CASE REPORT
La t e spon t a n e ou s r e ca n a liz a t ion of in t e r n a l ca r ot id a r t e r y : ca se r e por t
Gla u co Fe r n a n de s Sa e s; Tia go Ca lh e ir os H . Ba r bosa ; Joce fá bia Re ik a Lope s; Afon so Cé sa r Polim a n t i; Ra fa e l N or on h a Ca v a lca n t e ; M a r ia Alice Bosch ; Joã o Cor r ê a ; Oh a n n e s Ka fe j ia n IPhy sician, Angiology and Vascular Sur ger y , Faculdade de Medicina do ABC ( FMABC) , Sant o Andr é,
SP, Br azil.
I IResident s in Vascular Sur ger y , FMABC, Sant o Andr é, SP, Br azil.
I I IAssist ant pr ofessor , Angiology and Vascular Sur ger y , FMABC, Sant o Andr é, SP, Br azil.
I VPr ofessor , Angiology and Vascular Sur ger y , FMABC, Sant o Andr é, SP, Br azil.
Cor r espondence
J Vasc Br as. 2007; 6( 3) : 280- 3.
ABSTRACT
Lat e spont aneous r ecanalizat ion of int er nal car ot id ar t er y is an unusual ev ent t hat has r eceiv ed lit t le at t ent ion. The aut hor s r epor t a case of a 73- y ear - old m ale pat ient , hy per t ensiv e, w it h pr ev ious hist or y of cer ebr al v ascular accident 3 y ear s ago, w it h sensor im ot or sequela in t he r ight upper lim b. Duplex scanning and ar t er iogr aphy show ed t ot al occlusion of t he int er nal car ot id ar t er y . The pat ient pr ogr essed aft er 2 y ear s w it h new episodes of r ecur r ent t r ansient ischem ic at t ack s. When subm it t ed t o new im aging ex am inat ions t o assess ex t r a- and int r acr anial cir culat ion, v essel r ecanalizat ion w as dem onst r at ed, w it h sev er e st enosis. Left car ot id endar t er ect om y w as unev ent fully per for m ed. The pat ient pr ogr essed w it hout new episodes aft er a 1- m ont h follow - up. Consider ing t he case r ar it y and t he lack of lit er at ur e on lat e car ot id ar t er y r ecanalizat ion t hat can be sur gically r epair ed, w e decided t o pr esent t his case focusing on t he im por t ance of follow ing car ot id ar t er y occlusions.
Ke y w or ds: Car ot id ar t er y st enosis/ sur ger y , car ot id ar t er y st enosis/ ult r asonogr aphy , spont aneous r em ission, int er nal car ot id ar t er y , cer ebr al angiogr aphy , st r ok e.
RESU M O
A r ecanalização espont ânea t ar dia da car ót ida int er na é um ev ent o incom um e pouco est udado. Os aut or es r elat am o caso de pacient e de 73 anos, m asculino, hiper t enso, com ant ecedent e de
apr esent ando ao m apeam ent o dúplex e ar t er iogr afia oclusão t ot al da car ót ida int er na. Ev oluiu após 2 anos com nov os episódios de at aques isquêm icos t r ansit ór ios de r epet ição. Subm et ido a nov os ex am es de im agem par a av aliação da cir culação cer ebr al ex t r a e int r acr aniana, ev idenciou- se r ecanalização do v aso, com est enose sev er a. Foi r ealizada endar t er ect om ia de car ót ida esquer da, sem int er cor r ências. Pacient e ev oluiu sem nov os episódios após 1 m ês de seguim ent o.
Consider ando a r ar idade do caso e a par ca lit er at ur a sobr e r ecanalização t ar dia de car ót ida, passív el de r epar o cir úr gico, opt am os pela apr esent ação do caso enfocando a im por t ância do acom panham ent o de oclusões car ot ídeas.
Pa la v r a s- ch a v e : Est enose car ot ídea/ cir ur gia, est enose car ot ídea/ ult r a- sonogr afia, r em issão espont ânea, ar t ér ia car ót ida int er na, angiogr afia cer ebr al, acident e v ascular cer ebr al, acident e cer ebr ov ascular .
I n t r odu ct ion
Spont aneous r ecanalizat ion of t he int er nal car ot id ar t er y ( I CA) is a r ar e and lit t le inv est igat ed ev ent .1 I t s low incidence is pr obably due t o t he fact t hat , unt il som e y ear s ago, it s definit iv e diagnosis could only be obt ained by ar t er iogr aphy , an inv asiv e ex am inat ion.2
Ev olut ion of pat ient s w it h acut e occlusion of t he I CA can be negat iv e, w it h disabling deficit s and m or t alit y r at es as high as 55% .3
Occur r ence of r ecanalizat ion in t he acut e st age is m or e fr equent t han lat e r ecanalizat ion, and it m ay occur in up t o 33% of cases in som e st udies.1 , 2 , 4
Our st udy aim s at r epor t ing a case of spont aneous, sy m pt om at ic r ecanalizat ion of t he I CA, confir m ed by duplex scan, ar t er iogr aphy and int r aoper at iv e finding, as w ell as st r essing t he im por t ance of follow ing pat ient s w it h I CA occlusion.
Ca se de scr ipt ion
M., 73 y ear s old, hy per t ensiv e, w it h hist or y of ischem ic st r ok e 3 y ear s ago, w it h r ight upper lim b par esis and am aur osis fugax . At t hat t im e, t he pat ient w as subm it t ed t o br ain com put ed
t om ogr aphy ( Figur e 1) and duplex scan of t he car ot id ar t er ies, w hich show ed, r espect iv ely ,
Tw o y ear s aft er t he ischem ic ev ent , t he pat ient pr ogr essed w it h new episodes, char act er ized by am aur osis fugax t o t he left , aphasia, buccal angle dev iat ion t o t he left and t em por ar y w or sening of m ot or deficit , w hich r egr essed spont aneously .
The pat ient w as subm it t ed t o a new duplex scan of t he car ot id ar t er ies, w hich show ed st enosis gr eat er t han 70% in t he left I CA, w it h peak sy st olic v elocit y of 245 cm / s and final diast olic v elocit y of 78.5 cm / s. DSA confir m ed v essel r ecanalizat ion, w it h sev er e st enosis and no signs t hat could suggest dist al I CA filling t o t he point of occlusion by collat er al v eins or vasa vasor um ( Figur e 2) .
Sur gical cor r ect ion of t he lesion w as chosen, using endar t er ect om y of t he left car ot id ar t er y and ar t er ior r haphy using Dacr on pat ch. The pat ient w as dischar ged on t he four t h day aft er t he sur ger y and r em ains asy m pt om at ic so far , aft er 1 m ont h of out pat ient follow- up.
D iscu ssion
Diagnosis of I CA r ecanalizat ion is not fr equent , w it h no accur at e dat a in t he lit er at ur e about it s incidence or m ost com m on per iod of occur r ence, because it s definit iv e diagnosis is dependent on an inv asiv e ex am inat ion t hat is not fr ee fr om com plicat ions ( DSA) .2
Resear ch on I CA r ecanalizat ion is oft en neglect ed by v ascular sur geons due t o t he im pr ession of t her apeut ic im possibilit y and pr esum able asy m pt om at ic ev olut ion in m ost cases.5
This phenom enon occur s m or e fr equent ly t han pr ev iously supposed. Mev es, in a pr ospect iv e st udy , obser v ed spont aneous r ecanalizat ion of 33% in up t o 7 day s in 18 pat ient s w it h I CA occlusion.4
Sev er al ser ies of cases r epor t occur r ence of such fact bet w een 6 hour s and 2 w eek s aft er v essel occlusion.2 , 8 , 9 Consequent ly , it is a lit t le obser v ed ev ent by v ascular sur geons, w ho, m ost of t he t im es, deal w it h chr onic occlusions, inv est igat ing pot ent ially sur gical car ot id st enosis.1 I n t he lit er at ur e, t her e ar e few r epor t s of spont aneous r ecanalizat ion of t he I CA.1 , 5 , 1 0 , 1 1
The m echanism by w hich r ecanalizat ion of lat e occlusions occur s is st ill lit t le k now n. Lam m ie, in 1999, suggest ed t he possibilit y of occlusions r esult ing fr om ulcer at ed plaque t hr om bosis pr esent ing long- t er m r ecanalizat ion by t hr om boly sis.1 2
Callej a, in 2004, suggest ed t he possibilit y of occlusions r esult ing fr om int r aplaque hem or r hage inducing a local edem a, w hich causes occlusion. When such endot helial edem a r egr esses, t he v essel r ecanalizes spont aneously . This t heor y could j ust ify ear lier r ecanalizat ions.1 3
Colon, in 1999, published a ser ies of four cases of spont aneous r ecanalizat ion of t he I CA, w hich t hr ough im aging ex am inat ions and int r aoper at iv e finding, pr ov ed t o be a hy per t r ophy of vasa vasor um , causing r eper fusion of t he I CA dist al t o t he occlusion.1 4
The v asa v asor um , in lar ge- caliber v essels, such as t he I CA, ar e pr esent bot h in adv ent it ia and t unica m edia. I n case of m y oint im al hy per plasia or at her oscler ot ic disease, a neov ascular izat ion is induced, w hich, in t he long t er m , can allow per fusion dist al t o v essel occlusion.1 4
Per sist ence of som e em br y onic v essels can also account for t he com plet e nonocclusion of t he w hole int er nal car ot id ar t er y segm ent , allow ing act ion of v ar ied m echanism s for v essel r ecanalizat ion.
Now aday s som e gr oups hav e been follow ing pat ient s w it h car ot id occlusions, w it h t he aim of bet t er ev aluat ing t he nat ur al hist or y of such lesions.5
Ver lat o, in 2000, published a cohor t st udy including 41 pat ient s w it h car ot id occlusion, follow ed by 44.5 m ont hs in av er age, and ident ified one case of asy m pt om at ic car ot id occlusion t hat had
How ev er , as r epor t ed in our case, r ecanalizat ion can pr ogr ess sy m pt om at ically , w it h dist al em bolizat ions and subj ect t o r epair . Sur gical t act ics is also discussed in t he lit er at ur e for t hese cases.
Klonar is, in 2006, r epor t ed a case of a pat ient w ho, aft er a 1- year follow- up of car ot id occlusion, pr ogr essed w it h v essel r ecanalizat ion, choosing open r epair and av oiding t he endov ascular appr oach due t o t he anat om ic char act er ist ic of t he lesion, w hich pr ev ent ed t he passage of a pr ot ect ion sy st em , besides a high r isk of em bolizat ion of a possible local t hr om bus, w hich w as not obser v ed dur ing t he sur ger y .1
Kim , in 2006, pr esent ed t he case of a pat ient w it h st at us of br ain ischem ia, w it h r ecent occlusion of t he left I CA, w hich had spont aneous r ecanalizat ion 4 w eek s aft er t he diagnosis. Angioplast y w as per for m ed w it hout using a pr ot ect ion sy st em , and t he pat ient pr ogr essed unev ent fully , confir m ing t hat t he endov ascular t r eat m ent is also feasible in t hese cases.9
Con clu sion
Car ot id occlusion follow- up allow ed us t o obser v e v essel r ecanalizat ion, w hich pr ogr essed sy m pt om at ically , r equir ing sur gical int er v ent ion for it s t r eat m ent .
Re fe r e n ce s
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Cor r e spon de n ce :
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CEP 04111-010 – S•o Paulo, SP, Brazil Tel.: (11) 8111.2860
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