Balloon angioplasty for cerebrovascular disease

Percutaneous transluminal angioplasty (PTA) has become an established treatment for peripheral, renal and coronary vascular disease, where the success rate approaches 90% with complications occurring in less than 5% of patients. There has been a reluctance to recommend PTA of the internal carotid artery (ICA) because of concern about the risks of cerebral embolism. However, there are now a number of reports of technically successful PTA for ICA stenosis, as well as stenosis of other brachiocephalic arteries, demonstrating an improvement in vessel diameter and contour. Complications to date include transient neurological symptoms, asymptomatic carotid dissection and arterial spasm, but the risk of permanent stroke seems to be relatively low. The risks of embolization may be reduced by anticoagulation and avoiding arteries with obvious thrombus or ulceration. Current technical difficulties are likely to be surmounted by improvements in catheter design. PTA is most suitable for smooth ICA stenosis causing haemodynamic symptoms, fibromuscular dysplasia, surgically inaccessible stenosis, and patients with medical risk factors increasing the risks of carotid endarterectomy, such as ischaemic heart disease. Only brief admission is required, avoiding the surgical and anaesthetic risks of carotid endarterectomy. The preliminary results are encouraging enough to set up a randomized trial to determine the risks and benefits. It remains to be seen whether alterations in the calibre or contour of the vessel wall will reduce subsequent stroke. Whether cerebrovascular PTA will enter general use will depend on the balance of the risk-benefit equation.