Treatment of tandem lesions of the extracranial carotid artery.

The authors present a patient with bihemispheric transient ischemic attacks attributed to stenosis of the left common carotid origin and stenosis and ulceration of the left cervical internal carotid artery. Because of precarious cerebral blood supply secondary to occlusions of the right common carotid and left vertebral arteries, several measures were undertaken perioperatively to provide protection from cerebral ischemia during vessel occlusion. These included Swan-Ganz catheter monitoring to maximize cardiac output and maintain satisfactory hydration, normocarbia, satisfactory oxygenation, and moderate hypertension and barbiturate infusion. With these adjuncts, both lesions were treated together. Retrograde balloon angioplasty under fluoroscopic control of a significant stenosis of the common carotid artery origin was performed before carotid endarterectomy. Postoperative digital subtraction angiography demonstrated a satisfactory technical result. The management of tandem lesions of the extracranial carotid artery is discussed. Balloon angioplasty coupled with extracranial vascular reconstructive procedures may allow the management of lesions not treated safely or effectively by either technique alone.