Hemodynamic conditions at the carotid bifurcation during protective common carotid occlusion

Abstract

Objectives: Carotid angioplasty and stenting procedures are associated with an obligatory release of particulate debris into the distal cerebral circulation. Although most of the emboli are small and do not result in symptomatic neurologic deficits, some may be large enough to cause stroke. For this reason, a variety of filters and balloon occlusion devices have been employed as adjuvants to decrease the risk of distal embolization during carotid stenting. Some of these devices rely on the arrest of antegrade blood flow with the use of inflow arrest. The present study was undertaken to investigate the hemodynamic conditions that exist at the carotid bifurcation during common carotid artery (CCA) occlusion. Methods. Internal carotid artery (ICA) and external carotid artery (ECA) stump pressures were measured in 29 patients undergoing carotid endarterectomy. Duplex ultrasound scanning was used to measure the direction and velocity of blood flow in the ICA and ECA with the CCA cross-clamped but the ICA and ECA open, a clinical scenario analogous to CCA balloon occlusion at the time of carotid angioplasty and stenting. The direction and magnitude of ICA and ECA flow were compared with the stump pressures to determine whether a correlation existed between these variables. Results: The mean stump pressure in the ICA and ECA averaged 56 ± 16 and 53 ± 12 mm Hg, respectively. The ICA systolic stump pressure was lower than the ECA systolic stump pressure in six patients (21%), and all of these patients had persistent antegrade systolic duplex blood flow by duplex interrogation during CCA occlusion. The ICA systolic stump pressure exceeded the ECA systolic stump pressure in 19 patients (66%), and all of these patients had retrograde ICA flow during systole. Diastolic flow was also well correlated with the magnitude of the ICA/ECA stump pressure differential, with antegrade diastolic ICA blood flow in all nine patients with an ICA diastolic stump pressure less than the ECA diastolic stump pressure. None of the 10 patients with ICA diastolic stump pressure greater than ICA diastolic stump pressure maintained antegrade ICA diastolic flow, but four of these patients had flow to zero in diastole. Overall, 13 of 29 patients (45%) could be surmised to be at risk for distal embolization to the brain based on the persistence of some element of either systolic or diastolic antegrade ICA flow during common carotid occlusion. Conclusions: Common carotid occlusion alone appears insufficient to protect against distal embolization during manipulations of the carotid bifurcation. Persistent systolic or diastolic antegrade blood flow occurs in a high proportion of patients, lending credence to the use of additional protective strategies to ameliorate the risk of embolic complications.