Eversion endarterectomy and re-implantation in carotid stenosis and distal kink.

Kinking and coiling of the arteries are rare morphological alterations of the internal carotid artery (ICA) described as the most frequent sole cause of cerebrovascular insufficiency (CI), or as a combined cause together with carotid atherosclerosis. Although incidence of kinking and coiling of the ICA has been estimated to range from 10% to 16% in the general population, only 4% to 16% of these features cause symptomatic CI. Their natural course seems to be benign, and these alterations are asymptomatic in most cases. Morphological diagnosis is easy to determine with the help of current imaging techniques, but it is essential to determine, by means of a neurological examination and transcranial Doppler ultrasound, whether the anomaly is causing cerebral ischaemia. This letter presents the case of a patient with carotid stenosis and distal kink. Our patient is an 80-year-old man, a former smoker of one packet a day during 60 years with a medical history of arterial hypertension treated with 2 antihypertensive drugs (losartan and hydrochlorothiazide); he was also fitted with a cochlear implant. The patient visited the emergency department due to an episode of left-sided hemiparesia, plegic left arm, dysarthria, and amaurosis fugax of the right eye; symptoms had been present for several hours without remitting fully. Physical examination revealed left supranuclear facial paresis, distal brachial paresis with a tendency to pronation of the left forearm, and crural paresis with slow claudication after 10 seconds. Right flexor plantar reflex was observed. A Doppler ultrasound of the supra-aortic trunks revealed a heterogeneous and irregular plaque in the right carotid bifurcation, preocclusive stenosis (70%-99%) of the right internal carotid (RIC), and homogeneous plaque with moderate stenosis in the left internal carotid (LIC). Transcranial Doppler ultrasound showed the right middle cerebral artery (MCA) to be less curved than the left one. Head CT showed necrosis on the right superior parietal postrolandic area, and signs of diffuse brain atrophy (Fig. 1). A subsequent com-