THROMBOLYSIS OF THE CERVICAL INTERNAL CAROTID-ARTERY BEFORE BALLOON ANGIOPLASTY AND STENT PLACEMENT - REPORT OF 2 CASES

THE APPLICATION OF endovascular techniques to the treatment of cervica l carotid artery bifurcation atherosclerosis has been delayed because of the fear of causing embolic events while traversing the diseased po rtion of the artery with an angioplasty balloon catheter. Symptomatic carotid arteries often contain fresh or partially digested intralumina l thrombus. Before we cross certain carotid bifurcation lesions with a ngioplasty catheters, we deliver 100,000 to 200,000 units of urokinase in an attempt to digest loose thrombus. We have witnessed changes in the angiographic appearance of the diseased portion of the vessel afte r urokinase treatment, such as widening of the lumen, that suggest clo t lysis. We present two patients who had symptomatic internal carotid artery stenosis. Angiography showed irregular narrowing of the interna l carotid artery origin. One patient was selected for angioplasty inst ead of carotid endarterectomy because of severe cardiac risk factors. The other patient had major angiographic risk factors manifested by po or collateral circulation. The angiographic findings and history of tr ansient ischemic attacks led us to suspect the presence of soft, loose plaque debris or thrombus in both cases. Therefore, we performed thro mbolysis with urokinase before angioplasty. Repeat angiography showed widening of the arterial lumen and smoothing of the plaque profile. Su bsequent angioplasty and stent placement were uneventful. Intraarteria l thrombolysis can produce a change in the angiographic appearance of symptomatic atherosclerotic lesions of the cervical carotid artery bif urcation. Digestion of intralesional thrombus may provide a safer envi ronment for deployment of endovascular remodeling devices by decreasin g the likelihood of embolic phenomena. We believe thrombolysis should be done before angioplasty in select patients.