Carotid angioplasty with internal carotid artery flow reversal is well tolerated in the awake patient

Diagram illustrating the arteriovenous fistula between the common carotid artery and the internal jugular vein.

Intraoperative substraction angiogram illustrating reversal of flow from the internal carotid artery (ICA) to the internal jugular vein. Note (white arrows) a third introducer sheath in the internal jugular vein for cerebral oxygen monitoring. With the common carotid artery occluded with the Rummel loop, contrast is injected into the ICA through the sheath and antegrade flow is seen in the ICA (left black arrow), the arteriovenous fistula is immediately opened, and digital substraction is maintained until contrast is seen flowing retrogradely in the ICA and finally through the tubing into the jugular vein (right, black arrows). This sequence ascertains functioning of the fistula and that cerebral protection with ICA flow reversal is in place for the procedure.

Mixed venous oxygen saturation (SVO₂) in the internal jugular vein during carotid stenting at baseline, 1 to 2 minutes after common carotid artery occlusion with external to internal carotid flow preservation, during CCA occlusion with ICA flow reversal, immediately after ICA angioplasty balloon inflation, and upon return to baseline. *Statistically different from baseline; **statistically different than the 3 values to the left. Numbers under columns represent mean O₂ saturation ± SD. (CCA, common carotid artery; ICA, internal carotid artery; Flow rever., flow reversed in the ICA).