The options for carotid intervention have expanded from the situation where carotid endarterectomy (CEA) was the sole option for the treatment of carotid bifurcation disease, to the situation where carotid artery stenting (CAS) is an alternative for selected patients. There has also been an evolution in the availability and application of the various imaging modalities employed before embarking on carotid intervention. Initially angiography was the only available option. When carotid duplex ultrasound (CDUS) emerged it was initially employed as a screening test, but over time became the sole preoperative imaging modality prior to carotid endarterectomy for many patients, with complementary angiography reserved for selected patients. CT angiography (CTA) and MRA / MRI have emerged as non-invasive alternatives to catheter angiography (albeit with their own set of limitations) and allow interrogation of the carotid vessels from the arch to the intracranial circulation, together with the ability to combine with cerebral imaging. Because of the limited efficacy of carotid intervention for asymptomatic carotid stenosis interest has turned to attempting to identify the "vulnerable carotid plaque" in an effort to better select that small group of patients who might benefit from intervention. The advent of CAS mandates imaging of the arch and proximal carotid vessels to assess suitability for access for CAS and to assess the distal vasculature to plan embolic protection. This is beyond the scope of standard CDUS. Angiography, CTA and MRA have all been employed for preprocedural imaging prior to CAS.

This presentation will discuss the available options for imaging prior to carotid intervention, highlighting the differences between the requirements prior to CEA and CAS from a clinician's perspective.