Chapter 1: Introduction
Carotid surgery is a frequently performed operation that brings great satisfaction to both patients and surgeons. Supra-aortic artery disease is managed through open
and endovascular surgery, benefting our patients and preventing severe complications that could arise if left untreated. This book aims to provide residents and young
vascular surgeons with a quick overview of carotid and subclavian artery diseases, covering the diagnosis and surgical decision-making processes. By focusing on this
specifc topic within vascular surgery, readers can gain up-to-date knowledge, from diagnosis to treatment. The book introduces the reader to supra-aortic vessel diseases
and includes brief but important historical facts about the courageous pioneers and developments in vascular surgery. Clinical examination, diagnosis, conservative management,
open surgery, and endovascular treatment are discussed in separate chapters. The authors, who are experienced in both open and endovascular treatments of supra-aortic arteries,
hope this book will serve as a practical overview. Other surgical colleagues and medical students may also fnd this book useful.
The Editors would like to thank the contributing authors and welcome any suggestions or comments. Belgrade, Serbia Djordje Radak Copenhagen, Denmark Stevo Duvnjak 2024
Abstract
Cerebrovascular disease is the third leading cause of death, the second leading cause of dementia, and the most common cause of disability worldwide. Carotid disease is responsible for approximately 70% of ischemic stroke cases, but it is the only cause that can be addressed through revascularization. The primary goals of carotid reconstruction—whether through endarterectomy, bypass, or stenting—are to prevent ischemic stroke, alleviate neurological symptoms and complaints, and potentially prevent vascular dementia, cognitive disorders, and senility.
Abstract
Cerebrovascular disease is the third leading cause of death, the second leading cause of dementia, and the most common cause of disability worldwide. Carotid disease is responsible for approximately 70% of ischemic stroke cases, but it is the only cause that can be addressed through revascularization. The primary goals of carotid reconstruction—whether through endarterectomy, bypass, or stenting—are to prevent ischemic stroke, alleviate neurological symptoms and complaints, and potentially prevent vascular dementia, cognitive disorders, and senility.
Chapter 2: Relevant Historical Facts
Abstract
The word “carotid” is derived from the Greek word “karos,” meaning “to sink into a deep sleep.” In Latin, they were referred to as arteriae soporales or “arteries of sleep.” Compression of the carotid artery can cause a temporary loss of consciousness. For centuries, the cause of stroke was unknown and often attributed to “God’s punishment.” It was not understood that the brain is nourished by the carotid arteries, and therefore, these arteries were not initially considered as a potential cause of stroke.
The word “carotid” is derived from the Greek word “karos,” meaning “to sink into a deep sleep.” In Latin, they were referred to as arteriae soporales or “arteries of sleep.” Compression of the carotid artery can cause a temporary loss of consciousness. For centuries, the cause of stroke was unknown and often attributed to “God’s punishment.” It was not understood that the brain is nourished by the carotid arteries, and therefore, these arteries were not initially considered as a potential cause of stroke.
Chapter 3: Epidemiology and Pathology of Carotid Artery Diseases
Abstract
Carotid artery atherosclerosis is a common vascular disorder characterised by plaque deposition within the carotid arteries, major arteries supplying blood to the brain. Epidemiologically, it is associated with several risk factors and has significant implications for cardiovascular health. Carotid artery dissection is a condition that occurs when the layers of the carotid artery wall tear, leading to blood flow between the layers and potentially causing stroke or transient ischemic attack (TIA). Carotid artery aneurysms are relatively rare but potentially severe vascular abnormalities. Carotid vasculitis is a rare condition characterised by inflammation of the carotid arteries, which are major blood vessels supplying the head and neck. It can lead to significant morbidity and mortality if not promptly diagnosed and treated.
Carotid artery atherosclerosis is a common vascular disorder characterised by plaque deposition within the carotid arteries, major arteries supplying blood to the brain. Epidemiologically, it is associated with several risk factors and has significant implications for cardiovascular health. Carotid artery dissection is a condition that occurs when the layers of the carotid artery wall tear, leading to blood flow between the layers and potentially causing stroke or transient ischemic attack (TIA). Carotid artery aneurysms are relatively rare but potentially severe vascular abnormalities. Carotid vasculitis is a rare condition characterised by inflammation of the carotid arteries, which are major blood vessels supplying the head and neck. It can lead to significant morbidity and mortality if not promptly diagnosed and treated.
Chapter 4: Diagnosis of Carotid Artery Diseases
Abstract
The diagnosis of carotid artery disease involves a comprehensive vascular examination, which includes auscultation of the carotid bifurcation and palpation of the abdominal and limb arteries, as well as a focused neurological examination. Further diagnostic procedures include color duplex ultrasonography of the carotid and vertebral arteries and advanced imaging techniques such as computed tomography (CT) or magnetic resonance angiography (MRI) of the aortic arch, carotid arteries, vertebral arteries, and intracranial vessels.
The diagnosis of carotid artery disease involves a comprehensive vascular examination, which includes auscultation of the carotid bifurcation and palpation of the abdominal and limb arteries, as well as a focused neurological examination. Further diagnostic procedures include color duplex ultrasonography of the carotid and vertebral arteries and advanced imaging techniques such as computed tomography (CT) or magnetic resonance angiography (MRI) of the aortic arch, carotid arteries, vertebral arteries, and intracranial vessels.
Chapter 5: Conservative Medical Treatment
Abstract
Primary prevention of ischemic stroke focuses on identifying, eliminating, and treating risk factors in the general population before symptoms appear. Secondary prevention targets preventing subsequent strokes in patients with existing conditions, such as residual neurological deficits or transient ischemic attacks (TIAs). Genetic predisposition influences the rate of atherosclerosis progression, but preventive measures can mitigate its impact. Since early atherosclerosis typically causes no immediate problems, preventive measures should be a key component of patient education. Conservative treatment involves addressing risk factors and medical management. Following successful carotid artery surgery, ongoing conservative treatment with lifestyle modifications and medication remains essential.
Chapter 6: Open Surgical Treatment of Carotid Artery Stenosis
Abstract
The purpose of carotid reconstruction—whether through endarterectomy, bypass, or stenting—is to prevent ischemic stroke, alleviate neurological symptoms, and avert vascular dementia, cognitive disorders, and senility. Effective artery reconstruction requires judiciously setting indications and executing the operation with precision. The best outcomes are achieved at centers that perform a high volume of procedures annually, where the surgeons, anesthesiologists, and all staff are experienced and well-trained. When determining the need for carotid artery reconstruction, the following factors are considered, severity and frequency of episodes or symptoms of brain ischemia, degree of carotid stenosis, and morphological characteristics of the plaque, acuteness, and severity of any definitive brain damage. A preoperative conversation with the patient is important; it should neither be underestimated nor overemphasized. Such a discussion helps the patient relax and fosters an atmosphere of trust, maximizing motivation for both the patient and the surgeon.
The purpose of carotid reconstruction—whether through endarterectomy, bypass, or stenting—is to prevent ischemic stroke, alleviate neurological symptoms, and avert vascular dementia, cognitive disorders, and senility. Effective artery reconstruction requires judiciously setting indications and executing the operation with precision. The best outcomes are achieved at centers that perform a high volume of procedures annually, where the surgeons, anesthesiologists, and all staff are experienced and well-trained. When determining the need for carotid artery reconstruction, the following factors are considered, severity and frequency of episodes or symptoms of brain ischemia, degree of carotid stenosis, and morphological characteristics of the plaque, acuteness, and severity of any definitive brain damage. A preoperative conversation with the patient is important; it should neither be underestimated nor overemphasized. Such a discussion helps the patient relax and fosters an atmosphere of trust, maximizing motivation for both the patient and the surgeon.
Chapter 7: Endovascular Treatment of Carotid Stenosis and Neuroradiological Thrombectomy
Abstract
In 2024, carotid artery stenting (CAS) has become a widely accepted, well-established treatment choice for the treatment of carotid artery disease. Major technological advancements in tools and devices to perform the procedure as straight forward as possible with the key focus on neuroprotection have significantly improved procedural efficacy and patients’ safety. Operators’ experience and skills not only in performing the actual stenting procedure but also for managing procedural complications including removal of clots form the downstream circulation are mandatory to avoid and minimize complications. Rigorous medical management in the peri- and postprocedural period, especially the use of dual antiplatelet medication, is of crucial importance to ensure best possible results. Finally, the optimization of patient selection further contributes to improve clinical outcome underlining the current significant role of CAS as complementary rather than competitive treatment choice for patient with carotid artery disease.
In 2024, carotid artery stenting (CAS) has become a widely accepted, well-established treatment choice for the treatment of carotid artery disease. Major technological advancements in tools and devices to perform the procedure as straight forward as possible with the key focus on neuroprotection have significantly improved procedural efficacy and patients’ safety. Operators’ experience and skills not only in performing the actual stenting procedure but also for managing procedural complications including removal of clots form the downstream circulation are mandatory to avoid and minimize complications. Rigorous medical management in the peri- and postprocedural period, especially the use of dual antiplatelet medication, is of crucial importance to ensure best possible results. Finally, the optimization of patient selection further contributes to improve clinical outcome underlining the current significant role of CAS as complementary rather than competitive treatment choice for patient with carotid artery disease.
Chapter 8: Open and Endovascular Treatment of Carotid Aneurysms
Abstract
An aneurysm is generally defined as an expansion of the arterial lumen by more than 50% of its standard diameter. However, for the carotid artery, particularly due to the bulb region, this definition differs. In this context, an aneurysm is defined as a bulb dilation of 200% of the internal carotid artery’s diameter and 150% of the common carotid artery’s diameter. Most aneurysms involve the bulb region and the internal carotid artery, while aneurysms of the external carotid artery are very rare. Carotid aneurysm resection constitutes 0.1–3% of all carotid artery surgeries. The leading causes of carotid artery aneurysms include atherosclerosis, trauma, post-endarterectomy changes, congenital factors, inflammation, and fibromuscular dysplasia. Carotid aneurysms can be classified as true or false. True aneurysms typically develop due to atherosclerosis, arteritis, and fibromuscular dysplasia or are classified as pseudoaneurysms. The etiology is often post-traumatic or mycotic. A saccular aneurysm is characterized by a segmental, lateral (asymmetric) expansion of the artery, while a fusiform aneurysm involves a segmental (symmetric) expansion of the artery’s diameter. The fusiform form is more common than the saccular form, with fusiform aneurysms occurring more frequently at the bifurcation of the common carotid artery and saccular aneurysms typically found in the internal carotid artery. Carotid artery aneurysms can lead to severe complications such as distal embolization, compression symptoms, and rupture.
An aneurysm is generally defined as an expansion of the arterial lumen by more than 50% of its standard diameter. However, for the carotid artery, particularly due to the bulb region, this definition differs. In this context, an aneurysm is defined as a bulb dilation of 200% of the internal carotid artery’s diameter and 150% of the common carotid artery’s diameter. Most aneurysms involve the bulb region and the internal carotid artery, while aneurysms of the external carotid artery are very rare. Carotid aneurysm resection constitutes 0.1–3% of all carotid artery surgeries. The leading causes of carotid artery aneurysms include atherosclerosis, trauma, post-endarterectomy changes, congenital factors, inflammation, and fibromuscular dysplasia. Carotid aneurysms can be classified as true or false. True aneurysms typically develop due to atherosclerosis, arteritis, and fibromuscular dysplasia or are classified as pseudoaneurysms. The etiology is often post-traumatic or mycotic. A saccular aneurysm is characterized by a segmental, lateral (asymmetric) expansion of the artery, while a fusiform aneurysm involves a segmental (symmetric) expansion of the artery’s diameter. The fusiform form is more common than the saccular form, with fusiform aneurysms occurring more frequently at the bifurcation of the common carotid artery and saccular aneurysms typically found in the internal carotid artery. Carotid artery aneurysms can lead to severe complications such as distal embolization, compression symptoms, and rupture.
Chapter 9: Treatment of Carotid Dissection
Abstract
Spontaneous carotid dissection is a rare cause of stroke, accounting for up to 2% of cases. However, in individuals under 50 years of age, it is responsible for 25–30% of stroke symptoms. Carotid or vertebral dissection can lead to artery thrombosis, distal thromboembolic complications, stenosis or occlusion of the carotid/vertebral artery, and aneurysm formation. The mechanisms of dissection include intimal tear, vasa vasorum rupture, and intramural hematoma, which contribute to the symptoms. Patients typically present with unilateral facial or neck pain, headache, Horner syndrome (ptosis and miosis), and nerve compression. However, dissection can also manifest as a stroke or, less commonly, as spinal ischemia. Unspecified symptoms can lead to delayed diagnosis and progression of the condition. Detailed anamnesis and neurological examination are essential for diagnosing carotid dissection. Doppler ultrasound is the preferred initial diagnostic tool due to its high accuracy for carotid dissection, though it is less effective for vertebral artery dissection. Possible ultrasound findings include intimal flap, double lumen, thrombus, stenosis/occlusion, or dissection aneurysm. Cross-sectional imaging methods, such as computed tomography (CT) and magnetic resonance angiography (MRA), are also excellent diagnostic tools.
Spontaneous carotid dissection is a rare cause of stroke, accounting for up to 2% of cases. However, in individuals under 50 years of age, it is responsible for 25–30% of stroke symptoms. Carotid or vertebral dissection can lead to artery thrombosis, distal thromboembolic complications, stenosis or occlusion of the carotid/vertebral artery, and aneurysm formation. The mechanisms of dissection include intimal tear, vasa vasorum rupture, and intramural hematoma, which contribute to the symptoms. Patients typically present with unilateral facial or neck pain, headache, Horner syndrome (ptosis and miosis), and nerve compression. However, dissection can also manifest as a stroke or, less commonly, as spinal ischemia. Unspecified symptoms can lead to delayed diagnosis and progression of the condition. Detailed anamnesis and neurological examination are essential for diagnosing carotid dissection. Doppler ultrasound is the preferred initial diagnostic tool due to its high accuracy for carotid dissection, though it is less effective for vertebral artery dissection. Possible ultrasound findings include intimal flap, double lumen, thrombus, stenosis/occlusion, or dissection aneurysm. Cross-sectional imaging methods, such as computed tomography (CT) and magnetic resonance angiography (MRA), are also excellent diagnostic tools.
Chapter 10: Vasculitis Treatment
Abstract
Vasculitis is a noninfective systemic disease characterized by inflammation of vessels of various diameters. It can be idiopathic or secondary to known systemic diseases. Two types of vasculitis that commonly involve the supra-aortic vessels are giant cell arteritis and Takayasu’s arteritis. The Chapel Hill Consensus Conference on the Nomenclature of Vasculitides has effectively classified different types of vasculitis based on vessel diameter and localization. Giant cell arteritis and Takayasu’s arteritis are both granulomatous inflammations of the aorta and its major branches, sharing complex pathophysiology, similar clinical presentations, imaging features, and treatments. However, there are differences between them: giant cell arteritis typically occurs in patients over 50 years old, with a female predominance, while Takayasu’s arteritis is more common in a younger, predominantly female population aged 15–30 years, particularly of Asian origin. The usual symptoms of giant cell arteritis include headache, jaw pain, and scalp tenderness, with elevated C-reactive protein levels in 95% of cases. Additionally, approximately 15% of patients experience ischemic ophthalmologic complications, which can lead to partial or complete visual loss. Giant cell arteritis can also result in transient ischemic attacks or strokes in 2–7% of patients, either due to direct endothelial damage or a hypercoagulable state. Aortic aneurysm and dissection complications can be observed in up to 30% of cases.
Vasculitis is a noninfective systemic disease characterized by inflammation of vessels of various diameters. It can be idiopathic or secondary to known systemic diseases. Two types of vasculitis that commonly involve the supra-aortic vessels are giant cell arteritis and Takayasu’s arteritis. The Chapel Hill Consensus Conference on the Nomenclature of Vasculitides has effectively classified different types of vasculitis based on vessel diameter and localization. Giant cell arteritis and Takayasu’s arteritis are both granulomatous inflammations of the aorta and its major branches, sharing complex pathophysiology, similar clinical presentations, imaging features, and treatments. However, there are differences between them: giant cell arteritis typically occurs in patients over 50 years old, with a female predominance, while Takayasu’s arteritis is more common in a younger, predominantly female population aged 15–30 years, particularly of Asian origin. The usual symptoms of giant cell arteritis include headache, jaw pain, and scalp tenderness, with elevated C-reactive protein levels in 95% of cases. Additionally, approximately 15% of patients experience ischemic ophthalmologic complications, which can lead to partial or complete visual loss. Giant cell arteritis can also result in transient ischemic attacks or strokes in 2–7% of patients, either due to direct endothelial damage or a hypercoagulable state. Aortic aneurysm and dissection complications can be observed in up to 30% of cases.
Chapter 11: Subclavian and Vertebral Artery Stenosis
Abstract
The supra-aortic branches are large arterial vessels that arise from the aortic arch and supply the head and upper extremities. These branches include the brachiocephalic trunk, the left common carotid artery, and the left subclavian artery. There are several variations, with the most common being the bovine arch, where the left common carotid artery either shares a common trunk with the brachiocephalic trunk or arises directly from it. This variation is found in up to 20% of the population. Additionally, the left vertebral artery can arise directly from the aortic arch in up to 6% of individuals, and the right subclavian artery can arise as the last branch from the aortic arch, a condition known as an aberrant right subclavian artery or arteria lusoria, occurring in about 0.6% of the population. Atherosclerotic lesions in these large arteries are most common at their proximal segments, where they branch off from the aorta, and are more frequent in the left subclavian artery and the brachiocephalic trunk. This is due to the turbulence of arterial flow at these bifurcation points. Occlusive atherosclerotic disease of the supra-aortic branches is much less common than carotid bifurcation lesions, occurring in 0.5–6.4% of cases, and can involve single or multiple vessels. Other diseases affecting the supra-aortic branches, such as aneurysms, dissections, compressive syndromes of the upper thoracic cavity, and various types of vasculitis, are less common.
The supra-aortic branches are large arterial vessels that arise from the aortic arch and supply the head and upper extremities. These branches include the brachiocephalic trunk, the left common carotid artery, and the left subclavian artery. There are several variations, with the most common being the bovine arch, where the left common carotid artery either shares a common trunk with the brachiocephalic trunk or arises directly from it. This variation is found in up to 20% of the population. Additionally, the left vertebral artery can arise directly from the aortic arch in up to 6% of individuals, and the right subclavian artery can arise as the last branch from the aortic arch, a condition known as an aberrant right subclavian artery or arteria lusoria, occurring in about 0.6% of the population. Atherosclerotic lesions in these large arteries are most common at their proximal segments, where they branch off from the aorta, and are more frequent in the left subclavian artery and the brachiocephalic trunk. This is due to the turbulence of arterial flow at these bifurcation points. Occlusive atherosclerotic disease of the supra-aortic branches is much less common than carotid bifurcation lesions, occurring in 0.5–6.4% of cases, and can involve single or multiple vessels. Other diseases affecting the supra-aortic branches, such as aneurysms, dissections, compressive syndromes of the upper thoracic cavity, and various types of vasculitis, are less common.