Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels

Background. Carotid endarterectomy (CFA) is the standard of care for patien ts with high-grade carotid artery stenosis who are acceptable surgical cand idates. Focal occlusive lesions of the origin of aortic arch vessels can be effectively and safely treated with balloon angioplasty and primary stenti ng. The purpose of this study was to retrospectively review results of caro tid endarterectomy for high-grade carotid bifurcation stenosis combined wit h intraoperative retrograde transluminal angioplasty and primary stenting o f a hemodynamically significant stenosis at the origin of a proximal ipsila teral aortic arch vessel. Methods. Between October 1994 and August 1998, 592 patients underwent CEA, Six patients were found to have hemodynamically significant tandem lesions affecting one of the aortic arch vessels and the ipsilateral ICA for an ove rall incidence of 1%. Age ranged from 63 to 78 years (mean 74.7), Four of 6 (67%) patients had asymptomatic lesions, and 2 of 6 (33%) had symptoms of cerebral ischemia, Five patients had tandem lesions affecting the proximal left common carotid artery and the left ICA, One patient had a tandem lesio n affecting the innominate artery and the right ICA, Carotid duplex imaging and arch and cerebral arteriography was performed in all six patients. Art eriography confirmed high-grade stenoses in both the ICA and ipsilateral pr oximal aortic arch vessel, The range of stenoses in the ICA was 70 to 95% ( mean 80.8%) measured arteriographically, The range of stenoses at the origi n of the aortic arch vessels was 75-90% (mean 79.2%). All six patients unde rwent combined retrograde transluminal balloon angioplasty and primary sten ting of the ipsilateral CCA or innominate artery with temporary occlusion o f the ICA for cerebral protection, The endovascular procedure was then foll owed with standard surgical endarterectomy using an inline shunt, Results. All six procedures were successfully completed. There were no peri procedural strokes or other morbidities. Follow-up ranged from 6 to 43 mont hs (mean 23.6) and showed no evidence of recurrent stenosis by carotid dupl ex imaging. No TIAs or strokes related to the surgically corrected lesions were noted during the followup period. One patient suffered a right hemisph eric stroke secondary to a high-grade right carotid stenosis which occurred two months after her procedure surgically correcting tandem lesions on the opposite side. Conclusions, Carotid endarterectomy with balloon angioplasty and primary st enting of an ipsilateral hemodynamically significant aortic arch trunk vess el stenosis can be safely and successfully accomplished and avoids the need for an intra/extrathoracic bypass procedure.