Surgical vs medical treatment for isolated internal carotid artery elongation with coiling or kinking in symptomatic patients: A prospective randomized.

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Surgical vs medical treatment for isolated internal carotid artery elongation with coiling or kinking in symptomatic patients: A prospective randomized clinical study Enzo Ballotta, MD, Gaetano Thiene, MD, Claudio Baracchini, MD, Mario Ermani, MD, Carmelo Militello, MD, Giuseppe Da Giau, MD, Bruno Barbon, MD, Annalisa Angelini, MD Journal of Vascular Surgery Volume 42, Issue 5, Pages 838-846 (November 2005) DOI: 10.1016/j.jvs.2005.07.034 Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

Fig 1 (A) The internal carotid artery is transected at the bulb with an incision almost longitudinal to the common carotid artery. (B) After its straightening, the internal carotid artery is cephalad dilated using graduated olive-tipped metal dilators. (C) A large matching elliptic longitudinal window is cut in the lateral wall of the common carotid artery at the level of the reimplantation site, and then, (D) the internal carotid artery is caudal end-to-side reimplanted in the common carotid artery. Journal of Vascular Surgery 2005 42, 838-846DOI: (10.1016/j.jvs.2005.07.034) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

Fig 2 Kaplan-Meier life-table analysis of freedom from stroke between surgical and medical groups. Number of patients at risk for each interval is shown for each group. Percentages on the right represent freedom from stroke at 10 years for the groups: the difference was significant (p=0.01). Range of standard error for medical group is 0% to 4%. Journal of Vascular Surgery 2005 42, 838-846DOI: (10.1016/j.jvs.2005.07.034) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

Fig 3 Kaplan-Meier life-table analysis of freedom from late carotid occlusion between surgical and medical groups. Number of patients at risk for each interval is shown for each group. Percentages on the right represent freedom from stroke at 10 years for the groups: the difference was significant (p=0.02). Range of standard error for medical group is 0% to 4%. Journal of Vascular Surgery 2005 42, 838-846DOI: (10.1016/j.jvs.2005.07.034) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

Fig 4 (A) Angiographic picture of a left carotid elongation with kinking causing hemispheric symptoms. (B) Tranparietal section of the carotid artery at its origin showing degenerative findings in the tunica media, characterized by medionecrosis. Immunohistochemical staining with anti-α actin antibody for the identification of smooth muscle cells (in brown). Note the massive loss of smooth muscle cells within the tunica media. (C) Close-up of B. Original magnifications: B = x 8; C = x 31. Journal of Vascular Surgery 2005 42, 838-846DOI: (10.1016/j.jvs.2005.07.034) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

Fig 5 (A) Angiographic picture of bilateral carotid elongation with kinking causing right hemispheric symptoms. (B) Transparietal section of the carotid artery at its origin showing the tunica media hyperplasia characterized by increased extracellular matrix surrounding variously-oriented smooth muscle cells. Immunohistochemical staining with anti-α actin antibody for the identification of smooth muscle cells (in brown). Note the high number of variously-oriented smooth muscle cells within the tunica media. (C) Close-up of B. Original magnifications: B = x 8; C = x 31. Journal of Vascular Surgery 2005 42, 838-846DOI: (10.1016/j.jvs.2005.07.034) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions

Fig 6 (A) Angiographic picture of bilateral carotid elongation with coiling causing right hemispheric symptoms. (B) Transparietal section of the carotid artery at its origin showing a classic fibromuscular displasia characterized by thickened fibromuscular hyperplasia alternating with thinning of the media and superimposed intimal hyperplasia. Immunohistochemical staining with anti-α actin antibody for the identification of smooth muscle cells (in brown). Note the thinning of the media with superimposed intimal smooth muscle cell hyperplasia. (C) Close-up of B. Original magnifications: B = x 8; C = x 31. Journal of Vascular Surgery 2005 42, 838-846DOI: (10.1016/j.jvs.2005.07.034) Copyright © 2005 The Society for Vascular Surgery Terms and Conditions