• Arteriography has been the gold standard technique to demonstrate extracranial carotid occlusive disease.

• It outlines the inner surface of the arterial wall by providing direct visualization of blood flow inside the artery acting as a mould of the lesions from the arterial wall.

• It was first obtained by direct puncture of the common carotid.

• Following the development of arterial catheterization, it became standard practice to do it through selective retrograde catheterization, from the femoral or brachial/axillary arteries, providing full visualization of the extracranial vessels (Fig. 2.2.4) and also of the intracranial circulation.

• It provides no direct visualization of the arterial wall and its morphologic alterations, thus limiting its ability to reveal the underlying changes leading to stenosis or occlusion.

• Its use as a diagnostic tool in extracranial carotid disease was limited by local complications from arterial access (haematomas, false aneurysms) requiring treatment, allergic reactions to the contrast and deterioration of renal function.

• Digital subtraction techniques and the introduction of safer nonionic contrast media reduced its complications and improved the outcome of carotid arteri-ography, although recent published results [30] documented a stroke risk of 1.2%.

Fig. 2.2.4 Angiography of the carotid bifurcation showing a complex stenotic lesion involving the first portion of the internal carotid artery

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