European Journal of Vascular & Endovascular Surgery
Volume 39, Issue 2 , Pages 146-152, February 2010

Clinical Results of Carotid Denervation by Adventitial Stripping in Carotid Sinus Syndrome

  • R.J. Toorop

      Affiliations

    • Department of Vascular Surgery, University Medical Center, PO Box 85500, 3508 GA, Utrecht, The Netherlands
    • Corresponding Author InformationCorresponding author. Tel.: +31 887556965.
    • ,
  • M.R. Scheltinga

      Affiliations

    • Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
    • ,
  • M.C. Huige

      Affiliations

    • Department of Cardiology, Máxima Medical Center, Veldhoven, The Netherlands
    • ,
  • F.L. Moll

      Affiliations

    • Department of Vascular Surgery, University Medical Center, PO Box 85500, 3508 GA, Utrecht, The Netherlands

Received 28 April 2009; accepted 14 September 2009. published online 14 October 2009.

Article Outline

Abstract 

Aims

Older patients with spells of syncope may suffer from a carotid sinus syndrome (CSS). Patients with invalidating CSS routinely receive pacemaker treatment. This study evaluated the safety and early outcome of a surgical technique termed carotid denervation by adventitial stripping for CSS treatment.

Methods

Carotid sinus massage (CSM) during cardiovascular monitoring confirmed CSS in patients with a history of repeated syncope and dizziness. The internal carotid artery was surgically denervated by adventitial stripping over a minimum distance of 3cm via a standard open approach. Patient characteristics, perioperative complications and 30-day success rate were analyzed.

Results

A total of 39 carotid denervation procedures was performed in 27 individuals (23 males, mean age 70±3 years) between 1980 and 2007 in a single institution. Eleven patients had a bilateral hypersensitive carotid sinus. Procedure related complications included wound hematoma (n=4), neuropraxia of the marginal mandibular branch of the facial nerve (n=2) and dysrhythmia responding to conservative treatment (n=3). Significant alterations in systolic and diastolic blood pressure and heart rate were not observed. One patient developed a cerebral ischaemic vascular accident on the 24th postoperative day. One patient with residual disease had a successful redenervation within 1 month after the initial operation. Two patients with persistent symptoms received a pacemaker but also to no avail. At 30-day follow up 25 of 27 patients (93%) were free of syncope, and 24 free of a pacemaker (89%).

Conclusion

Carotid denervation by adventitial stripping of the proximal carotid internal artery is effective and safe and may offer a valid alternative for pacemaker treatment in patients with carotid sinus syndrome.

Keywords: Carotid sinus syndrome, Carotid denervation, Adventitial stripping

 

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Introduction 

Some elderly patients with recurrent syncope, dizziness and falls may harbour a hypersensitive carotid sinus. The carotid sinus is a small organ located in proximal portions of the internal carotid artery and is a major contributor to regulation of cardiac frequency and blood pressure. Nerve fibers originating from this baroreceptor area transfer pulses via an afferent carotid sinus nerve (CSN) and the glossopharyngeal nerve (IX) towards the brain. Efferent portions of the reflex loop may exert differential influence on cardiac performance. A stimulated vagus nerve (X) results in a fall in heart rate (cardioinhibition) and decreased conductivity. Diminished sympathetic vasoconstrictor activity induces arterial vasodilatation and venous vasodilatation with a subsequent decrease in preload and cardiac inotropism leading to lowered blood pressure (vasodepression). In carotid sinus hypersensitivity, this loop mechanism is dysregulated leading to an exaggerated response, either spontaneously or following mechanical strain in the neck area. When hypersensitivity results in incapacitating episodes of dizziness and syncope, this symptom complex is termed carotid sinus syndrome (CSS).1, 2, 3 The European Society of Cardiology (ESC) has defined 3 types of CSS (Table 1).4

Table 1. Criteria for diagnosis of CSS.
Symptomsrecurrent syncope/dizziness
TestsHolter ECGCardiac ultrasonography
Table tilt testCarotid duplex/angiography
CSMCardioinhibitoryVasodepressorMixed
Asystole>3sDrop SBP>50mm HgAsystole>3s and
drop SBP>50mmHga

CSM: carotid sinus massage, SBP: systolic blood pressure.

aWith pacing or after intravenous administration of 1mg atropin.

Patients with CSS are routinely evaluated by cardiologists who prefer to prescribe medication or insert a permanent pacemaker. However, these devices are not always effective in abolishing symptoms and have disadvantages including risk of pneumothorax, infection or lead displacement. Furthermore regular maintenance is necessary.5, 6, 7 Some studies evaluated operative treatment regimens aimed at interrupting the pathological baroreflex by means of a nerve transection (CSN or glossopharyngeal nerve) or adventitial stripping.8, 9 It was recently shown that, from an microanatomical point of view, transection of the CSN may be difficult and may possibly lead to an incomplete carotid sinus denervation.10 Glossopharyngeal nerve transection includes a craniotomy and may be associated with complications including loss of gag reflex and taste perception on the posterior third of the tongue.9

A recent review of 110 CSS patients demonstrated that clinical results of denervation of various portions of the carotid artery bifurcation by adventitial stripping were very encouraging, although most studies were small.11

Aim of this study is to report the safety and early postoperative results of carotid denervation by adventitial stripping of a 3-cm portion of the proximal internal carotid artery in 27 CSS patients.

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Materials and Methods 

Study population 

All patients receiving an operation for CSS between 1980 and 2007 were studied. The hospital (Máxima Medical Center) is a 865-bed community hospital in the southeastern part of the Netherlands and it accommodates approximately 350.000 inhabitants in a semi-rural area. Patients (>45yr) presenting to departments of emergency medicine or cardiology with a history suggestive of CSS were offered a standard evaluation program including a physical examination, a table tilt test, electrocardio-graphy, holter ECG and cardiac ultrasonography. The diagnosis CSS was confirmed by carotid sinus massage (CSM). Duplex scanning was used to exclude a diseased and stenotic carotid artery.

Patients were initially examined in supine position. CSM was performed during a 10s period by digital stretching of the skin and subcutaneous tissue of the neck area overlying the carotid bifurcation. This test was also repeated on the contralateral side after an 1min interval. After 1999, intra-arterial blood pressure using standard catheter techniques and cardiac rhythm were additionally recorded (n=11). If no pathological reflex was present, the manoeuvre was repeated in 60° tilt (anti-trendelenburg position). Criteria for CSS as described by the ESC were followed (Table 1).4 An asystole >3s (cardioinhibitory response) or a >50mmHg systolic blood pressure drop (vasodepressor response) were considered pathognomonic. Temporary cardiac pacing or a 1mg i.v. dose of atropine was used in cardioinhibitory CSS to maintain an adequate heart rate. These additional tests were helpful in identifying vasodepressive elements in the response (mixed type CSS, both cardioinhibitory and vasodepressor). Patients typically recognized symptoms during massage. Candidates were subsequently discussed in a team consisting of a cardiologist, vascular surgeon and anaesthesiologist, all having a long term interest in CSS.

Operative procedure 

Location of the carotid bifurcation was preoperatively marked on the skin by duplex ultrasonography. The operation was performed under general anesthesia and continuous monitoring of intra-arterial blood pressure and heart rate. The carotid bifurcation was exposed through a 6–7cm skin incision parallel to the anterior border of the sternocleidomastoid muscle. Nervous tissue attached to adventitial layers of the proximal internal carotid artery (ICA) was circumferentially removed over a distance of at least 3cm, starting at the carotid bifurcation (Figure 1, Figure 2). Surgical manipulation of the ICA frequently resulted in bradycardia or hypotension. Severe bradycardia (<30beats/min) or hypotension (systolic blood pressure <70mmHg) was treated by intravenous administration of atropine or norepinephrine or application of lidocaine around the ICA. Following completion of the stripping procedure, patients were monitored in a Cardiac Care Unit during the first 24 postoperative hours.

Data accrual 

Data were accumulated in two different ways. From 2000 on, a prospective registry of patients served as a basis for analysis. Characteristics of earlier patients were identified by a retrospective chart review. Once patients were identified, demographics, preoperative evaluation and perioperative data were extracted from cardiological and surgical charts.

Statistical analysis was performed using standard computer software. A paired T-test was utilised to compare values of pre- and postoperative blood pressure and heart rate. The Bonferroni correction was used. Data were expressed as mean±SEM. Significance was set at the P<.05 level.

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Results 

The patient's history combined with physical examination and diagnostic test panels identified a group of 27 patients diagnosed with CSS (23 male, mean age 70±3, range 48–83, Table 2).

Table 2. Demographics and symptomatology in CSS patients.
PatientSexAgeSymptomsProvocative factorCSMOperation
1M67SSpontaneousMIX pacingStaged bilateral
2F80SSpontaneousCIaRight
SpontaneousCIaLeft
3M79DSpontaneousCIaLeft
4F80SSpontaneousCIaStaged bilateral
5M55STurning headCIaRight
Coughing
6M69DTurning headCIaBilateral
Wearing collar
7M78DSpontaneousCIaBilateral
8M48DSpontaneousCIaBilateral
9M82SSpontaneousMIX pacingStaged bilateral
10M74STurning headMIX pacingRight
Wearing collar
11M62STurning headCIaRight
12M73SSpontaneousCIaRight
13M64DLooking upwardMIX pacingStaged bilateral
14M61STurning headCIaRight
15M80SSpontaneousCIaRight
16F81SCoughingCIaLeft
17M83SSpontaneousMIX pacingStaged bilateral
18M77SCoughingMIX pacingRight
19M65SSpontaneousMIX pacingLeft
20M81STurning headCIRight
21M56DTurning headCIBilateral
Collar, shaving
22M50SSpontaneousVDRight
23M81SSpontaneousMIX atropinBilateral
24M69SLooking downwardMIX atropinRight
25F53D, VWearing collarunknownRight
26M62SSpontaneousCIRight
27M83SSpontaneousMIX atropinBilateral

M: male, F: female, D: dizziness, S:syncope, V: vomitus, CI: cardioinhibitory, VD: vasodepressor, MIX: mixed.

aNot tested with atropin or pacing for vasodepressor component.

Symptoms are listed in Table 2. The majority experienced syncope (74%, n=20), and most episodes occurred spontaneously (56%, n=15). In a minority of patients (44%, n=12) provocative factors were reported, most frequently head movements (33%, n=9). Three patients regularly fainted following coughing. One patient consistently collapsed while knotting his tie. Symptoms resulted in serious complications including a car accident leading to loss of driver's license (n=1), or fractures of femoral neck (n=1) or humeral bone (n=1). Additional comorbidity is shown in Table 3.

Table 3. Comorbidity in CSS patients.
Hypertension37%
IHD/MI30%
COPD26%
Hyperchol19%
DM15%
PAOD15%
Malignancy15%
TIA/CVA11%
Dysrhythmias11%
LVH3%

LVH: left ventricular hypertrophy, IHD: ischaemic heart disease, MI: myocardial infarction, TIA: transient ischaemic attack, CVA: cerebrovascular accident, PAOD: peripheral arterial occlusive disease, hyperchol: hypercholesterolaemia, DM: diabetes mellitus, COPD: chronic obstructive pulmonary disease.

Carotid bruits were absent in all patients. Subsequently, CSM identified eleven patients (41%) with a bilateral CSS. In the remaining 16 patients (59%) symptoms were only evoked following unilateral neck stimulation, usually on the right side (80%). CSM elicited a cardioinhibitory response in most patients (59%, n=16) and a pure vasodepressor type in just one. A mixed response was observed in the remaining 10 individuals (37%). This latter subgroup was unveiled after atropine (n=3) or by temporary cardiac pacing (n=7). Mean duration of asystole was 7±2s (3–13s), and mean drop in systolic blood pressure was 66±3mmHg (50–120mmHg).

A total of 39 carotid denervations by adventitial stripping was performed in 27 patients. Staged bilateral surgery was done in 5 patients (1980–1995), whereas from 1995 onwards 6 patients received surgery in just one operation. The remaining 16 patients underwent unilateral carotid denervation (Table 2). Patient 2 developed a CSS on the contralateral side 2 years after carotid denervation and was again operated with a satisfying result.

Complications associated with surgery (Table 4) included wound hematoma and neuropraxia of the marginal mandibular branch of the facial nerve. Dysrhythmias (atrial fibrillation n=2, sinus tachycardia n=1) within 48h following surgery mandated temporary medication (n=2) or cardioversion (n=1). An elevated blood pressure (195/115mmHg, preoperative 145/85mmHg) some hours postoperatively in one patient undergoing an unilateral denervation was treated with a calcium antagonist for four weeks. However, normotension without antihypertensive medication was observed at the 30-day control period.

Table 4. 30-Day complication rate.
ComplicationManagement
Hematoma (n=4)Surgical evacuation (n=2)
Spontaneous resolution (n=2)
Dysrhythmia (n=3)Medication (n=2)
Cardioversion (n=1)
Neuropraxia (n=2)Spontaneous resolution (n=2)
Hypertension (n=2)Medication (n=2)
CVA (n=1)Full recovery

Fig. 3 demonstrates that systolic blood pressure (SBP) on the 1st postoperative day was not different compared to preoperative values (145±4 vs 141±5mmHg, P=.41). There was also no difference in diastolic blood pressure (DBP, 81±2 vs 77±3mmHg, P=.09) or heart rate (HR, 80±2 vs 75±3 beats/min, P=.17). SBP, DBP and HR were also determined in a portion of patients (n=9) just prior to discharge (day 4±1). No significant differences existed compared to preoperative values.

  • View full-size image.
  • Figure 3 

    Effect of adventitial stripping on systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) over time: preoperative (n=27), 1st day postoperative (n=27), prior to discharge (n=9). Values are shown as mean±SEM.

One patient experienced a CVA with left sided paralysis 24 days after a bilateral carotid denervation. He had an occlusion of the left ICA and 50% stenosis of the right ICA and may have suffered a CVA on the basis of a low flow state. Fortunately, recovery was uneventful and syncope free. One patient had residual disease within one month after the initial procedure. Repeat CSM could still evoke symptoms and an asystole. A redenervation 1 month after the initial operation resulted in abolishment of all symptoms. Two additional patients also did not respond to carotid denervation while still demonstrating a positive CSM. On their request, both received a permanent pacemaker instead of a reoperation. However, even with this device, they were still not free of symptoms. One patient experienced renewed CSS symptoms after pacemaker implantation for cardioinhibitory CSS 5 years earlier. CSM under pacing showed a significant drop in blood pressure. He underwent a successful bilateral carotid denervation. On the advice of the cardiologist his pacemaker was not removed.

After 30 days of follow up, 25 of 27 patients (93%) were free of syncope and 24 of them free of a pacemaker (89%).

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Discussion 

The incidence of CSS in elderly people is probably underreported.12 A 50% incidence was present in patients evaluated for unexplained dizziness and syncope.13 CSS was found associated with atherosclerosis, diabetes and hypertension as also observed in the present study.14, 15 Controversy exists on its natural history. One randomized study demonstrated that symptoms of severe CSS recurred within 3 years in more than half of individuals that were only observed.16 A decision for a ‘wait-and-see’ policy must be dictated by severity of the symptom complex. It should be appreciated that CSS patients with a vasodepressor component have a threefold increased incidence of recurrent symptoms compared to patients with a cardioinhibitory form.17 It must also be realized that a substantial portion of CSS patients is subject to additional morbidity associated with frequent falls including fractures.13, 18, 19 A 7% fracture rate was also observed in the present population.

Typology of CSS is diverse but largely dictates management. A pure cardioinhibitory form of CSS is thought to respond successfully to either pacemaker therapy or surgery.20 On the other hand, mixed or vasodepressor forms of CSS are not effectively treated by pacing but may exclusively benefit from surgery.15 For instance, successful carotid denervation was reported in 2 mixed CSS patients that were still experiencing syncope after earlier pacemaker treatment.21 Moreover, recent ESC guidelines also state that only cardioinhibitory CSS is a strict indication for pacemaker treatment.22 In the 1999–2007 period of our study (n=11), only one patient exhibited a pure vasodepressor form, whereas the minority of patients evaluated between 1980 and 1999 were additionally tested for a vasodepressor component. One may therefore assume that the vast majority of CSS patients is of a mixed type, whereas pure cardioinhibitory or pure vasodepressor forms are less common as also suggested by others.23, 24

Various treatment regimens for CSS have been explored including instructions avoiding stimulation of the neck area (head turning), medication3 and even carotid sinus irradiation.25, 26 Others have suggested pacemaker implantation27 or surgery including nerve transection or carotid denervation by means of adventitial stripping.28 This plethora of strategies illustrates that a tailored management in patients with CSS is not attained. Medication may be prescribed in mild disease but is ineffective in moderate and severe CSS.3, 24 Carotid irradiation is potentially hazardous, whereas glossopharyngeal transection requires a craniotomy and may be reserved for incurable patients not responding to any other regimen. Therefore, the treatment of choice in severe CSS is either pacemaker implantation or (limited) surgery.

Some vascular surgeons do not advise surgery for CSS but recommend pacemaker implantation.29 However, a claim that an electrical device is superior was based on a study just comparing populations with and without pacemaker.16 Patients without pacemaker showed a 62% recurrence of symptoms after a mean follow up of 4 years. In contrast, a 16% recurrence rate was observed in patients that were paced. This study merely illustrated that CSS requires an effective treatment rather than a wait-and-see policy but did not allow for a comparison of different treatment regimens. To date, no randomized trial comparing the efficacy of pacemaker versus surgical treatment has been completed yet.

A rather slim body of literature seems to indicate that many patients may benefit from surgery. However, which method is most effective? If one accepts the assumption that a hypersensitive carotid sinus plays a pivotal role in the pathophysiology of CSS, surgery that is based on removal of all nervous tissue that is in close contact to the carotid sinus (‘adventitial stripping’) may be effective. Several techniques have been reported in the literature, some in more detail than others.10 In the present study, an adventitial stripping of a minimal 3-cm portion of proximal internal carotid artery was performed since this section is hypothesized to contain the majority of afferent nerve fibers. The finding that 93% of patients were free of symptoms after this procedure confirms this hypothesis. Modern microanatomical studies may further identify distribution of nerve fibers in the carotid area.

Some have questioned the safety of a carotid denervation. However, their fear is fuelled by case studies reporting on severe baroreflex dysfunction due to iatrogenic denervation of the carotid sinus following bilateral carotid body tumor resection.30 For instance, a fatal hypertensive crisis was reported in the 1950s after an unilateral surgical carotid denervation.31 Because of these findings, bilateral disease in our patient population prior to 1995 was treated using a two stage procedure. As no baroreflex dysfunction was observed, we operated bilateral disease in just one operation after 1995. Patients demonstrated stable postoperative heart rate and blood pressure. The present study shows that, in experienced hands, carotid denervation by adventitial stripping has few complications.

The clinical results of carotid denervation by adventitial stripping, at least at short term follow up, are very satisfactory. Naturally, the limitations of a retrospective study and all its disadvantages should be taken into account. Although out of the scope of this paper, long term follow up is needed to evaluate the durability and definitive efficacy of carotid denervation, as possible reinnervation of the carotid baroreflex has been described.32

However, at long term follow up other factors and events may play a role in the clinical outcome of these elderly patients, which will ask for a renewed set of diagnostic tests.

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Conclusion 

Carotid denervation by adventitial stripping of a 3cm portion of the proximal internal carotid artery is simple, safe and effective at short term follow up. This operation may offer a valid alternative for pacemaker treatment in patients with carotid sinus syndrome. A randomized trial is needed to compare these two treatment options.

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Conflict of Interest 

None.

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Acknowledgements 

This study was supported by a grant from Stichting Hart- en Vaatziekten Zuid-Nederland

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References 

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PII: S1078-5884(09)00489-4

doi:10.1016/j.ejvs.2009.09.009

European Journal of Vascular & Endovascular Surgery
Volume 39, Issue 2 , Pages 146-152, February 2010

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