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Table of Contents    
ORIGINAL ARTICLE
Year : 2012  |  Volume : 60  |  Issue : 2  |  Page : 174-179

Monitored gradual occlusion of the internal carotid artery followed by ligation for giant internal carotid artery aneurysms


Department of Neuroradiology and Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission06-Aug-2011
Date of Decision22-Sep-2011
Date of Acceptance22-Jan-2012
Date of Web Publication19-May-2012

Correspondence Address:
P S Chandra
Room No. 7, 6th Floor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.96396

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 » Abstract 

Objective: To demonstrate a technique of gradual monitored occlusion of the internal carotid artery (ICA) followed by ligation for giant aneurysms as an option for balloon test occlusion followed by permanent ligation of ICA. Materials and Methods: Authors retrospectively analyzed 27 patients with giant and complex ICA aneurysms who underwent carotid artery ligation between January 2001 and December 2010. Clinical presentation included headache, vision loss and diplopia. There were 19 patients with cavernous aneurysm, 5 supraclinoid, 1 ophthalmic, 1 petrous segment and 1 cervical segment aneurysm located extracranially. All demonstrated good cross-circulation. Selverstone clamp was used for gradual occlusion of the ICA over 72 h under closed observation in the intensive care unit. Results: Six patients developed hemiparesis in the postoperative period. Improvement occurred in one patient over two to three weeks while the remaining five patients had residual hemiparesis. One patient developed malignant MCA infarct for which decompressive craniectomy had to be done. There was no mortality in the present series. Conclusions: Gradual monitored occlusion and ICA ligation may be a simple, safe alternative procedure to clipping in surgically inaccessible and complex aneurysms, especially for surgeons with limited experience. Cross circulation study is an absolute requisite for carotid ligation.


Keywords: Carotid ligation, giant aneurysm, gradual monitored occlusion, internal carotid artery aneurysm, outcome


How to cite this article:
Rathore YS, Chandra P S, Kumar R, Singh M, Sharma MS, Suri A, Mishra N K, Gaikwad S, Garg A, Sharma B S, Mahapatra A K. Monitored gradual occlusion of the internal carotid artery followed by ligation for giant internal carotid artery aneurysms. Neurol India 2012;60:174-9

How to cite this URL:
Rathore YS, Chandra P S, Kumar R, Singh M, Sharma MS, Suri A, Mishra N K, Gaikwad S, Garg A, Sharma B S, Mahapatra A K. Monitored gradual occlusion of the internal carotid artery followed by ligation for giant internal carotid artery aneurysms. Neurol India [serial online] 2012 [cited 2019 Dec 14];60:174-9. Available from: http://www.neurologyindia.com/text.asp?2012/60/2/174/96396



 » Introduction Top


Giant carotid aneurysms in the paraclinoid or cavernous segment, which are surgically complex and 'unclippable' may be considered for carotid ligation as it is a simple procedure to perform and may be performed even in a setup with limited infrastructure. Authors retrospectively analyzed patients with giant internal carotid artery (ICA) aneurysms who had undergone ICA ligation.


 » Materials and Methods Top


This study is a retrospective review of case records of patients who underwent ICA ligation between January 2001 and December 2010. Pre- and postoperative angiography was reviewed and compared to determine changes in aneurysm size, vessel caliber, appearance of new aneurysms, cross circulation, and functioning of bypass. All the patients had giant aneurysms not suitable/extremely difficult for clipping. The indications for this procedure were: (1) cannot afford endovascular procedure; (2) presence of severe medical condition or any other high-risk factor precluding surgery; and (3) morphology of aneurysm complex making clipping difficult. Adequate cross-circulation on angiography was a mandatory criterion before undertaking this procedure. During the angiographic procedure, a transient occlusion was provided for about 5 min while assessing for cross-circulation and patient was carefully assessed for any clinical deficits.

Surgical procedure

Procedure was performed under general anesthesia. Cervical ICA was exposed through a 5-cm transverse incision below the angle of mandible. After exposing the carotid bifurcation control of internal carotid, external carotid and common carotid artery was obtained, Heparin was administered intravenously at a dose of 85 IU/kg to prevent intravascular thrombosis. No. 1 prolene or silk sutures were passed both above and below the site of application of the Selverstone clamp and kept inside the wound untied. The Selverstone clamp was applied and approximately 40-50% lumen of the ICA was occluded. The clamp was brought out of the same incision, and the sutures were closely approximated around this. The clamp was gradually closed over the next 48-72 h starting a day after surgery. The Selverstone clamp was removed after another 24 h after complete closure of the ICA. During this entire period, all vital parameters were closely monitored in the ICU. The clamp was released if the patient complained of even subtle subjective symptoms. During this entire procedure, adequate hydration was maintained with colloids ensuring about 3-3.5liters of fluid intake per day. Thus even though a traditional balloon test occlusion (BTO) was not performed, we felt that the described procedure was better than this, as it allowed a gradual occlusion of the ICA over a much longer period of time in the ICU with close observation. In three patients there was poor collateral circulation, so superficial-middle cerebral artery (STA-MCA) bypass was done before the application of the Selverstone clamp. Carotid occlusion was begun three days after surgery in these three patients. Throughout the procedure, patients were kept in the neurosurgery ICU for careful neurological assessment and blood pressure monitoring. Colloids were given for 72 h to keep mean blood pressure approximately 10% higher than preoperative levels. Clamp was removed in the ICU itself under local anesthesia, after 24 h of complete occlusion of the ICA. Before its removal, permanent occlusion of the ICA was performed using no.1 prolene or silk sutures, applied both proximally and distal to the clamp to ensure complete occlusion [Figure 1], [Figure 2] and [Figure 3].
Figure 1: Right ICA giant aneurysm with good collateral circulation

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Figure 2: DSA after ligation of ICA, of the same patient shown in Figure 1, showing good collateral circulation

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Figure 3: Technique of application of the Selverstone clamp in both the opening and closing position

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Following ICA ligation angiography was usually carried out at an interval of three to six months. Long-term follow-up was done with computed tomography (CT) or magnetic resonance imaging (MRI).


 » Results Top


During the study period 27 patients (12 males, age range 20-75 years) underwent ICA ligation. Demographic details, presenting features, aneurysm location, postoperative complications are summarized in [Table 1]. There were 19 cavernous aneurysms, 5 supraclinoid, 1 ophthalmic, 1 petrous segment and 1 cervical segment aneurysm located extracranially. Clinical presentation included headache (18), diplopia (20) and vision loss (5). Examination revealed IIIrd nerve palsy (15), VIth nerve palsy (16), and IVth nerve palsy (7). The average size of the giant aneurysm was 4-5 cm. One patient had mild hemiparesis which persisted after the procedure. Postoperatively 17 patients had improved neurological outcome while four remained the same and six patients developed hemiparesis. Of the patients who developed hemiparesis, improvement occurred in one patient over two to three weeks and the remaining five patients were left with residual hemiparesis. One patient developed malignant MCA territory infarct requiring decompressive craniectomy. There was no mortality in the present series. Thus an overall of 22 patients benefitted from surgery.
Table 1: Summary of all 27 patients treated with gradual ICA compression followed by ICA ligation for giant aneurysms

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Of the 27 patients, three had poor collateral circulation. In these patients, bypass procedure was done before the carotid ligation. In two patients ST-MCA anastomosis was performed while in one patient external carotid to MCA anastomosis was performed.

Four patients were lost to follow-up. Mean follow-up was 2.4 years, median was 3.2 years (range 6 months to 10 years). Vision did not improve in any of the patients while diplopia improved in 17 patients. Post-ligation angiographic evaluation was done in 23 patients, all showing complete obliteration of the aneurysm. One patient showed a small aneurysm in the contralateral posterior communicating/ICA junction. Out of three patients who had undergone bypass followed by carotid ligation, one showed well-functioning bypass while other showed failure of bypass; the third patient with bypass was lost to follow-up.


 » Discussion Top


Clip occlusion cannot be performed in some aneurysms because of their size, complexity, inaccessible locations like giant cavernous segment carotid aneurysm, [1] and lack of surgeon expertise. The latter reason is particularly true for countries like India, because of large pockets of the population having access to centers with limited healthcare facilities. In such patients gradual monitored occlusion of the carotid artery and ligation may be a safe and effective alternative method as it can be performed even by surgeons with limited experience. Endovascular techniques like balloon trapping, stent-assisted coiling and flow diverter stents are ideal but require expertise and are expensive. [2],[3]

Hunter first used proximal ligation in 1784 for treatment of a popliteal aneurysm. [4] Cooper in 1805 used proximal artery ligation for the treatment of an extracranial carotid aneurysm. [5] Operating a patient in 1885 diagnosed to have a tumor of the middle fossa, Victor Horsley pioneered ligation of the ICA for intracranial aneurysm treatment. [6],[7] In 1969, a larger series of 461 patients with carotid artery ligation was published by Sahs and Locksley, in which they reported 20.7% mortality and a 30% stroke rate. [8]

Although carotid ligation is a simple operation as compared to intracranial clipping of an aneurysm, it carries the risk of producing ischemia of the ipsilateral cerebral hemisphere, 34% with abrupt occlusion and 25% with gradual occlusion in the Cooperative Aneurysm Study. [9] In 21%, ischemia were delayed > 48 h after ligation, and evidence suggests that deficits of delayed onset are more likely to be permanent than are ischemic complications occurring within the first few hours after ligation as was noted in one of our patients who developed hemiparesis immediately postoperatively which improved in two to three weeks. [10] A host of tests have been described in the literature starting with a simple BTO, along with SPECT, monitored BTO and xenon CT perfusion scans following BTO. Despite performing all possible investigations, the risk of developing deficits following ICA ligation cannot be ruled out completely and still ranges from 5-10%. At the same time one has to remember that clipping or bypass of such aneurysms carries a morbidity of 10-30% and a mortality of 3-10%. [1],[11],[12],[13] This could be considerably higher with surgeons who attempt to operate these pathologies without adequate experience. ICA ligation thus becomes an eminently practical alternative in such conditions. In the present series, six (22%) patients suffered ischemic complications. There was no mortality. Thus the outcome is comparable to surgical clipping with an advantage of this being a simple and an easily reproducible procedure with much less morbidity than an open craniotomy procedure.

ICA ligation is considered more effective than common carotid artery (CCA) occlusion. [14],[15],[16] Both ICA as well as CCA ligation have been associated with a similar incidence of aneurismal thrombosis, aneurysm size reduction and rebleeding rate. [9],[16],[17],[18],[19] In the present series all patients underwent internal carotid ligation. The efficacy of carotid ligation for induction of aneurysm thrombosis is inversely proportional to the degree of collateral circulation. [20],[21]

BTO has been the standard to study the tolerance of the affected hemisphere to carotid ligation. But even after BTO with SPECT supplementation, there is 15-20% risk of development of ischemia/infarction. Failure of BTO and decrease in cerebral blood flow on SPECT during the BTO can identify those patients at increased risk for stroke after carotid ligation. However, a normal SPECT after a successful BTO does not indicate that carotid ligation can be performed safely. [22] It is also not available in every center. Taking these factors into consideration, this simple technique has been suggested. Here, initially a temporary occlusion is provided for a period of 15 min during angiography while testing for cross-circulation under close monitoring. This is to ensure that the patient will be able to tolerate the 50% occlusion that is provided at the time of initial application of the Selverstone clamp. Once an adequate cross-circulation is confirmed, the patients underwent a surgical procedure, where the clamp was applied. The clamp gradually narrowed the ICA over the next 72 h in the ICU thus allowing a close monitoring. This technique is thus better than the standard BTO as: (1) a much longer period of time was provided as compared to the standard BTO and (2) the clamp could be released immediately even when the patient complained of minor symptoms thus providing an opportunity for immediate active intervention. We do agree that the cohort while itself being reasonably large is still small to derive any specific advantages of this procedure. However, the overall results are still comparable to surgical clipping with the advantage of this being a much simpler procedure.

The advent of the Selverstone clamp in the 1950s influenced aneurysm surgery profoundly. [23],[24] Nornes demonstrated that gradual occlusion of the ICA with the Selverstone clamp provides superior outcomes to those experienced with full occlusion. [25] Gradual occlusion of the artery is thought to allow the expansion of collateral circulation in cases of marginal flow. Silvani et al., showed that complete clamp closure is likely to cause ischemic side-effects. [26] However, over a period of time with the development of more effective tools like more advanced clips, advancement of endovascular techniques, etc., this procedure has lost its utility. In countries like India, high-end treatment, especially for neurosurgical disorders is still driven by financial restrictions of the general population, and lack of adequate infrastructure (limited SPECT availability and xenon-CT not available) in most hospitals. Taking this into consideration, this therapy may still have its usefulness in some cases of giant aneurysms. Hence in this manner, the following paper may be considered as a 'reinvention' of a well-established old procedure which has now been stopped 'being quoted in the recent literature' with the development of new technologies.

Late complications of carotid occlusion are well recognized, and may even occur many years after the procedure. [27],[28],[29],[30] One of our patients developed an aneurysm in the contralateral posterior communicating artery. De novo aneurysm formation may occur because of hemodynamic changes caused by carotid ligation. One patient developed lower motor neuron 7 th nerve palsy following ligation. This patient had a high ICA bifurcation. Thus it is possible that some branches of the facial nerve might get damaged during the surgical procedure.

In conclusion we feel that gradual internal carotid artery occlusion in the neck is an effective method of treating a highly selective group of giant and complex ICA aneurysms. In a hospital with limited facilities, especially true for India, ICA ligation may be a reasonable treatment option.

 
 » References Top

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8.Sahs AL, Perret GE, Locksley HB, et al. Intracranial aneurysms and subarachnoid haemorrhage: A Cooperative Study. Philadelphia: Lippincott; 1969.  Back to cited text no. 8
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]

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