising proximal to the origin of ICA [1, 2].

The External Carotid Artery

The external carotid artery (ECA) begins opposite to the upper border of the thyroid cartilage between the third and fourth cervical vertebrae and continues cephalad and anteriorly behind the angle of the mandible between the tip of the mastoid process and the angle of the jaw and divides into supercial temporal artery and maxillary arteries in the parotid gland. The external carotid artery branches in order are superior thyroid

Post belly digastri

branch of occipital artery

1 Surgical Anatomy ofCarotid andVertebral Arteries

XI Nerve

Vagus (X) nerve

ICA

ECA

IX Nerve

Stylopharyngeus

Occipital artery

XII Nerve

Sternocleidomastoid

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 pharyngeal (which may arise from internal carotid artery), lingual, facial, occipital, posterior auricular, supercial temporal, and maxillary artery [1].

Anatomic Variations

Occasionally, external carotid artery may be absent on one or both sides. Carotid basilar anastomoses are rare arterial anomalies in which embryonic connections between carotid and vertebral arterial system persists (Fig.1.3) [3].

common and most cephalad-located embryological anastomosis between the developing carotid artery and vertebrobasilar system to persist into adulthood. Its incidence ranges from 0.1% to 0.6% by MRA and DSA imaging. The persistent primi-

The persistent trigeminal artery is the most

tive hypoglossal artery (HA) has been reported in

0.03–0.26% on cerebral arteriography. Persistent HA arises from the ICA between c1 and c2 vertebral levels and traverses through the hypoglossal canal to join the vertebrobasilar circulation [3].

The Internal Carotid Artery

The internal carotid artery (ICA) is the primary source of oxygenated blood to anterior portion of the brain and the orbits. The ICA is divided into the following seven segments: cervical (c1), petrous (c2), lacerum (c3), cavernous (c4), clinoid (c5), ophthalmic (c6), and communicating (c7). ICA ascends into the skull base and becomes intracranial through the carotid canal of temporal bone. It continues anteriorly through the cavernous sinus and divides into anterior and middle cerebral artery.

Clivus

intersegmental

S. S. Hans

At the level of second cervical, the vagus nerve gives its superior laryngeal nerve branch which descends along the side of the pharynx

Trigeminal

OTIC

rst posterior and then medical to the internal carotid artery and divides into the internal and external laryngeal nerve [1].

Hypoglossal

Proatlantal

The Glossopharyngeal Nerve

Fig. 1.3 Diagrammatic representation of persistent embryological carotid-basilar connections

Anatomic Variations

Instead of ICA being straight, it may be tortuous and may course medially and become retropharyngeal close to tonsil and may appear as a retropharyngeal mass.

Relationship ofNerves intheNeck toCarotid Arteries

The vagus nerve runs vertically down within the carotid sheath lying between the internal jugular vein and the internal carotid artery and inferiorly between the same vein and the common carotid artery. On the right side, it descends posterior to internal jugular vein (IJV) and crosses the rst part of the subclavian artery. On the left side, vagus nerve enters the thorax between the common carotid and subclavian arteries and posterior to the left brachiocephalic vein. During the performance of carotid endarterectomy (CEA), the vagus nerve in the lower portion of the neck may course anterolaterally instead of its usual posterior course and thus may be subject to injury.

After its exit from the skull, it courses forward between the internal jugular vein and the ICA and descends anterior to the ICA deep to the styloid process and may get injured during cephalad mobilization of the ICA during CEA for high plaque as it courses deep to the styloid process. Injury to the glossopharyngeal nerve results in loss of sensation to the posterior third of the tongue and difculty swallowing requiring PEG tube placement.

The Accessory Spinal Nerve

After its exit from the jugular foramina, it runs posterolaterally behind the internal jugular vein in majority of instances but in front of the IJV in about 30% of cases and very rarely passes through the vein. It can be damaged in cases where IJV is more anterior in relation to ICA in the upper portion of the neck.

Ramus Mandibularis

Ramus mandibularis or the marginal mandibular branch of the facial nerve runs anteriorly below the angle of the mandible under cover of the platysma and can be injured during CEA if incision is more anteriorly placed. It can also be injured as a result of overzealous retraction of the tissues (stretch injury).

External Laryngeal Nerve

External laryngeal nerve is smaller than the internal laryngeal nerve and crosses the origin

1 Surgical Anatomy ofCarotid andVertebral Arteries

of superior thyroid artery and supplies the cricothyroid muscle. Injury to the external laryngeal nerve results in decreased pitch of the voice.

Hypoglossal Nerve

The hypoglossal nerve is usually posterior or posterosuperior to the common facial vein and is often crossed superiorly by another vein which drains into the internal jugular vein. The hypoglossal nerve curves around the sternocleidomastoid branch of the occipital artery, and its division and ligation aid in mobilization of the ICA during CEA.In a few instances, the hypoglossal nerve may be inferior in its course, close to the carotid bifurcation, and, if not carefully dissected, may result in an inadvertent injury.

Ansa Cervicalis

Ansa cervicalis is formed as a loop from the descending branch of the hypoglossal nerve which contains bers of the C1. The descending branch is joined by the lower root of ansa cervicalis from second and third cervical nerves, thus forming a loop. The author has encountered anatomic variations in the ansa cervicalis with its superior root arising from the vagus, and its division during CEA can result in hoarseness (Fig.1.4).

The Vertebral Arteries

The vertebral artery arises from the superior and posterior aspect of the rst part of the subclavian artery. It ascends through the foramina in the transverse process of all the cervical vertebra from sixth to the rst and then runs laterally entering the skull through the foramen magnum and joins with the opposite vertebral artery at the lower border of the pons to form the basilar artery. A vertebral artery can be divided into four segments. The rst part runs posteriorly and superiorly between the longus colli and

Fig. 1.4 Abnormal nerve connection of ansa cervicalis

the scalenus anticus and posterior to the common carotid artery. The vertebral vein crosses anterior to the artery, and it is crossed interiorly by the inferior thyroid artery. On the left side, the vertebral artery is crossed anteriorly by the thoracic duct. The cervico-dorsal ganglion rests on top of the vertebral artery with medial and lateral rami. The second part runs cephalad through the transverse foramina of the upper six cervical vertebrae and runs a straight course. The third part exits from the transverse pro- cess of the atlas and runs laterally in the suboccipital triangle. The fourth part enters the skull by piercing the dura and the arachnoid matter (Fig.1.5).

Anatomic Variations

Vertebral arteries are usually often variable (80– 85%) in their size. One vertebral artery may be large and dominant and contralateral hypoplastic or even absent [2]. The origin of vertebral arteries can also be variable. They can arise as

Left subclavian artery and vein

Left CCA

S. S. Hans

Fig. 1.5 Left subclavian artery and segments of vertebral artery

V-4

V-3

V-2

V-1

second branch of the subclavian artery and may have duplicate origin [2]. Left vertebral artery may arise from the arch of the aorta between the left common carotid artery and left subclavian artery (5–7%) [4, 5]. Vertebral artery may enter the fth, fourth, or seventh cervical vertebrae. Occasionally intracranial branches of the vertebral artery such as posterior inferior cerebellar artery may arise at the level of c1–c2 vertebral body. The abnormal course of v2 segment of the vertebral artery has been reported predisposing the patient to iatrogenic vascular injury during anterior spinal surgery [4, 5]. Vertebral artery may enter the transverse foramina of the third cervical vertebrae, fourth cervical vertebrae (1.6%), fth cervical vertebrae (3.3%), or seventh cervical vertebrae in 0.3% of cases [2, 4, 5].

Review Questions

1. The “bovine aortic arch” (a common origin of the brachiocephalic and left common carotid arteries) is present in: A. Under 10% of individuals B. 11–20% of individuals C. 21–20% of individuals D. More than 30% of individuals

Answer: A

2. Dysphagia lusoria is caused by: A. Aberrant aneurysmal left subclavian

artery

B. Aberrant aneurysmal right subcla-

vian artery

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