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.
Copyright (c) 2019 Shawn Stefan Albers, Andrew Stanton Kucey, Anish Engineer
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- The Author retains copyright in the Work, where the term “Work” shall include all digital objects that may result in subsequent electronic publication or distribution.
- Upon acceptance of the Work, the author shall grant to the Publisher the right of first publication of the Work.
- The Author shall grant to the Publisher and its agents the nonexclusive perpetual right and license to publish, archive, and make accessible the Work in whole or in part in all forms of media now or hereafter known under a Creative Commons Attribution 4.0 International License or its equivalent, which, for the avoidance of doubt, allows others to copy, distribute, and transmit the Work under the following conditions:
- Attribution—other users must attribute the Work in the manner specified by the author as indicated on the journal Web site; with the understanding that the above condition can be waived with permission from the Author and that where the Work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license.
- The Author is able to enter into separate, additional contractual arrangements for the nonexclusive distribution of the journal's published version of the Work (e.g., post it to an institutional repository or publish it in a book), as long as there is provided in the document an acknowledgment of its initial publication in this journal.
- Authors are permitted and encouraged to post online a prepublication manuscript (but not the Publisher’s final formatted PDF version of the Work) in institutional repositories or on their Websites prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work. Any such posting made before acceptance and publication of the Work shall be updated upon publication to include a reference to the Publisher-assigned DOI (Digital Object Identifier) and a link to the online abstract for the final published Work in the Journal.
- Upon Publisher’s request, the Author agrees to furnish promptly to Publisher, at the Author’s own expense, written evidence of the permissions, licenses, and consents for use of third-party material included within the Work, except as determined by Publisher to be covered by the principles of Fair Use.
- The Author represents and warrants that:
- the Work is the Author’s original work;
- the Author has not transferred, and will not transfer, exclusive rights in the Work to any third party;
- the Work is not pending review or under consideration by another publisher;
- the Work has not previously been published;
- the Work contains no misrepresentation or infringement of the Work or property of other authors or third parties; and
- the Work contains no libel, invasion of privacy, or other unlawful matter.
- The Author agrees to indemnify and hold Publisher harmless from the Author’s breach of the representations and warranties contained in Paragraph 6 above, as well as any claim or proceeding relating to Publisher’s use and publication of any content contained in the Work, including third-party content.
Enforcement of copyright
The IJMS takes the protection of copyright very seriously.
If the IJMS discovers that you have used its copyright materials in contravention of the license above, the IJMS may bring legal proceedings against you seeking reparation and an injunction to stop you using those materials. You could also be ordered to pay legal costs.
If you become aware of any use of the IJMS' copyright materials that contravenes or may contravene the license above, please report this by email to email@example.com
If you become aware of any material on the website that you believe infringes your or any other person's copyright, please report this by email to firstname.lastname@example.org