Bilateral carotid angioplasty and stenting

Abstract

Bilateral carotid stenosis is generally treated by staged stenting procedure and rarely simultaneously due to concerns about hemodynamic impairment from stimulation of the carotid sinus baroreflex (severe bradycardia, hypotension) and the risk of cerebral hyperperfusion syndrome. Most of the accounts of bilateral carotid stenting are of small series. The aim of this study was to evaluate the feasibility and safety of simultaneous bilateral carotid angioplasty and stenting (CAS) in comparison with staged procedure. We retrospectively analyzed the procedural outcome and complications of bilateral CAS done between February 1995 and June 2004 in a consecutive series of 57 high-risk patients. Mean age was 64 +/- 9 years (male, 43; female 14). One hundred fifteen arteries were treated (one patient had bilateral internal carotid artery stenosis associated to an ostial common carotid artery stenosis). Thirty-nine patients were symptomatic (70%). Thirty-six patients had severe coronary artery disease. Seventeen patients underwent a simultaneous bilateral CAS (group 1), 40 in a staged manner (group 2). Among these 40 patients 10 were treated with a time interval of 24 hr, while the 30 other ones were treated with a time interval of 2 days to 2 months. A neuroprotection device was used in the last 42 patients. There was technical success in all patients and transient bradycardia and/or hypotension in 25 patients (44%). There was no prolonged bradycardia or hypotension. At 30 days, we observed in group 1 (simultaneous bilateral CAS) no transient ischemic attack (TIA), no minor stroke, one (5.8%) major stroke (hyperperfusion syndrome with brain hemorrhage leading to death in a patient under IIb/IIIa inhibitors), one myocardial infarction leading to death, and two (11.7%) death/stroke/myocardial infarction; in group 2 (staged procedure), two (5%) TIAs, no minor stroke, no major stroke, and one (2.5%) hyperperfusion syndrome with rapid recovery. Among the 10 patients treated with a time interval of 24 hr, we observed one TIA. Among carefully selected patients, bilateral CAS is feasible simultaneously or the day after, with a safety and complication rate comparable to that of large published series of CAS or endarterectomies in high-risk patients. Nevertheless, careful monitoring of the patient, blood pressure, and heart rate is mandatory to avoid complications related to hyperperfusion syndrome. Routine use of neuroprotection device and meticulous technique should improve the outcomes of bilateral CAS.

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary

“…Seizures are related predominantly to hypoperfusion and also occur in <1% of cases. [234][235][236][237][238][239][240][241][242] Subclinical ischemic injury has also been detected by MRI. 172,243,244 In the recent randomized trial ICSS (International Carotid Stenting Study), comparisons were possible between patients with CAS and CEA.…”

The Brain First or the Heart: The Approach to Revascularizing Severe Co‐Existing Carotid and Coronary Artery Disease

“…3,8 These patients have a risk for stroke as high as 20% 4 due to fluctuations in blood pressure that might occur during coronary revascularization, and performing staged CAS first minimizes their risk. 11 Twenty three patients underwent staged CABG approximately 70 days after CAS. The overall rate of MI, CVA, and death was 10%.…”

“…18 Although staged CAS is associated with delayed treatment, increased cost, and patient inconvenience, 19 simultaneous bilateral CAS is rarely performed secondary to the theoretical risk of cerebral hyperperfusion syndrome and hemodynamic instability. 11,18,19 Cerebral hyperperfusion syndrome has been reported after CEA and unilateral CAS and results in cerebral edema, intracranial bleeding, CVA, and death. 19 Bilateral CAS increases the risk for cerebral hyperperfusion syndrome though a restoration of blood flow in both obstructed carotid vessels, which have impaired autoregulation and remain maximally dilated for several days.…”

“…19 Increased carotid sinus baroreflex stimulation during bilateral CAS causes severe hypotension and prolonged bradycardia. 11,19 While bradycardia and hypotension during carotid revascularization can certainly aggravate ischemic heart disease and possibly result in MI, hemodynamic stability can be achieved through the utilization of pacemakers and dopamine.…”

“…11 Simultaneous bilateral CAS was performed in 17 patients, and 40 patients underwent staged CAS (days to months). At 30-day follow-up, simultaneous bilateral CAS resulted in 2 strokes (11.8%), 1 MI resulting in death, and a cumulate event rate of 17.6%.…”