The Role of Intraindividual Carotid Artery Variation in the Development of Atherosclerotic Carotid Artery Disease: A Literature Review
Carotid artery disease (CAD) is associated with numerous risk factors, including hypertension, hyperlipidemia, hypercholesterolemia, diabetes mellitus, and smoking. These systemic risk factors do not affect the carotid arteries equally in most patients, resulting in asymmetrical bilateral and unilateral CAD. It is unclear if anatomic variations in the carotid arteries predispose an individual to formation of atherosclerotic CAD. We wanted to assess (1) the inter-individual or intra-individual anatomical variations in the carotid arteries and (2) whether anatomical variations predispose the development of atherosclerotic CAD. PubMed and Medline were utilized to identify relevant literature for critical appraisal, summarization and documentation. Inclusion and exclusion criteria were applied to narrow results and articles were critically appraised and analyzed. Evidence suggests that a low outflow/inflow ratio, elevated bifurcation height, and bifurcation angle are associated with increased risk for CAD. Sex and age demonstrated positive correlation with the disease. Additionally, tortuosity and kinking of the carotid arteries may affect the formation of CAD but coiling of the arteries is a natural age-dependent process and does not affect CAD development. This review suggests there are anatomic variations in the carotid arteries that increase the risk of developing carotid artery disease. The most significant risk factors include a low outflow/inflow ratio, increased internal carotid artery tortuosity, elevated bifurcation height, and bifurcation angle.
Prasad K. Pathophysiology and Medical Treatment of Carotid Artery Stenosis. Int J Angiol. 2015 Sep;24(3):158-72.
Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation. 2012 Jan 3;125(1):188-97.
Jashari F, Ibrahimi P, Nicoll R, Bajraktari G, Wester P, Henein MY. Coronary and carotid atherosclerosis: similarities and differences. Atherosclerosis. 2013 Apr;227(2):193-200.
Richardson PD, Davies MJ, Born GV. Influence of plaque configuration and stress distribution on fissuring of coronary atherosclerotic plaques. Lancet. 1989 Oct 21;2(8669):941-4
Gnasso A, Irace C, Carallo C, De Franceschi MS, Motti C, Mattioli PL, et al. In vivo association between low wall shear stress and plaque in subjects with asymmetrical carotid atherosclerosis. Stroke. 1997 May;28(5):993-8.
Ruan L, Chen W, Srinivasan SR, Sun M, Wang H, Toprak A, et al. Correlates of common carotid artery lumen diameter in black and white younger adults: the Bogalusa Heart Study. Stroke. 2009 Mar;40(3):702-7.
Goubergrits L, Affeld K, Fernandez-Britto J, Falcon L. Geometry of the human common carotid artery. A vessel cast study of 86 specimens. Pathol Res Pract. 2002;198(8):543-51.
Karino T, Goldsmith HL. Particle flow behavior in models of branching vessels. II. Effects of branching angle and diameter ratio on flow patterns. Biorheology. 1985;22(2):87-104.
Fabris F, Zanocchi M, Bo M, Fonte G, Poli L, Bergoglio I, et al. Carotid plaque, aging, and risk factors. A study of 457 subjects. Stroke. 1994 Jun;25(6):1133-40.
Lee SW, Antiga L, Spence JD, Steinman DA. Geometry of the carotid bifurcation predicts its exposure to disturbed flow. Stroke. 2008 Aug;39(8):2341-7.
Spelde AG, de Vos RA, Hoogendam IJ, Heethaar RM. Pathological-anatomical study concerning the geometry and atherosclerosis of the carotid bifurcation. European journal of vascular surgery. Eur J Vasc Surg. 1990 Aug;4(4):345-8.
Gosling RG, Newman DL, Bowden NL, Twinn KW. The area ration of normal aortic junctions. Aortic configuration and pulse-wave reflection. Br J Radiol. 1971 Nov;44(527):850-3.
Napoli C, Witztum JL, de Nigris F, Palumbo G, D'Armiento FP, Palinski W. Intracranial arteries of human fetuses are more resistant to hypercholesterolemia-induced fatty streak formation than extracranial arteries. Circulation. 1999 Apr 20;99(15):2003-10.
Del Corso L, Moruzzo D, Conte B, Agelli M, Romanelli AM, Pastine F, et al. Tortuosity, kinking, and coiling of the carotid artery: expression of atherosclerosis or aging? Angiology. 1998 May;49(5):361-71.
Zegers E, Meursing B, Zegers E, Oude Ophuis A. Coronary tortuosity: a long and winding road. Neth Heart J. 2007 May;15(5):191-5.
Wityk RJ, Lehman D, Klag M, Coresh J, Ahn H, Litt B. Race and sex differences in the distribution of cerebral atherosclerosis. Stroke. 1996 Nov;27(11):1974-80.
Schulz UG, Rothwell PM. Major variation in carotid bifurcation anatomy: a possible risk factor for plaque development? Stroke. 2001 Nov;32(11):2522-9.
Phan TG, Beare RJ, Jolley D, Das G, Ren M, Wong K, et al. Carotid artery anatomy and geometry as risk factors for carotid atherosclerotic disease. Stroke. 2012 Jun;43(6):1596-601.
De Syo D, Franjic BD, Lovricevic I, Vukelic M, Palenkic H. Carotid bifurcation position and branching angle in patients with atherosclerotic carotid disease. Coll Antropol. 2005 Dec;29(2):627-32.
Kamenskiy AV, Pipinos, II, Carson JS, MacTaggart JN, Baxter BT. Age and disease-related geometric and structural remodeling of the carotid artery. J Vasc Surg. 2015 Dec;62(6):1521-8.
Cappabianca S, Somma F, Negro A, Rotondo M, Scuotto A, Rotondo A. Extracranial internal carotid artery: anatomical variations in asymptomatic patients. Surg Radiol Anat. 2016 Oct;38(8):893-902.
Schulz UG, Rothwell PM. Sex differences in carotid bifurcation anatomy and the distribution of atherosclerotic plaque. Stroke. 2001 Jul;32(7):1525-31.
Sehirli US, Yalin A, Tulay CM, Cakmak YO, Gurdal E. The diameters of common carotid artery and its branches in newborns. Surg Radiol Anat. 2005 Nov;27(4):292-6.
McNamara JR, Fulton GJ, Manning BJ. Three-dimensional computed tomographic reconstruction of the carotid artery: identifying high bifurcation. Eur J Vasc Endovasc Surg. 2015 Feb;49(2):147-53.
Koch S, Nelson D, Rundek T, Mandrekar J, Rabinstein A. Race-ethnic variation in carotid bifurcation geometry. J Stroke Cerebrovasc Dis. 2009 Sep-Oct;18(5):349-53.
Schulz UG, Rothwell PM. Association between arterial bifurcation anatomy and angiographic plaque ulceration among 4,627 carotid stenoses. Cerebrovasc Dis. 2003;15(4):244-51.
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