Symptomatic internal carotid artery dissection and kinking in a patient with fibromuscular dysplasia / Dissecção e acotovelamento sintomáticos da artéria carótida interna em paciente com displasia fibromuscular

Abstract Isolated dissection of the internal carotid artery (ICA) is rare in young patients and is a cause for strong suspicion of fibromuscular dysplasia (FMD), especially when associated with artery elongation and tortuosity. The natural history of cerebrovascular FMD is unknown and management of symptomatic patients can be challenging. We report the case of a 44-year-old female patient with a history of transient ischemic attack in the absence of cardiovascular risk factors, associated with an isolated left ICA dissection and kinking. Carotid duplex ultrasound confirmed the diagnosis of dissection and demonstrated severe stenosis of the left ICA. The patient underwent surgical repair and histopathological evaluation confirmed the diagnosis of FMD with dissection. An autogenous great saphenous vein bypass was performed and the patient had an uneventful recovery. Cervical carotid artery dissection can be related to underlying arterial pathologies such as FMD, and the presence of ICA tortuosity highlights certain peculiarities for optimal management, which might be surgical.

Resumo A dissecção isolada da artéria carótida interna em pacientes jovens é rara, e a displasia fibromuscular deve ser altamente suspeitada principalmente quando estiver associada a alongamento e tortuosidade da artéria. A história natural da displasia fibromuscular cerebrovascular é desconhecida, e o manejo de pacientes sintomáticos pode ser desafiador. Apresentamos o caso de uma paciente de 44 anos com histórico de ataque isquêmico transitório sem fatores de risco cardiovasculares, associado a dissecção e acotovelamento isolados da artéria carótida interna esquerda. O ultrassom duplo das carótidas confirmou o diagnóstico de dissecção e demonstrou estenose grave na artéria carótida interna esquerda. A paciente foi submetida a reparo cirúrgico, e a avaliação histopatológica confirmou o diagnóstico de displasia fibromuscular com dissecção. Foi realizada cirurgia de ressecção do segmento e reconstrução com veia safena magna autógena, e a paciente se recuperou sem complicações. A dissecção da artéria carótida cervical pode estar relacionada a doenças arteriais subjacentes, como a displasia fibromuscular, e a presença da tortuosidade da artéria carótida interna destaca algumas particularidades no manejo ideal, o qual pode ser cirúrgico.

Kinking of Flow Diverter in a Giant Wide-Necked Supraclinoid Internal Carotid Artery Aneurysm / 신경중재치료의학

We report here a rare complication in the form of kinking of flow diverter in a case of giant wide-necked supraclinoid internal carotid artery (ICA) aneurysm 48 hours after the procedure. This 28-year female presented with giant wide-necked right supraclinoid ICA aneurysm which was managed by flow diversion. On 2nd post-op day, patient developed weakness of left side with altered sensorium - angiography and CT showed kinking of flow diverter at the neck of the aneurysm with poor distal flow. Eventually, the patient developed right middle cerebral artery infarct for which decompressive hemicraniectomy was done. The likely cause of development of kink is because the aneurysm was wide-necked, the hemodynamic forces have resulted in inward buckling of the flow diverter at the aneurysm neck. This case shows that kinking of flow diverter can still happen 48 hours post-procedure.

Intravascular stent implantation in treating patients with symptomatic vertebral artery kinking / 中国医师进修杂志

Objective To evaluate the feasibility and safety of stent implantation in treating patients with symptomatic vertebral artery kinking. Methods Forty-two patients with vertebral artery kinking confirmed by digital subtraction angiography and accorded with the stent implantation indications were chosen in our study; these patients were performed stent implantation. The stenosis and haemodynamics changes, and recent and postoperative complications were observed; Malek scale was adopted to evaluate the clinical efficacy during the 1-year follow-up. Results The success rate of stent implantation for patients with symptomatic vertebral artery kinking was 100%(42/42). The percentage of stenosis was significantly reduced from (75.6 ± 13.5)%to (8.3 ± 3.1)%after stenting, and the mean flow velocity of kinking lesion was obviously decreased from (49.5 ± 12.4) cm/s to (31.7 ± 15.0) cm/s, and there were statistical differences (P<0.01). The cerebellum hematoma was noted in 1 patient , subcutaneous hematoma of puncture point appeared in 2 and femoral artery pseudoaneurysm after the stenting in 1;all these complications did not cause serious consequences. Malek scale indicated that 36 cases got 1 point,4 cases got 2 points, 1 case got 3 points, 1 case got 4 points and no one got 5 points;36 patients (85.7%, 36/42) were asymptomatic during the 1-year follow-up;no significant in-stent restenosis was found. Conclusions Symptomatic vertebral artery kinking can be treated safely and effectively with stent implantation.

Aneurysm, tortuosity and kinking of abdominal aorta and iliac arteries in Thai cadavers / Aneurisma, tortousidad y torsión de la parte abdominal de la aorta y de las arterias ilíacas en cadáveres tailandeses

The prevalence of the aneurysm, tortuosity, and kinking of abdominal aorta and iliac arteries is important for primary consideration in operative planning. The present study was undertaken to investigate the prevalence of abnormality of abdominal aorta and iliac arteries and demonstrate the patterns of kinking external iliac arteries in Thai cadavers. Eighty-five Thai embalmed cadavers (58 males and 27 females) were observed and measured the diameter of abdominal aorta and iliac arteries using a vernier caliper for assessment of aortic aneurysm (AAA). To investigate the tortuosity and kinking of iliac arteries, a standard goniometer was applied to measure the individual angle of iliac artery. In addition, the kinking patterns of external iliac artery were classified. The prevalence of AAA was 4.71% and the aneurysms of common and internal iliac arteries were 4.12 and 0.59%. The tortuosity of common and external iliac arteries were 1.76 and 20%. No tortuosity of internal iliac artery was observed. In addition, the kinking of common, external, and internal iliac arteries were 4.71, 16.47, and 1.18%, respectively. Moreover, the patterns of external iliac aortic kinking were classified into 4 major types (S-shape; reversed ­C shape; low grade shape; and V-shape). We have observed the prevalence of the aneurysm, tortuosity, and kinking of abdominal aorta and iliac arteries in Thai cadavers. Currently, the 4 kinking variations of external iliac arteries were also first demonstrated.

La prevalencia de aneurisma, tortuosidad y torsión de la parte abdominal de la aorta y arterias ilíacas es relevante para la consideración primaria en la planificación quirúrgica. Se realizó un estudio para investigar la prevalencia de alteraciones en las parte abdominal de la aorta y arterias ilíacas y demostrar los patrones de torsión en las arterias ilíacas externas de cadáveres tailandeses. Se observaron 85 cadáveres tailandeses embalsamados (58 hombres y 27 mujeres); se midió el diámetro de la parte abdominal de la aorta y arterias ilíacas utilizando un pie de metro para la evaluación de aneurisma aórtico. Para investigar la tortuosidad y torsión de las arterias ilíacas, se utilizó un goniómetro estándar para medir el ángulo individual de la arteria ilíaca. Además, se clasificaron los patrones de torsión de las arterias ilíacas externas. La prevalencia de aneurisma aórtico fue 4,71% y los aneurismas de las arterias ilíacas comunes e internas fueron 4,12% y 0,59%. La tortuosidad de las arterias ilíacas comunes y externas fueron 1,76% y 20%. No se observó tortuosidad de la arteria ilíaca interna. Además, la torsión de las arterias ilíacas comunes, externas e internas fueron 4,71%, 16,47% y 1,18%, respectivamente. Por otra parte, los patrones de torsión fueron clasificados en 4 tipos principales (formas de S, de C invertida; de bajo grado y en V). Observamos la presencia de aneurisma, tortuosidad y torsión de la parte abdominal de la aorta y arterias ilíacas en cadáveres tailandeses. Demostramos también por primera vez, las 4 variaciones de torsión de las arterias ilíacas externas.

Effect of kinking on internal carotid artery hemodynamics / 中国综合临床

Objective Colour ultrasound was used to detect the hemodynamic changes in patients with internal carotid artery kingking,in order to investigate the relationship between the carotid distortion angle and blood flow changes and to explore the assessment of severe internal carotid artery twist operation indications.Methods Forty-five patients with carotid artery kingking hospitalized in the Brain Hospital of Liaocheng were performed colour ultrasound to detect systolic blood flow velocity (PSV), end-diastolic velocity EDV) and to measure the angle of carotid artery kingking.Results According Metz classification, of the 45 patients, Ⅰ level 17 cases, Ⅱ level 17 cases, Ⅲ level 11 cases.With the decrease of carotid distortion angle,the influence on hemodynamics was more and more obvious, especially while the angle less than 30 degrees, the carotid artery blood flow was severely affected.The difference of PSV before and after Kinking was statistically significant in patientes of Metz Ⅲ level (Z=-2.934,P=0.003) and Metz Ⅱ level (Z=-3.053,P=0.002), but was statistically no significant in patientes of Metz Ⅰ level (Z=-0.382, P=0.702).There was a negative correlation between the ratio of the twist angle and PSV before kinking/PSV after kinking (rz =-0.842, P ＜0.05),that was, with the decrease of the twist angle, PSV before kinking/ PSV after kinking increase accordingly.Conclusion Kinking seriously affect the carotid artery blood flow dynamics.Ultrasound can accurately detect distortions arterial hemodynamics

A Rare Unilateral Variation in the Course of External and Internal Carotid Arteries

Vascular variations in the neck region are not uncommon. Knowledge of incidence of morphological variations in the course and branching of the carotid arteries is important for radiological interpretation and surgical correction when they are symptomatic. Internal carotid artery (ICA) is known to show elongation in its extra cranial course. Previous studies have demonstrated the incidence and clinical symptoms of this morphological entity. However, the occurrence of elongation and looping of the external carotid artery (ECA) is seldom reported in the literature. During regular dissections, we came across a rare case of unilateral morphological variation of both ECA and ICA, in a male cadaver aged about 55 years. ICA presented a curved course with convexity directed posteriorly, at the level of the C2-C3 vertebrae. ECA presented a pronounced kinking or coiling, one inch below the level of the angle of the mandible. In addition, a linguo-facial trunk arising from the ECA also presented a pronounced kinking throughout its entire length.

The Characteristics of Senile Entropion of Lower Eyelid with Kinked Tarsus

PURPOSE: To report the clinical features and surgical results for lower lid entropion with kinked tarsus compared with entropion with weakened capsulopalpebral fascia. METHODS: From March 2008 to December 2009, 20 patients (24 eyes) with lower lid entropion were examined. The patients were divided into the aggravated entropion with kinked tarsus group or the weakened capsulopalpebral fascia group based on the height of tarsus, the shapes of the lower lid and tarsus, and conjunctiva changes. For treatment of entropion in the kinked tarsus group, full thickness tarsotomy with rotatory suture (tarsal fracture operation) was performed, and in the weakened CPF group, a CPF tight procedure was performed. The results of the operations were retrospectively evaluated. RESULTS: The mean age of the patients with entropion in the kinked tarsus group (15 cases) was 66.7 +/- 11.4 years, and the mean age of the patients with entropion in the weakened CPF group (9 cases) was 67.2 +/- 6.2 years. The height of the lower lid tarsus of each group was 3.80 +/- 0.39 mm and 5.20 +/- 0.30 mm, respectively. Except for one case of recurrence after tarsal fracture operation in the kinked tarsus group and reoperation with CPF tightening, there were no significant complications or recurrence in either group. CONCLUSIONS: Entropion with kinked tarsus was more common than entropion with weakened CPF in the present study. In addition, surgical treatment based on the shape and cause of entropion showed good results.

Successful removal of kinked J-guide wire under fluoroscopic guidance during central venous catheterization: A case report / 대한마취과학회지

Guidewire-associated complications that occur during the process of central venous catheterization include its kinking, looping, knotting and breakage. The removal of a looped or knotted guidewire is problematic because it can cause vessel damage, major hemorrhage, or embolization of a fractured guidewire. We report a case of guidewire kinking and its successful removal under fluoroscopic guidance.

An Unusual Case of Kinking Common Carotid Artery / 대한이비인후과학회지

An abnormal course of carotid artery may surprise surgeons during surgery and result in an transient ischemic attack or other ischemic symptoms. We report an unusual case of kinking in the common carotid artery located below the right thyroid lobe, which was found during a total thyroidectomy in a 74-years old patient. We emphasize in this case how important it is to palpate the neck before surgeries such as tracheostomy, thyroid surgery and so on.

Kinking of the Advanced Venous Access Device during Insertion of the Superior Vena Cava Cannula and the Pulmonary Artery Catheter in the Minimally Invasive Robot-assisted Cardiac Surgery: A case report / 대한마취과학회지

A 59-year-old woman was scheduled for mitral valvuloplasty and Maze operation. As operation was planed to use the robotically controlled camera (Aesop 3000, Computermotion(r), USA) for the minimally invasive robot-assisted thoracotomy, a superior vena cava (SVC) cannula (Femoral arterial cannula [21 Fr], Medtronic(r), USA) was inserted in the right internal jugular vein. After insertion of the SVC cannula, a pulmonary artery (PA) catheter (Swan-Ganz CCOmbo V [7.5 Fr], Edwards(r), USA) was inserted through an advanced venous access device (AVA 3Xi [8.5 Fr], Edwards(r), USA) in the right subclavian vein. The tip of the PA catheter could not be advanced into SVC and blood was not regurgitated. In the chest AP X-ray, it was found that the advanced venous access device was kinked by the SVC cannula. So the advanced venous access device was withdrawn about 5 cm and the PA catheter was advanced easily to the destination.

Tortuosity of the internal carotid artery cervicalcourse: case reports and literature review

Variations in the course of the internal carotid arteries (ICA) are reported in the literature as coiling, looping,kinking or tortuosities of the vessels. Nevertheless, the definitions between these variants are confusing. Also, the clinical relevance of morphological anomalies of extracranial ICA is a matter of debate because of up to date the natural history of kinking, coiling and tortuosities of this artery is not well known. However, some authors consider that these conditions are burdened with disabling, even fatal neurological complications.Also, variations of the ICA cervical course may lead to direct contact of the artery with the pharyngeal wall, being of great clinical relevance due to the large number of routine procedures performed in this region. In the present study, we describe two cases of ICA tortuosities and review the current literature regarding the causes, symptoms and clinical significances of the variations of the cervical ICA course. Tortuosity of the cervical ICA is not a rare condition and they can easily be mistaken clinically for an aneurysm, a tumor or an abscess and subsequently injured during an attempted biopsy or excision. Thus, regardless the controversy of its causes (congenital or acquired) it should be included in the differential diagnosis of cervical soft tissue widening. Also, they should be taken into consideration on the diagnostic procedures for ischemic transitory attacks and/or stroke.

Management of Post-operative Pulmonary Artery Stenosis in Tetralogy of Fallot

PURPOSE: Pulmonary artery stenosis is a common finding in post-operative tetralogy of Fallot (TOF), and it is one of the most frequent indication of reoperation. The objective of this study was to determine the procedural success rate of balloon angioplasty(BAP), endovascular stent, and reoperation for pulmonary artery stenosis in terms of its clinical impact on the subsequent management of these patients. METHODS: Hemodynamic and angiographic data from 71 patients who underwent balloon dilatation, stent implantation and reoperation for pulmonary artery stenosis between Jan. 1984 and Nov. 1999 were reviewed, retrospectively. The 71 patients had 94 vessels dilated by BAP. Criteria of BAP and stent implantation for success were > or =50% increase in vessel diameter or > or =20% decrease in right ventricular to aortic pressure ratio. Stent implantation was attempted in 16 patients and reoperation was performed in 11 patients. RESULTS: Of the 94 balloon angioplasty, 70(74%) were successfully dilated. In 16 patients, balloon angioplasty was ineffective for stenosis relief, thus endovascular stent implantation was attempted. All cases of endovascular stent were successfully implanted except one case which was dislodged. Reoperation was attempted in 11 patients in who balloon angioplasty failed or had ineffective results. CONCLUSION: BAP is beneficial for pulmonary artery stenosis. Left pulmonary artery kinking should be suspected at long-term follow up after tetralogy repair in patients with significant pulmonary regurgitation and right-side dilatation. Stent implantation or reoperation is considered when aneurysmal dilatation of pulmonary trunk, kinking components are suspected.

Aortic Arch Aneurysm Associated with Congenital Kinking of the Aorta / 日本心臓血管外科学会雑誌

A 31-year-old woman complained of dizziness. Preoperative aortogram revealed a saccular type of aneurysm of the aortic arch and abnormal origin of the left subclavian artery. She underwent reconstruction of the aortic arch through 4th intercostal thoracotomy on August 10th, 1996. The aneurysm originated distally to the left common carotid artery and its wall was very thin. Aortic arch replacement with woven Dacron prosthesis was performed between the left common carotid artery and the left subclavian artery using the inclusion method under hypothermic circulatory arrest. The post operative course was uneventful. Cystic medial necrosis of the aneurysmal wall, and normal arterial findings of the left femoral artery were recognized by the pathohistological examinations. Kinking of the aorta is a congenital disease due to abnormal embryonal development. The aortic arch elongates between the left common carotid artery and the left subclavian artery, and arch aneurysm originates in this portion, because the aneurysmal wall is very thin and fragile when accompanied with cystic medial necrosis. Therefore, it is important that the left subclavian artery originating distally to the arch aneurysm in this category of the aortic arch aneurysm be recognized. There are 11 cases which were successfully operated for aortic arch aneurysm associated with congenital kinking of the aorta in Japan.

Kinking of Axillobifemoral Bypass Graft: A case report

Axillofemoral bypass has been the preferred procedure for high risk patients who have aorto-iliac occlusive disease since the introduction of the procedure by Blaisdell in 1963. Widespread use of axillo- femoral bypass was limited in the past because long-term patency rates were inferior to aorto-femoral bypass. Since the mid-1980s, patency rates achieved with axillofemoral bypass have improved with the use of the externally supported prosthesis and the evolution of surgical thchnique. Reported pimary patency of axillo-femoral bypass is in excess of 70% at 5 years. Nowadays axillo-femoral bypass is a procedure of choice in elderly patients with associated comorbid risk factors, and its results is comparable to aorto-femoral bypass.The authors experienced one case of graft malfunction due to kinking of the graft at mid-portion which may not be infrequent.

The conformations and energetics of photodamaged DNA.

Energy minimization techniques are used in conjunction with the results of small molecule crystallographic studies on relevant compounds to propose structural models for photodamaged DNAs. Specifically, we present models both for a DNA molecule containing a psoralen photo-crosslink and for a DNA molecule containing a thymine photodimer. In both models, significant distortions of the nucleic acid helix are observed, including kinking and unwinding at the damage site and numerous changes in the backbone torsion angles relative to their standard conformations. Both the torsion angle geometries and the energetics of the models are presented in detail.