Bilateral carotid artery stenosis

Bilateral carotid artery stenosis

Bilateral carotid artery stenosis can be treated by carotid stenting. Bilateral carotid artery stenting, if done carefully and as a staged procedure has a low risk. Avoid those with TIA within 2 weeks/recent stroke and those with thrombus as they have a high risk of embolisation. Best medical therapy with statin, antithrombotic agents, control of blood pressure and smoking cessation are needed for all cases [1].

Best medical therapy has Class IA indication in total occlusion, where no other treatment is indicated. Additional carotid endarterectomy has Class IA indication in symptomatic stenosis of 70-99%. Carotid artery stenting has Class IIaB indication in such cases if considered high risk for carotid endarterectomy [2]. Procedures may also be considered in selected cases with lower grades of stenosis from 50-60% upto 99% in subsets of Class II.

Usually carotid stenting is done as a staged procedure to prevent hyperperfusion syndrome. Lesions at or above C2 and below the clavicle are not amenable to surgery and are taken up for carotid artery stenting. Same is true of severe comorbidities.

Stenting is seldom undertaken if there is large ipsilateral neurological deficit. Lesion length more than 3 cm and presence of clots are predictors of high risk. Headhunter catheters with various curve sizes are useful for carotid interventions. Marked tortuosity makes positioning of the distal protection device difficult.

Filters should be oversized by 2 mm compared to the distal internal carotid artery. Predilatation is done only if the lesion is very tight, of the order of 99%. Most of the embolisation occurs during post dilatation and distal protection devices are mandatory. Since most of the stents are self expanding, the lumen may increase over time after implantation as documented often by repeat angiography at a later date.

Collateral damage is less likely with incidental external carotid occlusion as there is good collateral flow for the external carotid territory. If the basket gets filled with debris, an export catheter may be used. Hyperperfusion syndrome producing headache, seizures and hemorrhage has a poor prognosis. This can be prevented by controlling the blood pressure very well.

References

1. Messas E, Goudot G, Halliday A, Sitruk J, Mirault T, Khider L, Saldmann F, Mazzolai L, Aboyans V. Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review. Eur Heart J Suppl. 2020 Dec 6;22(Suppl M):M35-M42. doi: 10.1093/eurheartj/suaa162. PMID: 33664638; PMCID: PMC7916422.
2. Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I; ESC Scientific Document Group. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Endorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018 Mar 1;39(9):763-816. doi: 10.1093/eurheartj/ehx095. PMID: 28886620.