Vertebrocarotid collateral in extracranial carotid artery occlusions: digital subtraction angiography findings

The internal and external carotid arteries are usually considered occluded distal to a common carotid artery occlusion but some collateral vessels may provide blood keeping the internal and external carotid arteries patent distal to the occlusion. Most common communication in such a case is diversion of blood from muscular branches of the vertebral artery to occipital branch of the external carotid artery which in turn could maintain blood flow into the internal carotid artery, a condition called carotid steal. We encountered vertebrocarotid anastomoses maintaining the patency of carotid circulation in six patients. Patients were four females and two males, ages ranging from 40 to 67 (mean age: 56) years. Five of the patients had ischemic cerebral symptoms. The origin of the external carotid artery was occluded in two and the whole common carotid artery in the remaining four patients. Two patients had double steal, carotid and subclavian at the same time. There was also severe stenosis or occlusion of at least one other major extracranial cerebral artery in all the cases. This concomitant involvement of the second extracranial cerebral artery was thought to be the main reason for the development of vertebrocarotid collateral. In contrast to most of the previously published reports claiming the inadequacy of angiography when compared with colour Doppler ultrasonography, angiography finely depicted the distal patency of the carotid circulation and all the collaterals in detail in every case. Selective injection of the vertebral artery ipsilateral to the occlusion, is the key to demonstrate distal patency of the carotid circulation in cases of proximal carotid occlusion. Demonstration of patency of the distal circulation is very important because some of the patients might get benefit from a reconstructive surgery.