[Abstract] Objective To investigate the treatment of carotid artery stenosis combined with contralateral carotid lesions. Methods The clinical data of 105 patients with carotid artery stenosis combined with contralateral carotid lesions admitted from July 2011 to December 2014 were retrospectively analyzed. 50 cases underwent CEA and 55 cases underwent CAS, and the perioperative outcomes were compared and analyzed. Results The perioperative complication rate in the CEA group was 14% (7/50), including focal cerebral infarction, TIA attack, hoarseness, incisional hematoma, and urinary tract infection. The perioperative complication rate in the CAS group was 20% (11/55), including focal cerebral infarction, carotid sinus syndrome, internal jugular vein thrombosis, renal insufficiency, and pulmonary infection. There was no significant difference in the complication rate between the 2 groups (P=0.415) Conclusion Both CAS and CEA are safe and effective methods for the treatment of carotid stenosis in combination with contralateral carotid lesions. Carotid artery stenosis is one of the important causes of stroke, which is the second highest contributor to death worldwide. As knowledge and stroke screening becomes more widespread, more and more patients are recognizing the risks associated with carotid stenosis and are receiving medications and surgical treatments. The main treatment options for carotid artery stenosis include carotid endarterectomy (CEA) and carotid stenting (CAS), with several prospective trials comparing the two. With the accumulation of cases, some details of carotid artery treatment are gaining attention. Patients with carotid artery stenosis with concurrent contralateral lesions are not uncommon today, and the specificity of treatment for these patients is becoming increasingly important to physicians. We retrospectively analyzed the data of 105 patients with carotid stenosis combined with contralateral carotid lesions and summarized them as follows. 1. Data and methods 1.1. General data 105 patients with severe bilateral carotid stenosis (diameter stenosis >70%) were admitted to the Department of Vascular Surgery of Beijing Anzhen Hospital from July 2011 to December 2014. All of them were confirmed as bilateral carotid artery stenotic lesions by color ultrasound and CT angiography (CTA) before surgery, and the stenosis was >70% bilaterally. The patients were divided into CEA group and CAS group according to treatment modality. There were 50 cases in the CEA group, including 41 males and 9 females; age ranged from 50 to 83 years, with a mean age of 68.02±8.20 years. Clinical manifestations were mainly dizziness in 23 cases and had TIA episodes in 27 cases. The combined diseases included: hypertension in 41 cases, coronary heart disease in 18 cases, diabetes mellitus in 8 cases, lower limb atherosclerosis occlusive disease in 5 cases, cerebral infarction in 26 cases, renal insufficiency in 4 cases, chronic obstructive pulmonary disease in 5 cases. 55 cases in the CAS group, 42 males and 13 females, age 52-84 years, mean age 67.65±8.84 years, clinical manifestations of dizziness mainly in 31 cases, had TIA episodes in 24 cases. There were no significant differences in gender, age and comorbidity between the 2 groups (P>0.05). 1.2. Methods Fifty patients underwent CEA treatment, all under general anesthesia. An oblique incision was made at the anterior border of the sternocleidomastoid muscle, and the sternocleidomastoid muscle was retracted to reveal the carotid sheath, and the common carotid artery, internal carotid artery and external carotid artery were free to reveal the carotid artery. After intravenous heparinization, the internal carotid artery, external carotid artery and common carotid artery were successively blocked, and the regurgitant pressure of the internal carotid artery was routinely measured; if the regurgitant pressure was >40 mmHg, no diverter tube was used, and if the regurgitant pressure was <40 mmHg, a diverter tube was used. A longitudinal incision was made along the common carotid artery and extended farther than the diseased segment of the internal carotid artery. The hyperplastic intima and plaque were completely debrided, and the distal intimal piece was fixed with 7-prolene suture. Polyester patches were routinely chosen to expand the shaping to prevent postoperative restenosis. Postoperative anticoagulation or antiplatelet therapy was given. Fifty-five patients were treated with CAS, including 33 cases under general anesthesia and 22 cases under local anesthesia. The femoral artery was punctured by the Seldinger technique, the arterial sheath was systemically heparinized, the carotid artery on the treated side was superselected, and the 2250px long sheath was placed into the common carotid artery, and a whole-brain angiogram was performed. The appropriate cerebral protection device was implanted in the distal internal carotid artery at a distance of more than 50px from the lesion. A suitable balloon was selected for pre-dilatation, then a suitable stent was implanted in the lesioned segment, and post-dilatation was given or not according to the intraoperative situation. The cerebral protection device was recovered and carotid angiography and whole brain angiography were performed again for comparison with the preoperative period. Dual antiplatelet therapy was routinely given during the perioperative period 1.3, Statistical analysis Statistics were analyzed and processed by SPSS13.0 statistical software, and the measurement data were expressed as x ± s. The 2 groups were compared and analyzed by independent sample t-test, and the count data were analyzed by chi-square test. The difference was considered statistically significant at P<0.05< span="">. 2, Results All patients completed the surgery successfully. 2 patients in the CEA group used a diversion tube, the rest did not use a diversion tube, and all patients used a patch to expand the shaping. the incidence of perioperative complications in the CEA group was 14% (7/50), including 1 case of ipsilateral focal cerebral infarction, which showed transient limb hypokinesia and recovered after drug treatment, 1 case of TIA attack, brain MRI No cerebral infarction was detected on brain MRI, and symptomatic treatment with medication was given, and the patient was discharged without further symptoms. Three cases of hoarseness were treated with neurotrophic drugs and all recovered after postoperative outpatient follow-up. One case of hematoma at the incision was caused by blockage of the drainage tube and local swelling, which was gradually absorbed and was not reoperated. The incidence of perioperative complications in the CAS group was 20% (11/55), including one case of focal cerebral infarction with postoperative impaired movement of one limb, which recovered after symptomatic treatment with medication. Five cases of carotid sinus syndrome presented with postoperative hypotension requiring the use of vasoactive drugs to maintain blood pressure, all of which were discontinued after 3-5 d of drug maintenance, and blood pressure returned to normal. One case of internal jugular vein thrombosis improved after anticoagulation therapy. Three cases of renal insufficiency were treated with medication and improved without dialysis. One case of pulmonary infection recovered after anti-infection treatment. All patients were discharged successfully, and no patient died during the perioperative period. there was no significant difference in the incidence of complications between the 2 groups of patients (P=0.415) 3. Discussion Carotid stenosis is a common disease in the elderly and an important cause of stroke. Stroke is the second highest contributor to death worldwide, and 15% to 20% of strokes are caused by carotid artery stenosis [1]. In the 1950s, DeBakey et al. performed the first carotid endarterectomy (CEA) [2], which began the era of surgical treatment of carotid artery disease, and CEA became the standard treatment for carotid artery sclerotic stenosis. After that, carotid artery stenting (CAS) was developed rapidly and became an alternative option for the treatment of carotid stenosis. The results of the CREST trial showed no significant difference in the 4-year endpoint event rates between the two treatments [4], and several randomized controlled trials such as ACT-1, ACST-2, and SPACE-2 are currently underway. In patients with contralateral carotid artery stenosis, especially severe stenosis, the choice between CEA or CAS, the priority of treatment on one side, and the specific intraoperative details are still controversial. In patients with severe bilateral carotid artery stenosis, the general opinion is to treat the side with the most severe stenosis first. Some investigators have studied the nature of bilateral carotid plaques. Selwaness M et al [5] performed MRI in 1414 patients and found that intraplaque hemorrhage occurred more often in the left carotid plaque, whereas the right carotid was more calcified, thus suggesting that the left carotid plaque was more unstable. However, some studies do not support this view, while Doonan RJ et al [6] showed that bilateral carotid plaques did not differ histologically or in terms of echogenicity, but required closer monitoring and more aggressive treatment due to the presence of contralateral carotid stenosis. The vast majority of our patients were treated first on the more stenotic side based on preoperative ultrasound and CTA findings. However, the decision is also based on the patient’s medical history, symptoms, and whether the ultrasound or MRA suggests an unstable plaque. If there is a clear previous history of cerebral infarction or recurrent TIA on one side, and the ultrasound and MAR indicate that the carotid plaque on that side is an unstable plaque, it can be assumed that the cerebral infarction or TIA is due to the stenosis on that side of the carotid artery, and the lesion on that side should be treated first. In addition, in some special cases, the priority treatment side needs to be determined based on the carotid angiography results. In two patients in this group, the preoperative ultrasound and CTA indicated that both sides had >70% stenosis, and CAS was proposed to be performed on the side with more severe stenosis first, but the intraoperative angiography revealed that the carotid plaque on the side to be operated was extremely irregular in shape, with a localized “cloudy” appearance, and the possibility of plaque dislodgement was very high if CAS was performed. Although we routinely use cerebral protection devices, it may increase the risk of cerebral infarction. The other side of the carotid artery was also severely stenosed, but the morphology was significantly more regular, so we decided to change the surgical plan intraoperatively and perform CAS on the other side first, and then perform CEA on that side 4-8 weeks after surgery. There is no definite decision on whether to choose CEA or CAS in patients with severe stenosis of the combined contralateral carotid artery. A meta-analysis by Antoniou GA et al. found that patients with contralateral carotid artery occlusion were at increased risk of CEA. A meta-analysis by Antoniou GA et al. They analyzed 46 reports of 28,846 CEA procedures, 3,120 patients with contralateral carotid occlusion and 25,726 patients with patency of the contralateral carotid artery. The results showed that the contralateral carotid occlusion group had a higher incidence of stroke, TIA and death compared to those with contralateral patency [7].Faggioli G et al. showed that CEA with contralateral carotid occlusion was a risk factor for cerebrovascular complications, but CAS was not a risk factor for cerebrovascular complications [8].Mercado N et al. reported 5500 cases of CAS, of which 1375 patients had contralateral carotid occlusion. Of these, 1375 patients had contralateral carotid occlusion and 4125 patients had patency of the contralateral carotid artery, showing no significant difference in mortality during hospitalization, incidence of nonfatal stroke and infarction between the two groups, thus suggesting that CAS is safe in patients with contralateral carotid occlusion [9]. However, there are different views. samson RH et al. retrospectively analyzed 2183 patients with CEA, all without a diverter, of whom 147 patients had contralateral carotid occlusion, and found that the incidence of stroke and mortality were not increased in the contralateral carotid occlusion group, thus concluding that CEA was safe in patients with contralateral carotid occlusion even without a diverter. However, the authors suggest that this may be due to the shorter carotid block time, delicate manipulation, general anesthesia, and good blood pressure control [10]. In this study, 55 patients were treated with CAS and 50 patients with CEA. there was no significant difference in the complication rates including neurological complications between the 2 groups. We routinely performed intraoperative internal carotid artery regurgitation pressure measurement, which to some extent can more accurately reflect the intracranial collateral circulation compensation. if the regurgitation pressure >40 mmHg, we did not use a diverter tube in any case, and if the regurgitation pressure <40 mmhg< span="">, a diverter tube was used. Because a diverter tube may also bring complications such as plaque dislodgement and distal internal carotid artery entrapment, we selectively apply a diverter tube during CEA. In some high-risk patients we applied transcranial Doppler ultrasound (TCD) to monitor intracranial blood flow, which provided a better guarantee for the safety of the procedure. Two patients in our group had intraoperative measurement of internal carotid artery regurgitation pressure <40 mmhg< span=""> and used a diverter tube, while the rest did not use a diverter tube, suggesting that despite the presence of severe stenosis in the contralateral carotid artery, a diverter tube was not necessary in most patients undergoing CEA due to the presence of anterior and posterior traffic and other collateral circulation in the skull. The possibility of simultaneous surgery for bilateral carotid artery lesions is also a controversial issue at present. Most scholars believe that bilateral carotid lesions should be staged, and a study by Diehm N et al. showed that bilateral CAS with a surgical interval >1 month is safe [11]. In recent years, it has also been suggested that simultaneous bilateral carotid lesions are safe and do not have an increased rate of perioperative complications [12], but evidence for large samples and long-term follow-up is lacking. Theoretically, simultaneous management of bilateral carotid lesions increases the incidence of hyperperfusion syndrome, especially in patients with difficult blood pressure control and an increased chance of cerebral hemorrhage. We have adopted a staged approach for all such patients, and the treatment interval is >6 weeks. Whether simultaneous management is possible needs to be confirmed by more clinical trials. From the results of our retrospective study, patients with severe stenosis of the combined contralateral carotid artery are safe and effective with either CAS or CEA, and the choice of procedure depends on the patient’s systemic condition, morphological characteristics of the carotid artery, and the nature of the plaque.