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Schematic drawing of morphological classification of carotid artery, viewed from the right lateral side. ICA, internal carotid artery; ECA, external carotid artery. #, internal carotid artery angle.
Source publication
Background:
Although the terms tortuous, coiling, and kinking have been used to describe the curvature of the carotid artery, the prevalence rates of these patterns have differed among studies. We morphologically evaluated the characteristics of the carotid artery by means of three-dimensional computed tomography (3DCT) to clarify the prevalence o...
Contexts in source publication
Context 1
... morphological classification used in this study was a modified version of the criteria proposed by Weibel and Fields (1965). Because there is no clear distinction between normal and tortuous in their original classification, we added Paulsen's criteria to facilitate objective evaluation ( Paulsen et al., 2000) (Fig. 1). Our classification was as follows: straight: the internal carotid artery (ICA) angle was less than 15 and the course of the ICA was straight; tortuous: the ICA angle was not less than 15 or the course of the ICA was S-or C-shaped; coiling: an exaggerated S-shaped curve or a circular configuration; and kinking, angulation of 1 or 2 or ...
Context 2
... ICA angle was defined as the angle between the common carotid artery and the ICA centerlines in the 3D space (Fig. 1). This angle was measured on the 3D ...
Context 3
... with carcinoma of the lower gum. 3DCT imaging showed tortuosity of the right carotid artery, with low bifurcation and kinking of the left carotid artery with posterior deviation. The kinking was apparent, but there was no occlusion. The right ICA angle was 19.2 , and the left ICA angle was 48.2 . The right TI was 1.20, and the left TI was 1.42 ( Fig. 10). Fig. ...
Context 4
... of the lower gum. 3DCT imaging showed tortuosity of the right carotid artery, with low bifurcation and kinking of the left carotid artery with posterior deviation. The kinking was apparent, but there was no occlusion. The right ICA angle was 19.2 , and the left ICA angle was 48.2 . The right TI was 1.20, and the left TI was 1.42 ( Fig. 10). Fig. ...
Context 5
... 1997). An abnormal appearance (omega shape) of the ICA in the accessory nerve region is not known; however, a corrosion vascular cast model has been described for 1 patient ( Paulsen et al., 2000). In this situation, the carotid artery is at high-risk for injury during neck dissection, potentially leading to the development of fatal complications (Fig. 12). Imaging evaluations are routinely performed by CT, MRI, and positron emission tomography before neck dissection, but it is easy to miss the highrisk curvature of the ICA on these slice images. On the other hand, 3DCT, which allows the status of the carotid artery to be precisely observed, was very effective for identifying variations ...
Citations
... Deep-seated tumors were defined in the following locations: anterior cranial fossa, orbital, sphenoid ridge, cavernous, petroclival, tentorial, and posterior fossa. A tortuous access route was defined by the presence of a type 3 aorta, 7) acute bifurcation angles of the brachiocephalic trunk and the left common carotid artery (CCA) from the aorta, 8) bovine origin to the left CCA, a coiled and kinked extracranial ICA, 9) and a tortuous iliofemoral artery with acute angulation. 10) Consecutive treatment cases during the observation period were included. ...
Objectives: The superiority and usefulness of liquid material over particles for embolization have been a topic of debate due to differences in materials and techniques. This study aimed to identify the complications and outcomes associated with both embolization materials.
Methods: This retrospective multicenter cohort study included 93 patients from an endovascular treatment registry, treated from January 1, 2018 to May 31, 2022. It included patients who underwent preoperative embolization for meningioma, solitary fibrous tumor/hemangiopericytoma, and hemangioblastoma. Data for patient characteristics, procedural factors, complications, and outcomes were collected from medical records.
Results: A tortuous access route was the only factor independently associated with complications (p = 0.020). Although liquid material was more frequently used for embolization in relatively high-risk conditions, complication rates did not differ significantly between the groups (p = 0.999). In the liquid material group, the tip of the microcatheter could be guided closer to the tumor (p <0.001) using a distal access catheter and flow-guide microcatheters. The subgroup middle meningeal artery embolization had less operative bleeding in the liquid material group (p <0.001), whereas the particles group exhibited less intraoperative blood loss than the liquid material group (p = 0.006).
Conclusion: The vascular tortuosity of the access route was only associated with complications in preoperative tumor embolization. Liquid material and particles showed no difference in complication rates. The use of particles in embolization may reduce intraoperative bleeding, but not in all cases can it be used safely. Therefore, a thorough understanding of the characteristics of both approaches and their relative advantages in clinical practice is essential to opt for the appropriate material according to the case.
... The extracranial ICA anatomy was assessed by cerebral angiographic roadmap view, then categorized into four types (straight, tortuous, kinked, and coiled) according to a previously described classification system [18]. The four types of extracranial ICA are shown in Fig. 3. Kinked-or coiledtype extracranial ICA was defined as an unfavorable ICA anatomy that poses a significant obstacle to the distal BGC placement during the procedure. ...
Purpose
Although balloon guide catheters (BGCs) have been demonstrated to improve recanalization and functional outcomes by enabling proximal flow control and forced aspiration during mechanical thrombectomy (MT), the significance of the BGC location has been overlooked. We evaluated the impact of BGC location during MT for anterior circulation acute ischemic stroke (AIS).
Methods
Patients were divided into the proximal and distal BGC groups according to the BGC tip location relative to the lower margin of the C1 vertebral body. Endovascular and clinical outcomes were compared between the two groups, including subgroup analyses of the two types of extracranial internal carotid artery (ICA) anatomy, categorized based on cerebral angiography.
Results
A total of 124 patients were analyzed, with 62 each in the proximal and distal BGC placement groups. The distal BGC group had higher rates of first-pass recanalization (FPR) (38.7% vs. 17.7%, P = 0.009) and favorable outcomes (64.5% vs. 46.8%, P = 0.047) with shorter procedure time (47.5 min vs. 65 min, P = 0.001) and fewer distal embolization (3.2% vs. 12.9%, P = 0.048) than the proximal BGC group. FPR was also more frequently achieved in the distal BGC group of patients with tortuous ICA (37.0% vs. 12.5%, P = 0.029). Multivariate analysis showed that distal BGC placement was an independent predictor of FPR (odds ratio, 3.092; 95% confidence interval, 1.326–7.210; P = 0.009).
Conclusion
Distal BGC placement facilitates MT for AIS in the anterior circulation. Therefore, we suggest distal BGC placement to maximize the effect of thrombectomy, even for tortuous extracranial ICA.
... Since the internal carotid artery (ICA) provides the only access to the anterior circulation, extra-and intracranial ICA tortuosity can pose a significant challenge when performing MT. Although the anatomic configurations of both the cervical and cavernous segments of the ICA have been classified previously, 11,12 there are few data on the impact of ICA tortuosity on MT outcomes. 13 We hypothesized that the ICA tortuosity adversely affects the likelihood of FPE because of reduced MT device performance. ...
... Tortuosity of the extracranial ICA was classified based on a previously reported grading system as follows: straight (angle between the centerlines of the common carotid artery and the ICA was <15°), tortuous (angle between the common carotid artery and the ICA centerlines was >15° or S-or C-shaped course of the ICA), coiled (an exaggerated S-shaped curve or circular configuration of the ICA), and kinked (acute [<90°] angulation associated with stenosis). 11 The extracranial ICA was considered tortuous if it was coiled or kinked ( Figure 1). Cavernous ICA tortuosity was also classified based on a previously reported grading system. ...
... For the extracranial ICA, A, Tortuosity of the extracranial ICA was classified into 4 types as follows: straight (angle between the centerlines of the common carotid artery and the ICA was <15°), tortuous (angle between the common carotid artery and the ICA centerlines was >15; or S-or C-shaped course of the ICA), coiled (an exaggerated S-shaped curve or circular configuration of the ICA), and kinked (acute [<90°] angulation associated with stenosis). 11 The extracranial ICA was considered tortuous if it was coiled or kinked. B, Cavernous ICA tortuosity was classified into 4 types based on the geometry of the anterior and posterior genus. ...
Background
Although tortuosity of the internal carotid artery (ICA) can pose a significant challenge when performing mechanical thrombectomy, few studies have examined the impact of ICA tortuosity on mechanical thrombectomy outcomes.
Methods
In a registry-based hospital cohort, consecutive patients with anterior circulation stroke in whom mechanical thrombectomy was attempted were divided into 2 groups: those with tortuosity in the extracranial or cavernous ICA (tortuous group) and those without (nontortuous group). The extracranial ICA tortuosity was defined as the presence of coiling or kinking. The cavernous ICA tortuosity was defined by the posterior deflection of the posterior genu or the shape resembling Simmons-type catheter. Outcomes included first pass effect (FPE; extended Thrombolysis in Cerebral Infarction score 2c/3 after first pass), favorable outcome (3-month modified Rankin Scale score of 0–2), and intracranial hemorrhage.
Results
Of 370 patients, 124 were in the tortuous group (extracranial ICA tortuosity, 35; cavernous ICA tortuosity, 70; tortuosity at both sites, 19). The tortuous group showed a higher proportion of women and atrial fibrillation than the nontortuous group. FPE was less frequently achieved in the tortuous group than the nontortuous group (21% versus 39%; adjusted odds ratio, 0.45 [95% CI, 0.26–0.77]). ICA tortuosity was independently associated with the longer time from puncture to extended Thrombolysis in Cerebral Infarction ≥2b reperfusion (β=23.19 [95% CI, 13.44–32.94]). Favorable outcome was similar between groups (46% versus 48%; P =0.87). Frequencies of any intracranial hemorrhage (54% versus 42%; adjusted odds ratio, 1.61 [95% CI, 1.02–2.53]) and parenchymal hematoma (11% versus 6%; adjusted odds ratio, 2.41 [95% CI, 1.04–5.58]) were higher in the tortuous group. In the tortuous group, the FPE rate was similar in patients who underwent combined stent retriever and contact aspiration thrombectomy and in those who underwent either procedure alone (22% versus 19%; P =0.80). However, in the nontortuous group, the FPE rate was significantly higher in patients who underwent combined stent retriever and contact aspiration (52% versus 35%; P =0.02).
Conclusions
ICA tortuosity was independently associated with reduced likelihood of FPE and increased risk of postmechanical thrombectomy intracranial hemorrhage.
Registration
URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02251665.
... Patients were considered to have significant extracranial ICA tortuosity if they were presented with kinking or coiling (12). Kinking represents solitary bends in the ICA with acute (<90 • ) angulation, while coiling produces a full 360 • turn in the artery (13,14) (Figure 2). We classified the normal vessel or mild tortuosity as grade 1, while severe tortuosity of the vessel, including kinking and coiling, was classified as grade 2. ...
... Of them, 137 were not treated with stent-retriever devices and 4 missed the procedure images and were therefore excluded from our study. The mean age of the 278 included patients was 69.3 ± 10.9 years, 51.1% (n = 142) of which were men, while the median baseline ASPECT score was 8 (IQR 8-10), and the median baseline NIHSS score was 15 (IQR [12][13][14][15][16][17][18][19]. Seventeen-point-six percent (n = 49) of the patients were identified to have a type III/Bovine configurations aortic arch and 52.2% (n = 145) had a severe tortuosity of extracranial ICA. ...
Background and Purpose
Successful recanalization after the first pass of the device in endovascular thrombectomy (EVT) can significantly improve patients' prognosis. We aimed to investigate the possible factors that influence achieving the first-pass effect (FPE).
Methods
We retrospectively analyzed the patients who underwent EVT caused by anterior circulation large vessel occlusion stroke (ALVOS) in our center. The FPE was defined as a successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 defined as modified FPE (mFPE); mTICI 3 as true FPE (tFPE)] after one pass of the device without rescue therapy. Univariate and multivariate regression analyses were used to explore the predictors of FPE and the relationship between FPE and prognosis.
Results
There were 278 patients (age, 69.3 ± 10.9 years, male, 51.1%) included, 30.2% of them achieved mFPE, while 21.2% achieved tFPE. We found the higher clot burden score (CBS), the truncal-type occlusion, and the favorable anatomy of both extracranial and intracranial segments of the internal carotid artery (ICA) were associated with achieving mFPE. The higher CBS and truncal-type occlusion were statistically significant predictors of tFPE. Moreover, FPE was significantly associated with improved clinical outcomes, regardless of mFPE and tFPE.
Conclusions
The CBS, tortuosity of ICA, and angiographic occlusion type were independent predictors of achieving FPE. The rate of improved clinical and safety outcomes was higher in patients with FPE, which has important clinical significance.
... Coiling was also strictly defined while others investigated a combined group of kinking, tortuosity and coiling. In addition, CTA is superior to Doppler ultrasonography used in other studies to evaluate the distal part of the extracranial carotid artery (>4 cm beyond the carotid bifurcation) [18]. One main limitation of the current study is that a selected population of patients suspected for having a stroke was used. ...
PurposeThe etiology of coiling (i.e. severe elongation) of the extracranial part of the internal carotid artery (ICA) is poorly understood with the proposed etiology being congenital, atherosclerotic or hypertension. The objective was to investigate the association of coiling with hypertension, carotid artery atherosclerosis and other cardiovascular risk factors.MethodsA case control study was performed in patients suspected of stroke, with (cases) or without (controls) coiling of the ICA determined on compute tomography angiography (CTA). Baseline characteristics included age, gender, hypertension, diabetes, smoking and hypercholesterolemia. Coiling of the ICA and atherosclerotic plaque at the carotid bifurcation were assessed on CTA. Logistic regression analyses were conducted.ResultsCoiling was identified in 108 patients with a median age of 71 years. Cases were compared with 256 controls with a median age of 69 years. Hypertension was present in 63% of the patients with coiling compared to 51% in the control group. Univariable analysis showed that hypertension was significantly associated with coiling, with an odds ratio of 1.65 (95% confidence interval (CI) 1.04–2.61, p = 0.034). Multivariable analysis corrected for age and sex resulted in an odds ratio of 1.71 (95% CI 1.05–2.80, p = 0.032), while correcting for atherosclerotic plaque at the bifurcation yielded an odds ratio of 1.63 (95% CI 1.00–2.66, p = 0.049). Age and atherosclerotic plaque were not significantly associated with coiling.Conclusion
The main finding of this study was the significant association of hypertension with coiling of the ICA and the absence of an association with age, plaques and atherosclerotic risk factors other than hypertension.
... Finally, a torque device is applied to the pusher wire; the balloon of the BGC is inflated; and the stent retriever and the DAC are slowly retrieved Image and patient analysis Preintervention and postintervention CT scans, in addition to the procedure angiograms, were independently reviewed by two interventional neuroradiologists. This image review included the initial CT ASPECTS, the occlusion site (terminus ICA, MCA M1/M2 segments and tandem occlusions), the arc type (types I-III), 20 cervical vessel tortuosity (straight, tortuosity, coiling and kinking), 21 intracranial vessel tortuosity (types IA, IB, II, III and IV), 22 the first-pass and final eTICI reperfusion scores, the presence of emboli to new territory (ENT) after the MT attempt and haemorrhagic complications in the postintervention CT scan. ...
Background and purpose
The first-pass effect (FPE), defined as a first-pass Expanded Treatment in Cerebral Ischaemia (eTICI) 2c/3 reperfusion, has emerged as a key metric of efficacy in mechanical thrombectomy (MT) for acute ischaemic stroke. The proximal balloon occlusion together with direct thrombus aspiration during stent retriever thrombectomy (PROTECT)-PLUS technique consists in the use of a balloon guide catheter and a combined MT approach involving contact aspiration and a stent retriever. The aim of this study is to assess the effectiveness and safety of the PROTECT-PLUS technique using distal aspiration catheters (DACs) with different inner diameters by comparing the large-bore DAC Catalyst 7 versus the use of medium-bore DACs.
Methods
Retrospective analysis of a prospectively maintained database of patients treated with PROTECT-PLUS using Catalyst 7, Catalyst 6 or Catalyst 5 with an occlusion of either the terminal carotid artery or the M1 or M2 segments of the middle cerebral artery from 2018 to 2020 in two comprehensive stroke centres. Baseline characteristics and procedural, safety and clinical outcomes were compared between groups. Multivariable logistic regression analysis was performed in order to find independent predictors of FPE.
Results
We identified 238 consecutive patients treated with PROTECT-PLUS as front-line approach using Catalyst 7 (n=86), Catalyst 6 (n=78) and Catalyst 5 (n=76). The rate of FPE was higher with Catalyst 7 (54%) than Catalyst 6 (33%, p=0.009) and Catalyst 5 (32%, p=0.005), in addition to higher final eTICI 2c/3 reperfusion rates, shorter procedural times, lower need of rescue therapy and fewer procedure-related complications. After multivariable analysis the sole independent factor associated to FPE was the use of Catalyst 7 (OR 2.34; 95% CI 1.19 to 4.58; p=0.014).
Conclusion
Further development of combined MT by incorporating larger-bore aspiration catheters is associated with higher reperfusion rates, shorter procedure times, and lower need of rescue therapy while reducing the complication rates.
... While the prevalence of these deformities varies according to the morphological criteria and the diagnostic techniques used, they are identified in up to 85.8% of patients. 49 Nagata et al. 49 considered an ICA to be tortuous if the angle between the CCA and the ICA centerlines was >15 o or if the course of the ICA was S-or C-shaped. ICA was considered straight if the angle was <15°. ...
... While the prevalence of these deformities varies according to the morphological criteria and the diagnostic techniques used, they are identified in up to 85.8% of patients. 49 Nagata et al. 49 considered an ICA to be tortuous if the angle between the CCA and the ICA centerlines was >15 o or if the course of the ICA was S-or C-shaped. ICA was considered straight if the angle was <15°. ...
... 22 / No. 2 / May 2020 lar configuration; 3.0% of cases) or kinking (angle between vessel segments <90° and associated with stenosis; 1.0% of cases) (Figure 8). 49 Such deformities may be related to congenital (e.g., fibromuscular dysplasia) or acquired diseases. In general, vascular abnormalities are acquired and associated with atherosclerosis risk factors such as hypertension, hyperlipidemia, and smoking. ...
The benefit of mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel intracranial occlusions is directly related to the technical success of the procedures in achieving fast and complete reperfusion. While a precise definition of refractoriness is lacking in the literature, it may be considered when there is reperfusion failure, long procedural times, or high number of passes with the MT devices. Detailed knowledge about the causes for refractory MT in AIS is limited; however, it is most likely a multifaceted problem including factors related to the vascular anatomy and the underlying nature of the occlusive lesion amongst other factors. We aim to review the impact of several key unfavorable anatomical factors that may be encountered during endovascular AIS treatment and discuss potential bail-out strategies to these challenging situations.
... CTA is used to detect the morphology of the cervical segment of ICAs and can even be used to diagnose some microaneurysms [84]. Moreover, 3D image reconstruction of CTAs is a more effective means of classifying morphological variations of the ICA and for detecting ICA abnormalities; therefore, this method can be used to reduce the risk of serious complications during neck surgery [85,86]. In addition to CTA, MRA is another useful non-invasive method for diagnosing DICAs [87]. ...
Dolichoarteriopathies of the internal carotid artery (DICAs) are not uncommon, and although several studies have investigated DICAs, several questions regarding the etiology and best management course for DICAs remain unanswered. It is also difficult to correlate the occurrence of DICAs with the onset of clinical symptoms. Therefore, we surveyed the literature in PubMed and performed a review of DICAs to offer a comprehensive picture of our understanding of DICAs. We found that DICAs can be classified into three types, specifically tortuous, coiling and kinking, and are not associated with atherosclerotic risk factors. Cerebral hemodynamic changes are mainly associated with the degree of bending of DICAs. DICAs can result in symptoms of the brain and eyes due to insufficient blood supply and can co-occur with a pulsatile cervical mass, a pharyngeal bulge and pulsation. The diagnostic tools for the assessment of DICAs include Doppler ultrasonography, computed tomography angiography (CTA), magnetic resonance angiography (MRA) and digital subtraction angiography (DSA), and although DSA remains the gold standard, Doppler ultrasonography is a convenient method that provides useful data for the morphological evaluation of DICAs. CTA and MRA are efficient methods for detecting the morphology of the cervical segment of DICAs. Some DICAs should be treated surgically based on certain indications, and several methods, including correcting the bending or shortening of DICAs, have been developed for the treatment of DICAs. The appropriate treatment of DICAs results in good outcomes and is associated with low morbidity and mortality rates. However, despite the success of surgical reconstruction, an appropriate therapeutic treatment remains a subject of numerous debates due to the lack of multicentric, randomized, prospective studies.
Background
The internal carotid artery (ICA) is one of the vital structures of the head and neck region to be preserved during neck dissection. It may present several unusual forms of tortuousness, and surgeons should be mindful of these variations while performing surgeries.
Case presentation
The patient is an 80‐year‐old woman presented with a T2N0M0 squamous cell carcinoma affecting the left side of the tongue. During neck dissection, significant tortuosity of the ICA was observed. With careful surgical manipulation, the surgery was a success, avoiding any potential damage.
Conclusion
Surgeons must avoid the potentially fatal complication through a detailed preoperative imaging evaluation and careful intraoperative observation.
