Stenting of atherosclerotic stenoses of the extracranial carotid artery

Background Percutaneous transluminal angioplasty (PTA) and stenting seems t o be, at present, the treatment of choice for early restenosis after endart erectomy and for atherosclerotic stenoses of supra-aortic trunks near or at the ostium. In contrast, the role of PTA and stenting for treatment of sym ptomatic and asymptomatic atherosclerotic stenosis of carotid bifurcation i s still debated. Methods. The present study comprises 27 consecutive cases of atheroscleroti c lesions of the carotid bifurcation treated with PTA and stenting. All pat ients were symptomatic, except for 2 suffering from asymptomatic stenosis w ith contralateral carotid occlusion. There were 23 stenoses occluding 70% o r more of the lumen according to the NASCET criteria and 4 mild stenoses (5 0-60% of the lumen) with large type C ulcers. Criteria for exclusion from s urgery in these cases were aged > 79 years, previous neck surgery for laryn geal cancer, carotid bifurcation at C2, association with intracranial aneur ysms, occlusion of the contralateral carotid artery, and heart, lung and ki dney diseases. All procedures were performed under local anaesthesia associ ated with mild sedation in a few cases. In all cases, self-expandable stent s (Wallstent) were used. Follow-up ranged from 6 to 37 months. Findings. Transient neurological deficit occurred in 3 cases (11%). One cas e (3.7%) experienced a minor stroke at three months. Asymptomatic tight res tenosis due to intimal hyperplasia occurred in one case (3.7%). In 8 cases (40%) of complex stenosis involving common and internal carotid arteries th ere was some loss of contact of the stent with the wall of the common carot id artery in the late follow-up. One case (3.7%) experienced severe and pro longed hypotension and bradycardia during the release of the stent. Interpretation. From literature data and our results it emerges that peripr ocedural catastrophic embolism is unlikely to occur. The best results are u ndoubtedly obtained when treating stenosis limited to the internal carotid artery. Nevertheless, the ideal stent to treat vessels of different calibre , as occurs at the carotid bifurcation, is not yet available. The problem o f periprocedural cerebral protection has not been resolved. Reported series are heterogeneous and retrospective, and an adequate follow-up of cases is still lacking.