This case report represents rare complication of carotid surgery, iatrogenic dissection of the common carotid artery and its successful endovascular treatment. We herein report a case of 55 year-old female patient in whom carotid surgery was performed due to constant tinnitus caused by kinking of right internal carotid artery. On day 7th carotid control ultrasound was performed, according to hospital’s protocol. The carotid ultrasound showed dissecting lesion of right common carotid artery in a length of three centimeters that was confirmed with computed tomography angiography of neck vessels, and dual antithrombotic therapy was initiated. One month later percutaneous angioplasty was performed with stent implantation

Budinčević, Hrvoje

Ivkošić, Ante

Pavić, Predrag

Vidjak, Vinko

English

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C!"# R#$%&'RAD 553. Medical Sciences 60-61 (2022) : 124-127                  www.rad-med.com 124 December 2022   -   Vol 553 = 60-61Abstract!is case report represents rare complication of carotid surgery, iatrogenic dissection of the common carotid artery and its successful endovascular treatment. We herein report a case of 55 year-old female patient in whom carotid surgery was performed due to constant tinnitus caused by kinking of right internal carotid artery. On day 7th carotid control ultrasound was performed, according to hospital’s protocol. !e carotid ultrasound showed dissecting lesion of right common carotid artery in a length of three centimeters that was con"rmed with computed tomography angiography of neck vessels, and dual antithrombotic therapy was initiated. One month later percutaneous angioplasty was performed with stent implantation. Keywords: carotid kinking, carotid dissection, endovascular treatment, carotid surgery.  Sažetak:D#$%&#'()*+% ,%-#)% -()%./#01% 1('23#./% ('3%'#)% /(12/ 24%'(&#)% 1('23#.%: 4'#1(- $,*0()(Ovaj prikaz slu5aja predstavlja rijetku komplikaciju karotidnog kirur6kog zahvata, jatrogenu disekciju zajedni5ke karotidne arterije i njene uspje6no endovaskularno lije5enje. Prikazujemo slu5aj 55-godi6nje pacijentice kod koje je u5injena karotidna operacija zbog stalnog tinitusa uzrokovanog uvijanjem desne unutarnje karotidne arterije. Sedmog dana u5injen je kontrolni ultrazvuk karotida, prema bolni5kom protokolu. Ultrazvuk karotide pokazao je diseciraju7u leziju desne zajedni5ke karotidne arterije u du8ini od tri centimetara 6to je potvr9eno kompjutoriziranom tomografskom angiogra"jom 8ila vrata, a dvojna antitrombotska terapija pokrenut. Mjesec dana kasnije u5injena je perkutana angioplastika s implantacijom stenta. Ključne riječi: karotidno presavinu7e, karotidna disekcija, endovaskularno lije5enje, karotidna kirurgijaDissecting lesions of  common carotid artery after carotid surgery: a case reportHrvoje Budin5evi7 1,2, Ante Ivko6i7 3,4, Vinko Vidjak4,5, Predrag Pavi7 4,6 1 Sveti Duh University Hospital, Department of Neurology, Zagreb, Croatia2 University J. J. Strossmayer, Faculty of Medicine, Department of Neurology and Neurosurgery, Osijek, Croatia3 Sveti Duh University Hospital, Department of Surgery, Zagreb, Croatia4 University of Zagreb, School of Medicine, Zagreb, Croatia 5 Clinical Hospital Merkur, Clinical Department of Diagnostic and Interventional Radiology, Zagreb, Croatia6 University Hospital Center Zagreb, Department of Surgery, Zagreb, CroatiaOPEN ACCESSCorrespondence:Hrvoje Budincevichbudincevic@gmail.comThis article was submitted to RAD CASA - Medical Sciencesas the original articleConflict of Interest Statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.Received: 29 November 2022 Accepted: 13 December 2022 Published: 21 December 2022Citation:Budincevic H, Ivkosic A, Vidjak V, Pavic P. Dissecting lesions of common carotid artery after carotid surgery: a case reportRAD CASA - Medical Sciences. 553=60-61 (2022): 124-127DOI: 10.21857/mjrl3uglr9Copyright (C) 2022 Budincevic H, Ivkosic A, Vidjak V, Pavic P. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owners(s) are credited and that the original publication in this journal is cited, in accordance whit accepted adacemic practice. No use, distribution or reproduction is permitted which does not comply with these terms. C!"# R#$%&'RAD 553. Medical Sciences 60-61 (2022) : 124-127                  www.rad-med.com 125 December 2022   -   Vol 553 = 60-61INTRODUCTIONCarotid artery dissections include two types, spontaneous, which occurs without cause and others usually caused as a result of blunt or penetrating trauma (1). Carotid surgery is commonly performed in patients with symptomatic high grade carotid stenosis, while rarely in uncommon disorders a:ecting carotid ar-teries such as kinking and coiling of internal carotid artery which produce ischemic symptoms, carotid body tumor and dissection of the carotid artery (2-5). !is case report represents a potentially dangerous and rare com-plication of carotid surgery and the role of ultrasound in early detection of the dissecting lesion. Case report We herein report a case of 55 year-old female patient in whom carotid surgery was performed due to kinking of right internal carotid artery which caused constant tinnitus. !e kinking of the right internal carotid artery was con"rmed with computed tomography angiography (Figure 1.) and digital subtraction angiography of the neck. !e patient complained of pain and palpable pulsating tumorous mass on right side of the neck, with symptoms of constant tinnitus. Her prior medical history included low back pain and gastritis, whilst six months prior to surgery the patient underwent a microdiscectomy for cervical radiculopathy  (C5-C6).  Carotid surgery was performed in the patient and included segmental resection of right internal carotid artery with re-anastomosis with common carotid artery. !e patient did not complain of symptoms after the surgery, while previous symptoms disappeared.  On day 7th carotid control ultrasound was performed, according to hospital’s protocol. !e carotid ultrasound showed dissecting lesion of right common ca-rotid artery in a length of three centimeters ending at the carotid bifurcation that formed double ;aps at the beginning and at the end of dissection and produced moderate hemodynamic stenosis (60%) (Figure 2.), that was con"rmed with computed tomog-raphy angiography of neck vessels (Figure 3. and Figure 4.). !e neurological and physical status was normal, except for the pain experienced in the neck again. For stroke prevention dual anti-platelet and antihypertensive therapy were introduced. Due to presence of symptoms, one month later percutaneous angioplasty was performed with stent implantation. !e control carotid ultrasound showed stent implantation with normal hemodynam-ics, without any sign of dissection (Figure 5. and Figure 6.).   DiscussionOur case demonstrated a potentially dangerous and rare com-plication of carotid surgery and the role of ultrasound in early detection of the lesion. !e proposed mechanism of the lesion was the tight clamping with Rumel tourniquet of the right com-mon carotid artery during surgery that produced intimal tear of the common carotid artery and led to dissection. !e other re-Figure 1. Computed tomography angiography of the neck vessels shows kinking of the right internal carotid arteryFigure 2. Carotid ultrasound shows dissecting lessions of the right common carotid artery C!"# R#$%&'RAD 553. Medical Sciences 60-61 (2022) : 124-127                  www.rad-med.com 126 December 2022   -   Vol 553 = 60-61ported mechanism of dissecting lesion is shunt placement during surgery, the surgical technique and clamping time (6). Intimal lesions such as dissections are rarely described but they might be a important factor for the development of thromboembolic in-cident (6). Although the carotid irregularities are common after carotid surgery, they rarely cause re-stenosis (7). !ese irregulari-ties are intimal ;aps, intimal steps and dissecting lesions (8). Previous reports using ultrasound  showed that in patients with carotid surgery for symptomatic high grade stenosis asymptomat-ic dissecting lesions of carotid arteries are 5% (6). Endovascular treatment might be indicated and it is a safe procedure (9, 10). Carotid artery abnormalities such as tortuosity, kinking and coiling are common, and it might be present in one fourth of patients refered to carotid ultrasound (11). Mumoli et al. showed that carotid kinking and coiling are prevalent in female patients (female to male ratio 4:1), and it is associated with smoking, hyperlipidemia, and ischemic heart disease (12). !ese "nd-ing might be acquired or congenital (2).  Kinkings are usually associated with mild atherosclerotic plaques that cause di:erent degrees of carotid stenosis (11).  Symptoms which are related to tortuosity of carotid artery are neck pain, vertigo, tinnitus, and in rare cases transient ischemic attack or even stroke (11). Surgery of carotid artery is advocated in symptomatic kinking or coiling with high grade stenosis (4). Carotid surgery might be performed in other but selected symptomatic patients (3). !ere are reported cases with pulsatile tinnitus in which carotid surgery of kinking produced good clinical outcome (13, 14).   Ballotta et al. showed that carotid surgery for symptomatic (causing cerebral ischemic symptoms) carotid kinking is superior in preventing stroke in comparison to the best medical therapy (15). Asympto-matic patients should be treated with conservative approach (3). ConclusionGenerally surgery of carotid abnormalities (such as kinkings) without ischemic symptoms should be avoided, except in care-fully selected cases. !e carotid surgery complications such as dissecting lesion might be successfully treated with percutaneous angioplasty with stent implantation. Carotid ultrasound has its place as a screening method for demonstrating these undisclosed lesions.  Figure 3. Computed tomography angiography of the neck vessels after surgery shows dissecting lesions of the right common carotid arteryFigure 4. Computed tomography angiography of the neck vessels shows  dissecting lesions of the right common carotid arteryC!"# R#$%&'RAD 553. Medical Sciences 60-61 (2022) : 124-127                  www.rad-med.com 127 December 2022   -   Vol 553 = 60-61References:1. !anvi B, Munshi SK, Dawson SL, Robinson TG: Carotid and vertebral artery dissection syndromes. Postgrad Med J 2005, 81(956):383-388.2. Ivkosic A, Trajbar T, Antolic S, Lojo N, Budincevic H, Mrsic V: [Rare disorders of extracranial carotid arteries]. Acta Med Croatica 2014, 68(3):307-310.3. Radak D, Babic S, Tanaskovic S, Matic P, Sotirovic V, Stevanovic P, Jovanovic P, Gajin P: Are the carotid kinking and coiling underestimated entities? Vojnosanit Pregl 2012, 69(7):616-619.4. Demarin V, Lovrencic-Huzjan A, Basic S, Basic-Kes V, Bie-len I, Breitenfeld T, Brkljacic B, Cambi-Sapunar L, Jurjevic A, Kadojic D et al: Recommendations for the management of patients with carotid stenosis. Acta Clin Croat 2010, 49(1):101-118.5. Ivkosic A, Trajbar T, Budincevic H, Antolic S, Lojo N, Oberhofer D: [Early carotid endarterectomy in sympto-matic patients - our experience]. Acta Med Croatica 2014, 68(3):289-293.6. Budincevic H, Ivkosic A, Martinac M, Trajbar T, Bielen I, Csiba L: Asymptomatic dissecting intimal lesions of com-mon carotid arteries after carotid endarterectomy. Surg Today 2015, 45(10):1227-1232.7. Sharpe R, Sayers RD, McCarthy MJ, Dennis M, London NJ, Nasim A, Bown MJ, Naylor AR: !e war against error: a 15 year experience of completion angioscopy following carotid en-darterectomy. Eur J Vasc Endovasc Surg 2012, 43(2):139-145.8. van der Kolk AG, de Borst GJ, Jongen LM, den Hartog AG, Moll FL, Mali WP, Hendrikse J: Prevalence and clinical consequences of carotid artery residual defects following Figure 5. Carotid ultrasound shows stent placement and normal morphology of the right common carotid arteryFigure 6. Carotid ultrasound shows normal hemodynamics in right internal carotid artery after endovascular treatment. endarterectomy: a prospective CT angiography evaluation study. Eur J Vasc Endovasc Surg 2011, 42(2):144-152.9. Marone EM, Coppi G, Tshomba Y, Chiesa R: Eight-year experience with carotid artery stenting for correction of symptomatic and asymptomatic post-endarterectomy de-fects. J Vasc Surg 2010, 52(6):1511-1517.10. Vidjak V, Krnic A, Novacic K, Slavica M, Lovrencic-Huzjan A, Demarin V: [Stenting of dissected carotid arteries as a minimally invasive treatment modality]. Lijec Vjesn 2012, 134(1-2):12-19.11. Togay-Isikay C, Kim J, Betterman K, Andrews C, Meads D, Tesh P, Tegeler C, Oztuna D: Carotid artery tortuosity, kinking, coiling: stroke risk factor, marker, or curiosity? Acta Neurol Belg 2005, 105(2):68-72.12. Mumoli N, Cei M: Asymptomatic carotid kinking. Circ J 2008, 72(4):682-683.13. De Ridder D, Vanneste S, Menovsky T: Pulsatile Tinnitus due to a Tortuous Siphon-Like Internal Carotid Artery Suc-cessfully Treated by Arterial Remodeling. Case Rep Otolaryn-gol 2013, 2013:938787.14. Lukyanchikov VA, Khasauov RK, Kordonskaya OO, Dalibaldyan VA, Senko IV: Endoscopy-assisted surgi-cal treatment of carotid artery kinking. Khirurgiia (Mosk) 2020(2):13-20.15. Ballotta E, !iene G, Baracchini C, Ermani M, Militello C, Da Giau G, Barbon B, Angelini A: Surgical vs medical treatment for isolated internal carotid artery elongation with coiling or kinking in symptomatic patients: a prospective randomized clinical study. J Vasc Surg 2005, 42(5):838-846; discussion 846.

Dissecting lesions of common carotid artery after carotid surgery: a case report

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