Carotid stenting and transcranial Doppler monitorino (DTC): our experience

Objective: The aim of the study was to assess the role of Transcranial Doppler (TCD) in detecting the embolic events during carotid angioplasty and/or stenting and to identify which steps of this procedure are at higher risk in mobilizing debris from the atherosclerothic plaque that could develop brain damage. Methods: From January 1999 to September 2005, eighty-four patients, mean age 69 years, were submitted to endovascular treatment of carotid stenosis: 63 (75.0%) were asymptomatic and 21 (25.0%) symptomatic. In 65 cases (77.4%) the ICA lesions was primitive while in the remaining 19 (22.6%) a restenosis was present. In 61 cases (72.6%), a primary stenting of the ICA was performed; 18 patients (21.4%) were submitted to a predilatation followed by stent deployement and in other 4 (4.8%) a simple angioplasty was carried out. In the last patient (1.2%) the procedure was stopped after selective carotid angiography due to the onset of controlateral iposthenia of the superior arm and worsening confusion. All the carotid stenosis were haemodinamically significative as assessed by Duplex scanning; all the treated plaques were smooth and mainly fibrous with low morphologic embolic aspects. Before the procedure, a TCD monitoring was performed under basal conditions (at least 20–30 min) and digital compression of common carotid artery was performed to detect micromembolic signals and to evaluate the cerebral haemodynamic tolerance. In all treated patients a TCD monitoring was maintained for 30 min after the procedure. A spiral-CT scan or MR angiography was performed also in 73 cases (86.9%) to evaluate the cerebral vessels origin and calcification. Results: Two main neurological complications: a TIA during the selective catheterization of the CCA with TCD detection of only bubbles signals and a controlateral RIND occurred at the end of the procedure related to particulate microemboli in rapid succession. The mortality was nihil. In all patients TCD recorded bubbles signals during selective catheterization and angiography. In 96% of cases corpuscolate but isolated microemboli were detected during predilatation, positioning of the filter through the lesions, stent deployement and ballooning. All these MES were asymptomatic. Conclusion: Despite the high incidence of MES during the procedure, the neurological complications are related to TCD detection of corpuscolate signals in rapid succession. Even if no reduction of the overall incidence rate of MES was observed, a decrease in the number of corpuscolate emboli were recorded when a cerebral protection was used