Background: Despite advances in the surgical treatment of patients with severe internal carotid stenosis (ICA), there are selective groups of patients who, due to several reasons, are not good candidates for surgery. Patients with contralateral occlusion are one of these subgroups. Thereby, other therapeutic alternatives, such as angioplasty may be of value. So far, there has been little published data about carotid angioplasty (CA) or stenting (CAS) in those patients. The objective of this study was to evaluate the efficacy and safety of angioplasty and stenting in patients with severe internal carotid stenosis and contralateral occlusion. Methods: Between 1991 and June 2004, 519 consecutive patients who underwent CA or CAS for severe stenosis of the ICA were registered in our prospective CA Data Bank. Of them, we identified 96 with contralateral occlusion (18.5%), who formed the basis of the present analysis. Results: Mean age was 64 ± 9 (range 40–80), 85 (88.5%) were men, and 61 (63.5%) were symptomatic. Thirty-two patients (33.3%) did not meet the criteria to be included in the NASCET. CA was done in 25 patients (26%) and CAS in 71 (74%). Distal protection was used in 38 patients (39.6%). Asymptomatic stenosis was treated in cases of progression (>85%), exhausted vasoreactivity, positive microemboli detection in transcranial Doppler, and/or asymptomatic lesions in CT/MRI. Transient hemodynamic effects were frequent: hypotension (54.5%), bradycardia (61.5%), asystole (33.3%), and syncope (33.3%). TIA occurred in 1 patient (1%), minor stroke in 1 (1%), and disabling stroke in 2 patients (2.1%). Mortality was 0%. Morbidity was 0% in cases done with distal protection. Conclusion: In our experience, CA/CAS performed in patients with severe carotid stenosis and contralateral occlusion compared favorably with the results obtained with carotid endarterectomy (CEA), to the extent that if randomized series comparing CEA and CA/CAS are done, CA/CAS might be considered as the treatment of choice in this subgroup of patients.

1.
Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP, Hachinski VC, Sackett DL, Thorpe KE, Meldrum HE, Spence JD: Benefit of carotid endarterectomy in patients with symptomatic carotid moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998;339:1415–1425.
2.
European Carotid Surgery Trialists’ Collaborative Group: Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998;351:1379–1387.
3.
MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group: Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet 2004;363:1491–1502.
4.
Gasecki AP, Eliasziw M, Ferguson GG, Hachinski V, Barnett HJ: Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: results from NASCET. J Neurosurg 1995;83:778–782.
5.
Mericle RA, Kim SH, Lanzino G, Lopes DK, Wakhloo AK, Guterman LR, Hopkins LN: Carotid artery angioplasty and use of stents in high-risk patients with contralateral occlusions. J Neurosurg 1999;90:1031–1036.
6.
Mathur A, Roubin GS, Gomez CR, Iyer SS, Wong PM, Piamsomboon C, Yadav SS, Dean LS, Vitek JJ: Elective carotid artery stenting in the presence of contralateral occlusion. Am J Cardiol 1998;81:1315–1317.
7.
Naylor AR, Rothwell PM, Bell PRF: Overview of the principal results and secondary analyses from the European and North American randomised trials of endarterectomy for symptomatic carotid stenosis. Eur J Vasc Endovasc Surg 2003;26:115–129.
8.
Fields WS, Lemak NA: Joint Study of Extracranial Arterial Occlusion. X. Internal carotid artery occlusion. JAMA 1976;235:2734–2738.
9.
Anderson CA, Rich NM, Collins GJ, McDonald PT, Boone SCl: Unilateral internal carotid occlusion: special considerations. Stroke 1977;8:669–671.
10.
Chung WB: Long-term results of carotid artery surgery for cerebrovascular insufficiency. Am J Surg 1974;128:262–268.
11.
Mackey WC, O’Donnell TF Jr, Callow AD: Carotid endarterectomy contralateral to an occluded carotid artery: perioperative risk and late results. J Vasc Surg 1990;11:778–783.
12.
Mattos MA, Barkmeier LD, Hodgson KJ, Ramsey DE, Sumner DS: Internal carotid artery occlusion: operative risks and long-term stroke rates after contralateral carotid endarterectomy. Surgery 1992;112:670–679.
13.
Perler BA, Burdick JF, Williams GM: Does contralateral internal carotid artery occlusion increase the risk of carotid endarterectomy. J Vasc Surg 1992;16:347–352.
14.
McCarthy WJ, Wang R, Pearce WH, Flinn WR, Yao JS: Carotid endarterectomy with an occluded contralateral carotid artery. Am J Surg 1993;166:168–171.
15.
da Silva AF, McCollum P, Szymanska T, de Cossart L: Prospective study of carotid endarterectomy and contralateral carotid occlusion. Br J Surg 1996;83:1370–1372.
16.
Ballotta E, Da Giau G, Guerra M: Carotid endarterectomy and contralateral internal carotid artery occlusion: perioperative risks and long-term stroke and survival rates. Surgery 1998;123:234–240.
17.
Dimakakos PB, Antoniou A, Papasava M, Mourikis D, Rizos D: Carotid endarterectomy without protective measures in patients with occluded and non occluded contralateral carotid artery. J Cardiovasc Surg (Torino) 1999;40:849–855.
18.
AbuRahma AF, Robinson P, Holt SM, Herzog TA, Mowery NT: Perioperative and late stroke rates of carotid endarterectomy contralateral to carotid artery occlusion: results from a randomized trial. Stroke 2000;31:1566–1571.
19.
Rockman CB, Su W, Lamparello PJ, Adelman MA, Jacobowitz GR, Gagne PJ, Landis R, Riles TS: A reassessment of carotid endarterectomy in the face of contralateral carotid occlusion: surgical results in symptomatic and asymptomatic patients. J Vasc Surg 2002;36:668–673.
20.
Weise J, Kuschke S, Bahr M: Gender-specific risk of perioperative complications in carotid endarterectomy patients with contralateral carotid artery stenosis or occlusion. J Neurol 2004;251:838–844.
21.
Rothwell PM, Slattery J, Warlow CP: Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review. Br Med J 1997;315:1571–1577.
22.
Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, Wallace MC, Taylor DW, Haynes RB, Finan JW, Hachinski VC, Barnett HJ: The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke 1999;30:1751–1758.
23.
Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JF, Snead DB, Cutlip DE, Firth BG, Ouriel K; for the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators: Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004;351:1493–1501.
24.
Hertzer NR, O’Hara PJ, Mascha EJ, Krajewski LP, Sullivan TM, Beven EG: Early outcome assessment for 2,228 consecutive carotid endarterectomy procedures: the Cleveland Clinic experience from 1989 to 1995. J Vasc Surg 1997;26:1–10.
25.
Baker WH, Howard VJ, Howard G, Toole JF; for the ACAS Investigators: Effect of contralateral occlusion on long-term efficacy of endarterectomy in the asymptomatic carotid atherosclerotic study (ACAS). Stroke 2000;31:2330–2334.
26.
North American Symptomatic Carotid Endarterectomy Trial (NASCET) steering Committee: North American Symptomatic Carotid Endarterectomy Trial: Methods, patient characteristics, and progress. Stroke 1991;22:711–720.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.