Carotid Artery Kinks and Coils

Christopher J. Smolock, Javier E. Anaya-Ayala, Daynene Vykoukal, Alan B. Lumsden and Mark G. Davies

Most anatomic descriptions of the cervical carotid artery note a straight course to the skull base free of branches. Although angulated cervical carotid arteries, especially the internal carotid artery (ICA), are a relatively common finding in adults (∼25%), the excessive elongation of the internal carotid artery in a confined space results in a curvature termed coiling. Kinking of the internal carotid artery also results from elongation of the vessel, but it is defined as an angulation of the vessel of 90 degrees or less. Kinks are often associated with stenoses of the vessel and have been linked with arterial wall degeneration and loss of elasticity. Coiling and kinking of the vessels may also be associated with the formation of an actual looped vessel. This can result in the formation of single or double vessel loops. Metz and colleagues and Weibel and Fields have each proposed a grading system (Figure 1). Togay-Isikay modified and combined these grading systems into a single set of criteria (Table 1).

TABLE 1

Modified Criteria of Metz and Weibel-Fields by Togay-Isikay

Malformation	Description
Tortuosity	S- or C-shaped elongation or undulation of ICA course
Mild kinking	Acute angulation of ICA between segments forming kink ≥60 degrees
Moderate kinking	Acute angulation of ICA between segments forming kink 30–60 degrees
Severe kinking	Acute angulation of ICA between segments forming kink <30 degrees
Coiling	Exaggerated S shape or circular configuration of ICA course

ICA, Internal carotid artery.

Etiology

Controversy exists as to the possible etiologies of vessel elongation and the resultant conditions. Whether these are sequelae of atherosclerosis, post–carotid endarterectomy changes, fibromuscular dysplasia, age-related degeneration, or simply normal variation or developmental differences remains a matter of debate. Observation of kinks and coils in fetuses and infants support the argument that at least a portion of these phenomena arise from congenital anatomic variation and are not simply acquired. Of note, such an aberrant course and variable location can place the ICA at risk during certain pharyngeal and cervical procedures. The otolaryngology literature discusses tortuous internal carotid arteries manifesting as pharyngeal masses.

Epidemiology

The incidence of cervical ICA anatomic variations, such as those described earlier, ranges from 10% to 40%, and most cases are bilateral. Several older studies with biased sample groups that are not representative of the general population put prevalence of carotid artery tortuosity at 30% to 35%, with 5% kinks and 6% coils. A majority of these are seen in female patients. An association exists between extracranial carotid kinks and coils and intracranial arterial aneurysms.

More recently, a study population was found to have ICA tortuosity in 22% of vessels. Fifty percent of patients demonstrated bilateral tortuosity. Occurrence is typically 2 to 3 cm distal to the carotid bifurcation. A higher incidence of tortuosity in female patients was also reported. However, the true incidence and prevalence of carotid artery kinks and coils is more difficult to determine given that most patients with this condition are believed to be asymptomatic and are therefore never evaluated.

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