Age-related geometric analysis of the extracranial artery for endovascular access planning

Introduction

Among the etiologies of ischemic stroke, atheroma of the carotid artery plays an important role as a leading stroke etiology in one-third of cases (1). Some studies have investigated the importance of the angle and tortuosity of the carotid arteries and the clinical significance of the common carotid artery (CCA) angle during radiological intervention and surgery in regions (2-4). The angle of the internal carotid artery (ICA) and variations in the carotid artery bifurcation (CAB) have been reported as independent risk factors for early atherosclerosis (4,5). Moreover, the CAB angle is associated with risk of ischemic stroke (2). Some studies have shown that the maximal diameter, cross-sectional area, and area ratios of the CAB exhibit considerable variations among individuals, and variations in the geometry of the CAB increase significantly with age or early atherosclerotic progression (5-7).

The normal aging process is associated with aortic elongation and serial changes in aortic geometry (8). Therefore, the diameter and circumference of the CCA and the bifurcation angle significantly increase over a decade of life (9). Thomas et al. (6) compared the geometry of the carotid artery between young and older individuals. The results showed major inter-individual variations in the carotid arteries of older adults. Although several studies have evaluated age-related changes in the carotid bifurcation or proximal ICA, most have focused on localized segments or single geometric parameters. To the best of our knowledge, no study has comprehensively assessed the continuous geometric profile extending from the aortic arch to the proximal ICA, including vascular tortuosity and angular configuration across multiple anatomical segments.

Therefore, the primary motivation for this study was to establish a comprehensive, quantitative geometric baseline of the supra-aortic access route. Given the increasing reliance on endovascular treatment (EVT) for conditions such as acute stroke, a detailed understanding of the age-related anatomical changes in this pathway is critically needed to inform pre-procedural planning, anticipate challenges in catheter navigation, and guide device selection. We analyzed the vascular geometry from the aortic arch to the proximal ICA using a semi-automated method to provide quantitative data relevant to these clinical applications. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1369/rc).

Methods

Study population

This is a retrospective, single-center study. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Jeonbuk National University Hospital (No. 2024-03-014) and informed consent was obtained from all individual participants. From January 2020 to December 2022, 1,930 patients underwent computed tomography angiography (CTA) from the aortic arch to the intracranial vessels for the evaluation of neurovascular diseases. To minimize segmentation artifacts from venous overlap, we excluded scans with significant venous contamination at the aortic arch/CCA level that precluded accurate lumen segmentation. All CTAs were acquired with right-arm contrast injection under a uniform protocol to ensure consistency. Of these participants, 573 were excluded because of incomplete examination of the CCA stemming from incomplete CCA visualization due to venous contrast contamination (n=505) or incomplete coverage of the aortic arch (n=68). Moreover, 701 patients were excluded because of carotid plaque or stenosis based on the North American Symptomatic Carotid Endarterectomy Trial (NASCET). In addition, 73 patients were excluded from the study for the following reasons that could lead to geometric deformation of the CCA: carotid stent (n=21), massive CCA plaque (n=15), Moyamoya disease (n=10), complete occlusion of the ICA orifice (n=15), destroyed lung (n=10), and carotid web (n=2). We categorized the participants into two non-overlapping age groups to achieve a robust contrast between two physiologically distinct cohorts: those under 60 years of age (‘young group’), representing a population prior to the acceleration of significant vascular remodeling, and those over 70 years of age (‘old group’), where such changes are established. We intentionally excluded the transitional decade of 61–69 years to minimize the confounding effects of this highly heterogeneous period, thereby providing a clearer comparison between these two defined states. Ultimately, 485 patients with normal CTA findings were enrolled in this study. Participants with focal calcified nodules without carotid stenosis based on the NASCET criteria were included in our study. We analyzed the changes in carotid artery geometry between the two groups (Figure 1). Participants were clinically indicated patients without carotid stenosis, rather than healthy volunteers. Clinical indications for CTA included evaluation of suspected ischemic stroke, intracranial hemorrhage, or unexplained headache.

Figure 1 Flowchart of participant enrollment. CCA, common carotid artery; CTA, computed tomography angiography; ICA, internal carotid artery; NASCET, North American Symptomatic Carotid Endarterectomy Trial.

CT acquisition

CTA data were obtained using dual-source CT (SOMATOM Definition Flash; Siemens Healthcare, Erlangen, Germany). Initial non-contrast CT was performed from the foramen magnum through the vertex. All CTAs were acquired with the patient in a standardized supine position, with the head placed in a neutral alignment within a non-metallic head cradle to minimize motion artifact and ensure consistency. CTA was performed from the heart to the intracranial artery, and a contrast agent (Ioversol; Optiray, Gerbet, France) was injected at a rate of 4 mL/sec followed by a 30-mL saline solution bolus. The imaging parameters were as follows: 80–140 kVp, 174–256 mA, with 1.0 mm slice reconstruction and 40 mm maximum intensity projection reconstruction in 3 mm increments.

Image processing and measurement

Axial DICOM files of CTA were identified and imported into a semi-automated segmentation software (Materialise Mimics v24.0; Materialise NV, Leuven, Belgium). CTA data were processed using an image-processing pipeline (thresholding and region growing), consistent with prior studies (9,10). The lumen was segmented and the carotid centerline extracted; orthogonal cross-sections were generated at predefined intervals to obtain diameters and areas; tortuosity was computed as the ratio of centerline path length to straight-line distance between endpoints (Figure 2). The CTA data obtained via the image-processing algorithm, including thresholding and region growth, were commensurate with those of previous studies (9,10) (Figure 2). A 3-dimensional geometric surface of the vascular reconstruction model was included on the aortic arch, brachiocephalic artery, and both sides of the CCA, CAB, ICA, and external carotid artery (ECA) (Figure 2) (10). Thereafter, geometric variables were transformed to mimic the identified “optimal resolution” to ensure that complex flow patterns in CAB configuration, particularly near curved and branching regions, appeared as smooth surfaces. Subsequently, the noise file was simplified for centerline computation (Figure 2).

Figure 2 Image processing with measurement of tortuosity. (A) Segmentation performed using a craniocervical CT angiogram. (B) Acquisition of 3D reconstruction, including an aortic arch, ICA, CCA, and ECA. (C) Central lines generated individually from the aortic arch to the CCA to the ECA and ICA. (D) Tortuosity index of the following three segments: CCA, cervical ICA, and ECA. 3D, 3-dimensional; CCA, common carotid artery; CT, computed tomography; CTA, computed tomography angiography; ECA, external carotid artery; ICA, internal carotid artery.

Measurement of CCA geometry

Using a previously described method, the 3-dimensional (3D) geometric characteristics of the arterial tree were estimated from the CCA generated by the MIMICS segmentation software, where the central lines were first fitted to the vascular lumen generated from the aortic arch to the ICA and ECA individually. According to their definition, the centers of the spheres of maximal radius in the vessel are hosted by each centerline (Figures 2,3). Tortuosity was calculated for both CCAs [i.e., brachiocephalic artery to the CAB (right) and CCA to CAB (left)]. The tortuosity of the CCA, ICA, and ECA were defined as the ratio of the length of the centerline between the actual length of the vessel and vessel endpoints. In addition, tortuosity was calculated for each segment using the semi-automated MIMICS software (Figure 2).

Figure 3 Segmentation of carotid artery with MIMICS software depicting diameter measurement. MIMICS software computing the 3-dimensional geometry of CCA; central lines were generated from the CCA to the ECA and ICA; the CAB point (i) was defined automatically on the MIMICS software; the points on the central lines of the CCA (ii), ICA (iii), and ECA (iv) at a 2-cm distance based on the CAB point were identified. CAB, carotid artery bifurcation; CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery.

Thereafter, the associated sphere radius and central line tracts were used to take advantage of the nominal plane of the bifurcation and origin, allowing the division of the vessel into three branches (11-13). The maximal diameter and cross-sectional area at the carotid bifurcation were recorded separately (Figure 3). In addition, the diameters and cross-sectional areas of the ICA and ECA were measured at predefined fixed distances (2 cm) from the CAB to ensure consistency across subjects. The ICA angle was defined as the angle between the vertical lines of the CCA and ICA in the anterior plane (Figure 4). The CAB angle was measured to evaluate changes in tortuosity, and was defined as the angle between the projections of the ICA and ECA at a wide bifurcation angle.

Figure 4 Measurement of the ICA angle. The ICA angle is defined as the angle of central lines between the vertical line of the ICA and CCA vectors. (A) and (B) comparing of two female patients aged 79 years old and 31 years old. CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery.

Statistical analysis

Statistical analyses were performed using SPSS software (SPSS version 24.0; IBM Corp., Armonk, NY, USA). Continuous data between the young and old age groups were presented as means ± standard deviation of the mean. Continuous variables were assessed for normal distribution using the Shapiro-Wilk test. Comparisons between groups were performed using the Student’s t-test for normally distributed continuous variables. Categorical data on clinical symptoms or calcified nodules on CTA were expressed as counts and percentages. We used the Pearson’s Chi-squared test for categorical variables. Statistical significance was defined as P<0.05.

Results

Of the 485 patients who were enrolled in our study, 228 (47%) were in the young age group (mean age, 50.74±0.59 years; 55.7% male) and 257 in the old age group (mean age, 78.77±0.36 years, 46.7% male). A focal thrombus of the aortic arch and calcified nodules in the aortic arch, CCA, or ICA were observed in the old age group (Table 1).

A more detailed description of the geometric features and results of the statistical analysis of the two groups are listed in Table 2. Vascular tortuosity from the CCA to the CAB on both sides was significantly higher in the old age group than in the young age group (P<0.001). The maximal bifurcation diameter and the maximal cross-sectional area at the bifurcation were significantly larger in the old age group (P<0.001). Moreover, ICA diameters and cross-sectional areas measured at predefined fixed distances from the bifurcation were significantly larger in the old age groups (P<0.001). In the old age group, the maximal bifurcation diameter increased from an average of 6.3 to 7.8 mm compared with the young age group, representing a 23.8% enlargement. Likewise, the bifurcation cross-sectional area increased by 31.2% (from 31.6 to 41.5 mm²), reflecting significant structural remodeling of the carotid artery associated with aging (P<0.001 for both measures). The ICA and bifurcation angles were significantly higher in the old age group (P<0.001).

Discussion

Our findings demonstrate that significant age-related geometric remodeling occurs along the entire supra-aortic access route, from the aortic arch to the proximal ICA. These changes—specifically increased tortuosity, wider diameters, and larger bifurcation angles—are not merely descriptive findings of aging but represent clinically significant anatomical alterations that directly impact the planning and execution of EVT. This study confirmed that these geometric changes are substantial in older adults, which has important implications for navigating the access route during time-sensitive interventions.

Aging arteries exhibit alterations in autophagy, migration and proliferation of smooth muscle cells, and arterial calcification (14). During aging, SMCs undergo functional changes that alter the normal structure of the vessel wall, predisposing them to atherosclerosis. Arteries are exposed to various mechanical forces that act on arterial walls (circumferential, radial, and longitudinal forces) or endothelial surfaces (shear stress) (15). The complex embryology underlying the development of CCA, aging, hypertension, and occurrence of atherosclerotic lesions lead to several anomalous courses of the CCA (15). Aging is associated with gradual aortic elongation and notable changes in aortic geometry (8). The aorta lengthens during life, and tortuous deformation and kinking are frequently observed in older patients (8,16). The observed geometric changes, specifically increased vessel diameter, tortuosity, and wider bifurcation angles, are likely manifestations of cumulative biomechanical and cellular alterations, such as elastin fragmentation, smooth muscle cell proliferation, and progressive wall stiffening. These changes not only reflect vascular aging, but also create a hemodynamic environment that promotes early atherosclerotic lesion formation. Previous studies have reported geometric changes in the CAB in healthy participants and in patients with atherosclerosis (2,6,7,9,10,17,18). In one of such studies, Jeon et al. (7) reported that there were significant increases in the vessel volume and diameter of the CCA, ICA, and CAB during aging. ICA and CAB angles have been reported to increase significantly during aging. In addition, widening and rotation of the carotid artery increase with age. In a longitudinal study of CAB geometry using MR at baseline and after 10 years, Ngo et al. (9) reported a significant increase in the CAB angle diameter and cross-sectional area of the CCA. Changes in the CAB angle over 10 years are predominant in the right CCA, whereas changes in the cross-sectional area and diameter of the CCA are predominant in the left CCA (18). In our study, the maximal diameter and cross-sectional area of the CCA and CAB and the diameter and area of the ICA were significantly larger in the old age group. Therefore, geometric changes such as elongation and enlargement of the artery during life are considered important factors.

CAB geometry has been considered an important risk factor for early atherosclerosis because of its significant effect on local hemodynamics (2,19). The increase in the CAB angle is related to geometric remodeling due to aging. Furthermore, the CAB angle during the normal aging process progressively widens with arterial dilatation and becomes more tortuous (7,19). In addition, the CAB angle substantially increased over the past decade using MR (9,19). In the present study, the ICA and CAB angles were substantially greater in the old age group than in the young age group. These geometric changes are likely associated with the degradation and fragmentation of intramural elastin. Moreover, compared with participants with normal carotid arteries, those with carotid atherosclerotic disease demonstrated a smaller CAB angle (19). In another study, Noh and Kang reported that both ICA angles were significantly larger in patients with stroke than in controls (2). In addition, the right ICA angle was associated with the risk of ischemic stroke in multiple logistic regression models. Another study showed that the CAB angle on the right side was substantially increased compared to that on the left side (9). Therefore, the ICA and CAB angles can be considered important factors in aging, atherosclerosis, and ischemic stroke.

Vascular tortuosity is a common finding, indicating normal aging and vascular disease. Various mechanisms such as elevated blood pressure (20), reduced axial tension (15), and weakening of arterial walls, which result in elastin degradation or abnormal deposits within the vessel walls (21), are associated with vascular tortuosity. Jackson et al. (22) reported that when this tension is artificially reduced, the artery falls to restore homeostatic stress and state, and tortuosity subsequently develops. Kliś et al. (23) reported that higher tortuosity of the ICA was associated with the presence of ICA aneurysms. Kamenskiy et al. (19) reported that CCA tortuosity increased in atherosclerotic carotid arteries compared to that in normal arteries; however, tortuosity of the ICA decreased in patients with atherosclerotic disease. In our study, bilateral CCA tortuosity was significantly higher in the old age group than in the young age group. This finding supports the role of vascular tortuosity as an important geometric marker of age-related vascular remodeling.

These quantified geometric changes in older adults have direct implications for the technical feasibility and safety of endovascular procedures. For instance, the increased tortuosity of the CCA, combined with a wider and more angulated carotid bifurcation as observed in our older cohort, can significantly hinder the navigation and stable placement of large-bore guide catheters required for mechanical thrombectomy. This anatomical challenge can increase procedural times, raise the risk of iatrogenic complications such as arterial dissection or embolic events during catheter manipulation, and may lead to a failure to achieve successful revascularization. Furthermore, a pre-procedural geometric analysis, such as the one performed in our study, holds significant potential for decision support in access route selection. Quantitative metrics of aortic arch and CCA tortuosity are critical for determining the optimal approach (e.g., choosing a transfemoral vs. a transradial approach, which is increasingly relevant) and for selecting the appropriate catheter shape and stiffness. Our data suggest that in patients over 70 years, a higher degree of anatomical variation should be anticipated, necessitating careful pre-procedural planning. In the time-sensitive workflow of acute stroke intervention, manually performing these comprehensive measurements is not feasible. Therefore, the future potential of automating this geometric analysis is highly relevant. An automated segmentation and analysis software integrated into the initial imaging protocol could provide invaluable, real-time decision support for the interventional team, helping to rapidly identify challenging anatomy and optimize the strategy for EVT.

We also acknowledge that our analysis focused on tortuosity and angles, but did not measure the vertical spatial position, or ‘height’, of the carotid bifurcation. It is clinically recognized that vessel elongation is mechanistically linked to a cranial shift of the bifurcation (i.e., ‘high-riding bifurcation’), which poses a significant challenge for both surgical and endovascular access. While the increased tortuosity we measured is likely a surrogate for this phenomenon, a direct 3D coordinate analysis of the bifurcation height is an important limitation of our study and a clear direction for future research.

This study had several limitations that warrant consideration. First, its retrospective design inherently introduces the possibility of selection bias and restricts causal inferences. Second, the study population consists of individuals who underwent CTA to evaluate suspected neurovascular conditions such as stroke or hemorrhage. Although we excluded participants with overt carotid artery stenosis or prior stroke, these individuals may still harbor underlying vascular risk factors or subclinical pathologies, which could skew the distribution of vascular geometry and limit the applicability of our findings to a healthy population. In addition, we acknowledge that excluding 505 scans due to venous contamination may have introduced selection bias and could limit the generalizability of our findings. Furthermore, minor measurement bias from smoothing, the lack of ECG gating, and potential minor variations in patient neck flexion despite standardized positioning may have influenced the magnitude of observed effects. Third, our study did not specifically evaluate potential left-right asymmetry in carotid geometry. Prior longitudinal reports suggest that side-specific remodeling patterns may exist, and future prospective studies with larger cohorts will be required to clarify these differences. Fourth, baseline vascular risk factors (hypertension, diabetes, dyslipidemia, smoking history, and prior cardiovascular disease) were not comprehensively collected or reported, and these factors can influence carotid tortuosity and caliber. Residual confounding therefore cannot be excluded. In future work, we will prospectively capture these variables and present both age-adjusted and multivariable models to more robustly account for potential confounding. Fifth, our a priori design choice to compare two distinct age cohorts (<60 vs. >70 years) and exclude the transitional 61–69 years age group means our findings cannot be generalized to this intermediate decade. This exclusion was intended to maximize statistical contrast, but a continuous or multi-group analysis would be required to map the linear progression of aging, which we recommend for future studies. Finally, because this was a cross-sectional analysis, longitudinal associations between geometric changes and the development of atherosclerosis or cardiovascular events could not be established. Future prospective studies are needed to confirm whether these geometric parameters serve as early markers of vascular aging or disease progression.

Conclusions

In this cross-sectional, clinically indicated CTA cohort, older adults exhibited greater vascular tortuosity, larger maximal diameters and cross-sectional areas, and a wider carotid bifurcation angle compared with younger individuals. These associations are consistent with age-related remodeling hypotheses (e.g., elastin degradation, altered wall shear stress, early stiffening) but should not be interpreted as causal. Accordingly, we frame these geometric metrics as potential, hypothesis-generating imaging markers that may aid risk assessment pending external validation. Furthermore, recognizing these age-specific geometric challenges is crucial for pre-procedural planning, as they may directly influence catheter navigation and the safety of endovascular interventions. Non-invasive CTA-based evaluation of carotid geometry may complement early risk assessment in the future; however, prospective longitudinal studies are required to establish prognostic significance and to determine whether these parameters improve prediction of atherosclerosis progression, plaque formation, and ischemic events.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1369/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1369/dss

Funding: This work was supported by National University Development Project at Jeonbuk National University in 2024.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1369/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Jeonbuk National University Hospital (No. 2024-03-014) and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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