Carotid angioplasty: the Atkinson Morley’s/St. George’s Hospital experience and the results of transcranial Doppler monitoring for emboli and assessment of middle cerebral artery flow and CO2 reactivity before and after angioplasty

Abstract

The European Carotid Surgery Trial and the North American Carotid Endarterectomy Trial have recently shown the value of carotid endarterectomy in patients with 70–90% stenosis who have had recent cerebrovascular symptoms in that carotid artery territory. Percutaneous transluminal angioplasty (PTA) may offer an alternative. We have, to date, performed 25 PTA, 21 being randomised to PTA from our participation in the Carotid and Vertebral Artery Transluminal Angioplasty Study, the others being elective procedures. We have performed successful dilatations in 21, being unable to cross the stenosis in 4; 1 patient suffered a stroke. Transcranial Doppler ultrasound (TCD) was used to monitor for embolic signals and to assess middle cerebral artery flow velocity and ipsilateral CO2 reactivity. Asymptomatic emboli were detected and cerebral haemodynam-ics were shown to be improved following angioplasty. The risk of stroke or death from carotid PTA is thus thought to be similar to that of carotid endarterectomy; it may offer a practical alternative. TCD has shown embolisation usually occurs but is asymptomatic. This is consistent with a low risk of stroke and successful PTA results in improved cerebral haemodynamics.