Graduated Internal Dilatation in the Treatment of Fibromuscular

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					 244                                                 SA   MEDICAL       JOURNAL                               19 February 1977


           Graduated Internal Dilatation in the Treatment of
        Fibromuscular Dysplasia of the Internal Carotid Artery
                                                          M. APPLEBERG

                               SUMMARY                                  X-ray examination of the chest, electrocardiography and
                                                                     routine haematological studies revealed no abnormality.
   A patient with transient ischaemic attacks due to fibro-          A four-vessel-arch angiogram was performed by the
   muscular dysplasia of the internal carotid artery is pre-         Seldinger technique, via the left femoral artery. There was
   sented. Standard methods of vascular reconstruction may           no abnormality in the aortic arch or in the origin of the
   not be possible as the disease often involves the distal          three great arch vessels. The left internal carotid artery
   half or two-thirds of the extracranial internal carotid artery.   was totally occluded at its origin, but the left common
   For this reason the technique of graduated internal dilata-       and external carotid arteries showed no abnormality. The
   tion first described by Morris et al. was employed and            right vertebral artery was patent and enlarged and the
   showed satisfactory results on short-term follow-up.              left vertebral artery was normal.
                                                                        On the right side, the characteristic beading, irregularity
   S. Air. med. l., 51, 244 (1977).                                  and stenosis of fibromuscular dysplasia were noted in the
                                                                     internal carotid artery, extending from a point just distal
Fi bromuscular dysplasia of the internal carotid artery is
rare. It may, however, cause symptoms of cerebrovascular
insufficiency and surgical therapy may present a con-
siderable technical problem. The difficulty arises from the
fact that unlike atherosclerosis, which predominantly affects
the readily accessible carotid bifurcation, fibromuscular
dysplasia frequently involves the internal carotid artery up
to the base of the skull, and conventional methods of
endarterectomy of the carotid bifurcation may therefore
not be possible. For this reason, the technique of graduated
internal dilatation was developed.' This technique was
recently used by us and forms the basis of this report.

                         CASE REPORT
A 41-year-old White woman presented with an 18-month
history of frequent transient ischaemic episodes characte-
rized by left hemiparesis and paraesthesia, which usually
lasted for only a few minutes before complete recovery.
These attacks occurred daily just before admission. Some
12 months previously she had had an episode during which
she lost consciousness and developed a left hemiplegia. The
hemiplegia improved but a minimal weakness of the left
upper extremity remained. At times she complained of
mental confusion and vertigo. She was a heavy smoker of
cigarettes and was under psychiatric care for endogenous
depression.
   On physical examination, a loud, high-pitched carotid
bruit was present on the right side, and was maximal over
the carotid bifurcation. The left common carotid pulse was
present but pulsation was diminished and there was no
bruit. The blood pressure in the arms was 165/80 mmHg.
There was a bruit over the right common femoral artery,
but the remainder of the vascular system was normal.


Department of Surgery, University of the Witwatersrand and
  Johannesburg General Hospital, Johannesburg
M. APPLEBERG,         l\'f.B. B.CH., F.C.S. (S.A.)
                                                                      Fig. 1. Pre-operative angiogram showing the characteristic
                                                                      beading, irregularity and stenosis of fibromuscular hyper-
Date received: 19 July 1976.                                          plasia involving the right internal carotid artery.
19 Februarie 1977                                MEDIE         E     TVD     KRIF                                          245

to it origin to a point above the angle of the mandible.           ju I be reached. but re ection and anastomo        were not
The intracranial portion of the internal carotid artery wa         attempted.
normal to the level of the carotid iphon. The right com·                fter administration of 7 500 I of heparin the three
mon carotid artery and its bifurcation were normal (Fig. I).       carotid ve sels were clamped and graduated Bake dilator
The intracranial vessels distal to thi were not adequately         ( ize 2 - - mm) were pas ed up the internal carotid artery
visualized. Subsequently. arteriography of the abdominal           via an oblique incision just proximal to the bifur ation.
aorta howed normal coeliac. mesenteric. renal and iliac            Dilatation was performed under direct vi ion and manual
ves els.                                                           control. A definite relief of pres ure wa ensed when the
  The operation, with the patient under general anaesthesia.       diaphragms were dilated. After dilatation. the ves el wa
was performed on the right side. either hypercarbia nor            irrigated with heparin-saline and the arteriotomy was closed
hypertensive anaesthesia was employed. and pressure at             with 6/0 Tevdek. The period of occlusion was just under 4
the carotid stump was not measured. The common inter-              minute. The internal carotid artery dilated well when the
nal and external carotid arteries were mobilized as high           clamp were released. and normal blood flow. without a
as possible, through a standard approach anterior to the           thrill. returned. The postoperative course was uneventful.
sternocleidomastoid muscle. The finding relative to the            Arteriography. repeated on the 10th postoperative day.
internal carotid artery were those of fibromuscular dys-           prior to the patient's discharge. showed very considerable
plasia. The vessel was elongated and somewhat redundant.           improvement (Fig. 2).      During the next 3 months there
with multiple thin-walled sacculation through which                were no ischaemic attacks.
turbulent blood flow could be seen. Between these regions
of dilatation there was narrowing. The upper limit of the
dysplasia wa such that apparently normal artery could                                    DISCUSSION
                                                                    Fibromuscular dysplasia of the renal artery is well
                                                                   described.'·3 Fibromuscular dysplasia of the internal caro-
                                                                   tid artery, however, is uncommon and in surveys of 7000
                                                                   carotid angiograms' only 21 cases were found.
                                                                       Most authors regard fibromu cular dysplasia as a
                                                                   generalized vascular di order which affects almost all
                                                                   major vessels. Its aetiology i obscure, although ethnic,
                                                                   congenital, and hormonal factors have been implicated.
                                                                   The dysplasia occurs predominantly in females. usually
                                                                   White. in the age-group 50 years and over. although cases
                                                                   have been reported in patients a young as 29 years.'
                                                                      Fibrodysplasia has been categorized by Stanley el a/."
                                                                   into four main histological groups: intimal fibroplasia,
                                                                   medial hyperplasia. medial fibroplasia. and perimedial dys-
                                                                   plasia. Involvement of the renal artery by medial fibroplasia
                                                                   accounts for nearly 85~o of cases. The multifocal areas of
                                                                   stenosis are due to thickened fibrous and muscular ridges
                                                                   which alternate with areas of marked thinning of the
                                                                   vessel wall, resulting in aneurysm formation. The muscle
                                                                   is replaced by fibrous tissue and loosely arranged bundles
                                                                   of collagen. This loss of muscle results in the aneurysm
                                                                   formation while areas of increased fibrous tissue are Fe-
                                                                   sponsible for the areas of stenosis or web formation.
                                                                      Each of the histological types of dysplasia may cause
                                                                   arterial stenosis or occlusion. The mechanism which under-
                                                                   lies transient ischaemic attacks is probably the same a
                                                                   that in atherosclerosis. Significant tenosis may, therefore.
                                                                   reduce the cerebral blood flow. or emboli may originate in
                                                                   the aneurysmal dilatations of the affected vessel. Symptoms
                                                                   may occur in a subject at rest. or be precipitated by move-
                                                                   ment of the head and change in po ture. Associated intra-
                                                                   cranial aneurysms have been de cri bed' but the histopatho-
                                                                   logy has not been documented. This association ha
                                                                   prompted some authors to perform cerebral arteriograph
                                                                   in all patient with fibromuscular dyspla ia.
                                                                      The symptom produced are tho e of cerebral ischaemia.
                                                                   and do not differ from those arising from atherosclerosis
                                                                   of extracranial arteries. The condition is bilateral in 90°,
 Fig. 2. Postoperative angiogram showing the improvement           of reported cases' whereas bilateral fibrodysplasia of the
 after internal dilatation.                                        renal arteries occur in only 50o~ of ca e .
246                                          SA        EDICAl         Jo     RNAl                                  19 February 1977

   Phy ical findings are not diagnostic; the only sign may       the tandard techniques of re ection and autografting of
be a bruit over the carotid artery. However. the bruit is        the aphenous vein. or direct anastomosis. are usually not
not necessarily maximal at the site of the carotid bifurca-      possible. For this reason. the technique of graduated in-
tion as it is in athercsclerosi . The diagnosis. therefore.      ternal dilatation. first described by Morris et al ..' seems to
can be made only by arteriography. The affected vessel           be the best method for many patients. Few cases have
appears irregular. with alternating narrow and wide seg-         been reported in the literature. however. and a long-term
ments producing the characteristic beaded appearance.            follow-up study of the results of this method has not been
These changes. typically seen in the middle third of the         publi hed. Morris et al.' reported 8 patients who had under-
extracranial portion of the internal carotid artery, frequent-   gone internal dilatation. with no evidence of recurrence or
ly spare the carotid bifurcation and have not been reported      further neurological symptoms after a follow-up period of
in the intracranial portion of this ves el.                      2 months to 4 years. Levin and Sonderheime" reported a
   Surgery appears to be indicated for patients with symp-       similar satisfactory result in 3 patients who were followed-
toms of transient ischaemic attacks. or who have unilateral      up for 27 months.
occlusion associated with significant disease of the contra-                                   REFERE CES
lateral carotid artery. The natural history of fibromuscular     I.   Morris, G. C .. Letcher, A. and De Bakey, M. E. (196 ): Arch. Surg ..
dyspla ia of the extracranial vessels has not been docu-              96. 636.
                                                                 2.   Stanley. J. C. and Fry, W. J. (1975): Ibid., 110, 922.
mented. but should it be like that of renal artery involve-      3.   Harrison. E. G. and McComlack, L. J. (1971): Mayo Clin. Proc ..
                                                                      46. 161.
ment. it is probably progressive.'                               4.   Nunn. D. B. (1974): Amer. J. Surg., 40, 309.
   The surgical technique employed will vary from patient             Lamis, P. A.. Carsons. W. P.. Wilson, J. P. and Lelton, A. H.
                                                                      (1971): Surgery. 69, 498.
to patient. Because the dysplasia so frequently involves         6.   Stanley, J. C., Gewertz. B. L.. Bove, E. L., Sottiarai, I. and Fry,
                                                                      W. J. (1975): Arch. Surg .. 110,561.
the distal half or two-thirds of the internal carotid artery.    7.   Levin. S. M. and Sonderheime. R. F. (1971): Angiology, 22, 463.




      The Use of Phenothiazines and Tricyclic Antidepressants
               in the Treatment of Intractable Pain
                                                     A. M. DUTHIE

                           SUMMARY                               pain. The narcotic analgesics cause a diminution of con-
                                                                 sciousness, and carry the danger of habituation; they are
  The use of trifluoperazine and amitriptyline in the treat-     to be avoided. if at all possible. in patients with pain not
  ment of pain is described. Of 12 patients who were             caused by malignancy.
  suffering chronic pain from various causes, 8 obtained a          A recent development in the treatment of pain has been
  major degree of relief from the use of this combination of     the use of the analgesic properties of th~ phenothiazines
  drugs.                                                         and the tricyclic antidepressants, separately and in com-
                                                                 bination.'" They were used in a number of patients in
  S. A/I'. med. J., 51, 246 (1977).                              whom other treatment had been unsuccessful. and en-
                                                                 couraging results were obtained.
In spite of the many forms of treatment available, there
are a number of patients who suffer from intractable pain                        PATIE TS AND METHODS
and whose distress remains even after the most energetic
therapy. Radiotherapy.' sensory and sympathetic nerve            Twelve patients suffering from chronic pain from a variety
blocks'-' and cordotomy' may be unsuccessful, and the            of causes were selected. All had received no relief from
only solution may be the administration of systemic anal-        other treatments.
gesic drugs with all their attendant adverse effects. The           Each patient was treated with amitriptyline and trifluo-
mild analgesics cause constipation and sometimes gastritis.      perazine. the latter being the least sedative of the locally
and are effective only in patients with mild or moderate         available phenothiazines. Each patient received 75 mg of
                                                                 the antidepressant at night and I mg of the phenothiazine
Department of Anaesthetics, Godfrey Huggins School of            three times daily. All patients were ambulant and were
  Medicine and Harari Central Hospital, Salisbury, Rhodesia      observed weekly during the period of treatment at the
A. ~r. DUTHIE. ~r.D .. F.F.A .. D.A .. D.H.C.O.C.                Pain Clinic. In 2 patients it was necessary to reduce the
Date received: 26 October 1976.
                                                                 dose of trifluoperazine to I mg twice daily owing to the