Surgical Endarterectomy Research Articles

Adjunct brachytherapy: a new concept to prevent intimal hyperplasia after surgical endarterectomy?

Endarterectomy represents a therapeutical option for patients with advanced coronary artery disease. The mid-term results are compromised by restenosis due to neointima formation. The aim of this study was to evaluate a new treatment concept - endarterectomy with consecutive gamma-irradiation - in a rat model. Male Sprague-Dawley rats underwent left carotid endarterectomy with removal of intima: control (n=10) or were irradiated with 15 Gray (Gy) (n=13) or 20 Gy (n=10) postoperatively and compared with sham-operated rats (n=10). After 3 weeks, carotid arteries were perfusion-fixed and vessel compartment areas were measured. Transmission electron microscopy and immunohistochemical staining were used to confirm neointima formation. Three weeks after endarterectomy, neointimal hyperplasia was found in the control group (0.07+/-0.04 mm(2)). After irradiation, a dose-dependent reduction of neointima was observed (0.003 mm(2) at 15 Gy and 0.0007 mm(2) at 20 Gy, P<0.0001). However, immunohistochemical staining revealed that thin re-endothelialization after irradiation was not inhibited. Gamma-irradiation significantly suppressed neointimal hyperplasia in a rat model of surgical endarterectomy. Despite inhibition of intimal hyperplasia, re-endothelialization after adjuvant brachytherapy was present. Adjuvant brachytherapy may be therefore a new concept to prevent restenosis after endarterectomy in patients.

Surgical Management of Takayasu's Arteritis

The results of surgical bypass and endarterectomy in Takayasu's arteritis (TA) were reported to be poor compared to usual atherosclerosis patients. However, if ischemic symptoms due to occlusive disease were severe, surgical procedures were inevitable. We report surgical experience of 5 patients with TA. Five women (ranged from 26 to 58 yr) were operated between June 1998 and May 2004. Three patients showed occlusion of main branches of aortic arch and had symptoms of cerebral ischemia. One patient showed near total occlusion in the midabdominal aorta and had symptoms of orthopnea and uncontrolled hypertension. One patient showed total occlusion of abdominal aorta at the level of aortic bifurcation and had a symptom of severe claudication on both legs. Bypasses from the ascending aorta to the carotid artery were performed in 3 cases. Bypass from the thoracic aorta to the left common iliac artery was performed in one case and endarterectomy of abdominal aorta in one case. The ischemic symptoms related with arterial occlusion were resolved after surgery. And the symptoms of cardiac failure disappeared. The symptomatic TA frequently required arterial reconstruction. The symptomatic improvement and excellent mid-term patency could be expected after arterial reconstruction and endarterectomy.

Management of superficial femoral artery occlusive disease.

The prevalence of intermittent claudication in men aged 55-74 years is 4.5 per cent and a common cause of such claudication is superficial femoral artery (SFA) occlusive disease. The preferred management of patients with this condition remains a subject of discussion. Therapeutic options range from conservative treatment to endovascular intervention and surgical bypass or endarterectomy. Conservative therapy is the primary treatment of choice. However, if this fails and an endovascular technique is chosen, percutaneous transluminal angioplasty (PTA) is the best option; other endovascular methods have failed to achieve higher rates of technical success or patency. PTA should be considered only for short lesions (< or = 10 cm). The usual surgical option for SFA occlusive disease is femoropopliteal bypass using autogenous vein, which has an expected 5-year patency rate of 56-76 per cent. Patency rates decrease if other types of graft are used. An alternative to vein bypass is endarterectomy, with an expected 5-year patency rate of 35-71 per cent. A multicentre randomized trial should be conducted to determine the optimal management of claudication caused by SFA occlusive disease.

Intervention for renal artery stenosis: endovascular and surgical roles

The treatment options for renal artery stenosis include bypass surgery, surgical endarterectomy, or balloon angioplasty with/without stenting. Each of these procedures is delivered today with differing frequency, morbidity/mortality, and outcomes. The procedure most applicable to patients with atherosclerotic disease is percutaneous transluminal renal angioplasty with stenting. Stents prevent plaque recoil, minimizing early restenosis, and the relatively large size of the renal artery (5-7 mm) minimizes late stent restenosis rates. The clinical features that help predict a favorable response to intervention are reviewed. In short, intervention provides a durable means to control renovascular hypertension, ischemic nephropathy, and congestive heart failure due to poor renal volume control.

What Is the Latest in Inventory for Carotid Stenting and Cerebral Protection?

Carotid angioplasty is fast being incorporated into the treatment options for patients with carotid occlusive disease. The results of the SAPPHIRE and ARCHER trials have demonstrated that carotid angioplasty and stenting with the use of cerebral protection devices is not inferior to open surgical endarterectomy in high-risk patients. The limiting step for percutaneous carotid interventions was the potential for cerebral embolization during the intervention. However, the ready availability of several embolic protection devices has placed this technology into the hands of many endovascular specialists. A brief outline of the basic inventory necessary for a carotid stent program is presented.

Safety and Efficacy of Endovascular Treatment of Carotid Artery Stenosis Compared With Carotid Endarterectomy

Endovascular treatment of atherosclerotic carotid artery stenosis may be an alternative to surgical endarterectomy. To evaluate the safety and efficacy of endovascular techniques, we conducted a systematic review of randomized studies that compared endovascular treatment with surgery for carotid stenosis. We searched the Cochrane Stroke Group trials register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Science Citation Index for randomized trials of carotid angioplasty and/or stenting compared with surgery. We also contacted researchers in the field and balloon catheter and stent manufacturers. Five trials involving 1269 patients were included. Analysis of 30-day safety data found no significant difference in the odds of treatment-related death or any stroke (odds ratio [OR], endovascular surgery, 1.33; 95% confidence interval [CI], 0.86 to 2.04), death or disabling stroke (OR, 1.22; CI, 0.61 to 2.41), or death, any stroke, or myocardial infarction (OR, 1.04; CI, 0.69 to 1.57). At 1 year after randomization, there was no significant difference between the 2 treatments in the rate of any stroke or death (OR, 1.01; CI, 0.71 to 1.44). Endovascular treatment significantly reduced the risk of cranial nerve injury (OR, 0.13; CI, 0.06 to 0.25). There was substantial heterogeneity between the trials for 4 of the 5 outcomes. No significant difference in the major risks of treatment was found but the wide confidence intervals indicate that it is not possible to exclude a difference in favor of one treatment. Minor complication rates favor endovascular treatment. There is currently insufficient evidence to support a widespread change in clinical practice away from recommending carotid endarterectomy as the treatment of choice for suitable carotid artery stenosis. Patients suitable for carotid endarterectomy should only be offered stenting within the ongoing randomized trials of stenting versus surgery.

Percutaneous carotid artery stenting: a strategy in evolution

Carotid stenting was initially proposed as an alternative to surgical endarterectomy for selected high-risk patients. More recently, patients of standard surgical risk are being considered for percutaneous treatment of their carotid disease. To describe the clinical outcomes of an initial consecutive cohort of patients treated by carotid stenting at one institution. Between December 1997 and July 2003, 111 patients underwent stenting of 118 carotid arteries. Peri-procedural and long-term outcome data were collected. Most patients (>70%) were high-risk candidates for endarterectomy. Stents were successfully placed in 117/118 carotid arteries (99.2%). Distal protection devices were used in 43/118 (36.4%). The peri-procedural rate of death or disabling stroke was 3/118 (2.5%). Death or any stroke occurred in 11/118 (9.3%). However, only 7/118 (5.9%) procedures resulted in death or any persistent stroke (neurological deficit >1 week post-procedure). No myocardial infarction occurred. Median length of post-procedure hospitalization was 1 day. Long-term follow up was possible for 101 patients (91.0%) over a mean period of 27.1 months. The Kaplan-Meier estimate of survival free of ipsilateral stroke 36 and 66 months after carotid stenting was 77.0 +/- 9.5% and 68.2 +/- 15.1%, respectively. The estimated survival free of any stroke or stent failure was 70.9 +/- 10.7% and 60.7 +/- 17.4%, respectively. The majority of late deaths (7/11) were due to cardiac disease. We conclude that stenting of carotid stenoses is feasible, with a high procedural success rate and low complication rate. Carotid stenting should be considered the procedure of choice for high-risk patients.

Revascularization of the Posterior Circulation

The primary objective of revascularization procedures in the posterior circulation is the prevention of vertebrobasilar ischemic stroke. Specific anatomical and neurophysiologic characteristics such as posterior communicating artery size affect the susceptibility to ischemia. Current indications for revascularization include symptomatic vertebrobasilar ischemia refractory to medical therapy and ischemia caused by parent vessel occlusion as treatment for complex aneurysms. Treatment options include endovascular angioplasty and stenting, surgical endarterectomy, arterial reimplantation, extracranial-to-intracranial anastomosis, and indirect bypasses. Pretreatment studies including cerebral blood flow measurements with assessment of hemodynamic reserve can affect treatment decisions. Careful blood pressure regulation, neurophysiologic monitoring, and neuroprotective measures such as mild brain hypothermia can help minimize the risks of intervention. Microscope, microinstruments and intraoperative Doppler are routinely used. The superficial temporal artery, occipital artery, and external carotid artery can be used to augment blood flow to the superior cerebellar artery, posterior cerebral artery, posterior inferior cerebellar artery, or anterior inferior cerebellar artery. Interposition venous or arterial grafts can be used to increase length. Several published series report improvement or relief of symptoms in 60 to 100% of patients with a reduction of risk of future stroke and low complication rates.

Coronary Endarterectomy and Stent Removal in Patients With In-Stent restenosis

In-stent restenosis (ISR) remains the major limitation of coronary stent implantation. Controversies exist regarding optional treatment for ISR. Recently, we developed aggressive surgical options, coronary endarterectomy and stent removal, in this complex setting. Between April 2001 and March 2004, 11 consecutive patients who presented with angina and angiographically severe ISR were treated with coronary endarterectomy and stent removal with concomitant multivessel coronary bypass grafting. There were 10 men and 1 woman. The age ranged from 43 to 75 years old (mean 64.1 +/- 9.6 years). The mean number of target vessel interventions was 1.6 +/- 0.7. Data were analyzed retrospectively. The target vessel was the left anterior descending artery (LAD) in all patients. The mean interval from the last intervention was 4.8 +/- 1.9 months. The mean number of target vessel interventions was 1.6 +/- 0.7. The mean LAD incision length was 57.3 +/- 11.0 mm. The left internal mammary artery (LIMA) was grafted in situ, as an on-lay patch. Procedural success without in-hospital complications was achieved in all cases, except one patient with low output syndrome. Postprocedure angiography demonstrated that all LIMA patches and LAD arteries were patent and left ventricular functions were preserved. Coronary endarterectomy and stent removal with on-lay LIMA patch is a safe and effective technique used in patients with ISR involving diffuse target vessel disease.

INVITED COMMENTARY

Fukui and colleagues report in this issue, a series where in-stent restenosis has been removed at surgery by endarterectomy and arterial patch reconstruction using the pedicled left internal mammary artery. This raises numerous issues of importance to both surgeons and cardiologists. Where stents have been placed more distally, and are accessible to surgical removal, endarterectomy and arterial onlay patch angioplasty may be potentially curative. In-stent restenosis may be ameliorated by drugs or other agents attached to stents that suppress the growth of neointimal hyperplasia. But until abnormal vessel tissue is covered by a normal layer of endothelium at the time of or soon after stenting, restenosis can be expected in some. If the in-stent stenosis is removed, then flow competition from the native coronary circulation may cause inflow conduits to fail. Therefore, should the notion of arterial patch angioplasty (without an inflow conduit) be revisited? Much work remains to determine early success and later durability of the approach advocated by Fukui and colleagues. While flow to stent compromised side branches could be addressed by this technique, the relative indications for this approach over the theoretically simpler conventional coronary artery bypass grafting to branches distal to the in-stent stenosis, remain to be defined. Finally, coronary endarterectomy for diffusely stenosed coronary arteries was largely abandoned due to poor results and it is not very clear how this approach by Fukui and colleagues differs from that.

Endovascular Significance of the External Carotid Artery in the Treatment of Cerebrovascular Insufficiency

To present illustrative cases that demonstrate the feasibility and clinical benefits of endovascular treatment of external carotid artery (ECA) stenoses in patients with occluded internal carotid arteries (ICA). Three patients with symptoms of cerebrovascular insufficiency and a stenosis of the ECA in the presence of occluded ICAs and diseased vertebral arteries were treated successfully by percutaneous stent or stent-graft implantation with and without cerebral protection. The ECAs play an important role in providing collateral blood supply to the brain through the many connections between branches of the ECA and cranial branches of the ICA and vertebral arteries. If these important pathways of collateral cerebral blood flow become diseased, ischemic symptoms become apparent. We recommend an endovascular procedure as a potential alternative to surgical endarterectomy of the ECA in patients with severe extracranial arterial disease.

Extracranial Thrombotically Active Carotid Plaque as a Risk Factor for Ischemic Stroke

Recent studies suggest that factors other than the degree of carotid stenosis are involved in ischemic stroke pathogenesis, especially modifications of plaque composition and related complications. To examine the role of carotid plaque rupture and thrombosis in ischemic stroke pathogenesis in patients undergoing carotid endarterectomy, excluding those with possible cardiac embolization or with severe stenosis of the circle of Willis. A total of 269 carotid plaques selected from an Interinstitutional Carotid Tissue Bank were studied by histology after surgical endarterectomy between January 1995 and December 2002. A total of 96 plaques were from patients with ipsilateral major stroke, 91 plaques from patients with transient ischemic attack (TIA), and 82 plaques from patients without symptoms. Differences in the frequency of thrombosis, cap rupture, cap erosion, inflammatory infiltrate, and major cardiovascular risk factors between study groups. A thrombotically active carotid plaque associated with high inflammatory infiltrate was observed in 71 (74.0%) of 96 patients with ipsilateral major stroke (and in all 32 plaques from patients operated within 2 months of symptom onset) compared with 32 (35.2%) of 91 patients with TIA (P < .001) or 12 (14.6%) of 82 patients who were without symptoms (P < .001). In addition, a fresh thrombus was observed in 53.8% of patients with stroke operated 13 to 24 months after the cerebrovascular event. An acute thrombus was associated with cap rupture in 64 (90.1%) of 71 thrombosed plaques from patients with stroke and with cap erosion in the remaining 7 cases (9.9%). Ruptured plaques of patients affected by stroke were characterized by the presence of a more severe inflammatory infiltrate, constituted by monocytes, macrophages, and T lymphocyte cells compared with that observed in the TIA and asymptomatic groups (P = .001). There was no significant difference between groups in major cardiovascular risk factors. These results demonstrate a major role of carotid thrombosis and inflammation in ischemic stroke in patients affected by carotid atherosclerotic disease.

Reporting Standards for Carotid Artery Angioplasty and Stent Placement

Reporting Standards for Carotid Artery Angioplasty and Stent Placement

Reporting Standards for Carotid Artery Angioplasty and Stent Placement

Cerebrovascular disease is the third leading cause of death in the United States. Approximately 750,000 people have a stroke annually, costing an estimated $45 to $50 billion in treatment and lost productivity according to the National Institutes of Health. Carotid occlusive disease is responsible for 20% to 25% of these strokes. Surgical carotid endarterectomy is currently the accepted standard of treatment for revascularization of extracranial carotid occlusive disease. This has been validated by multiple, randomized, controlled clinical trials that have demonstrated its efficacy over best medical therapy in North America and Europe. However, in the past several years, carotid artery stenting has emerged as a potential therapeutic alternative to surgical carotid endarterectomy for the treatment of atherosclerotic carotid artery disease. The future status of this endovascular approach will be determined by well designed, randomized, multicenter trials directly comparing carotid artery stenting to surgical endarterectomy, as well as by the potential for further innovation and improvement in endovascular devices, techniques, and safety. Comparisons of carotid artery stenting and endarterectomy are difficult because of differences in patient selection, the use of case series rather than randomized controlled trials for stenting, differences in definitions of outcomes and complications, and observer bias. The suggested reporting standards for carotid endarterectomy have not been uniformly followed-up for surgical trials and have also not been used in trials of carotid artery stenting. It is the purpose of this document to standardize the reporting of carotid stent trials and to recommend trial designs so that carotid stenting and endarterectomy may be fairly compared. This document is a consensus statement of the Technology Assessment Committees of the American Society of Interventional and Therapeutic Neuroradiology and the Society of Interventional Radiology.

Parametric analysis of carotid plaque using a clinical ultrasound imaging system

We evaluated quantitative ultrasonic methods for assessment of carotid plaque content. In vitro measurements of fixed, carotid plaque specimens obtained by surgical endarterectomy were performed using a clinical Philips HDI 5000 imaging system connected to a radiofrequency (RF) signal-acquisition system. We acquired RF signals and grey-scale images from carotid specimens ( n = 17) and a tissue-mimicking reference phantom. Imaged plaque sections were then classified according to histology. Parametric images were constructed from the integrated backscatter (IBS), and the midband, slope and intercept values of a straight-line fit to the apparent backscatter transfer function. Analysis was performed on 82 regions-of-interest (ROIs). The IBS values for collagen, lipid and hemorrhage plaques were 5.8 ± 5.4, 3.9 ± 3.7, 2.8 ± 2.2 dB, respectively. Midband and IBS parameter images exhibited good agreement in morphology with histology, whereas the slope and intercept parameter images were noisy. Mean IBS, midband, and grey-scale values of complex plaques were found to be statistically different ( p < 0.05) from lipid, hemorrhage and fibrolipid plaques. The bias and limits of agreement (1.3 ± 4.9 dB) between the grey-scale and IBS methods, however, indicated that the two methods were not interchangeable. Results indicate necessary improvements, such as reduction of large measurement variances and identification of robust parameters, that will permit multiparametric characterization of carotid plaque under in vivo conditions. (E-mail: krwaters@boulder.nist.gov)

Carotid Artery Angioplasty and Stent Placement: Quality Improvement Guidelines to Ensure Stroke Risk Reduction

CERVICAL carotid atherosclerotic stenosis has been correctly surmised to be a potentially preventable cause of stroke for a half-century. For most of this time, neither the absolute risk of the condition nor the specific contributing factors were known. Not surprisingly, therefore, medical therapy was poorly understood and offered a limited armamentarium. Prior dogma maintained that medical therapy alone neither significantly affected the progression of atherosclerosis nor caused its regression. Today an extensive body of literature confirms that cervical carotid artery atherosclerosis is common, relatively easy to evaluate, a major health threat, and surgically correctable. The appropriateness of carotid endarterectomy (CEA) has been evaluated by at least seven randomized trials, and further study is warranted and ongoing. While great strides have been made in the last decade in understanding cervical carotid atherosclerotic stenosis, there are still many important unknowns concerning the clinicopathologic condition, its various manifestations, precipitating biochemical and pathophysiologic events, specific patient risk characteristics, optimal medical therapy, as well as indications for, and best methods of, surgical and interventional therapies. Perhaps one of the best examples of the evolutionary nature of knowledge in this field is the relatively new concept that the principal culpability for clinical neurologic events is not the “degree-of-stenosis” per se, but rather the pathology of the plaque and the ischemia produced by atherothrombotic emboli. This belief is universally accepted in the cardiovascular community but seems to be under-appreciated in the neuroscience community. The ultimate confirmation of this concept is the 10-fold or greater difference in risk for someone with an 80% “nonembologenic” (ie, “asymptomatic”) carotid stenosis as compared to an 80% “embologenic” (symptomatic) stenosis. For the former there is about 1% to 2% per year stroke risk from the lesion itself as compared to the latter, which has about 10% to 20% risk of stroke in the first year (1,2). Further, recent studies of newer pharmacologic agents including antiplatelet agents (such as clopidogrel) and plaque-stabilizing agents (such as HMGCoA-reductase inhibitors [“statins”] and angiotensin converting enzyme [“ACE”] inhibitors) do indeed demonstrate that the natural history of atherosclerotic plaques can be positively influenced in a way that changes the risk/benefit ratio of all therapies for not only coronary atherosclerosis but also for carotid atherosclerosis (3,4). However, none of these new medical therapies have been systematically compared to CEA or carotid artery stent placement (CAS) in controlled clinical trials aimed at evaluating the best method to reduce stroke and stroke-related morbidity and mortality. In March 2000, the American Society of Interventional and Therapeutic Neuroradiology (ASITN), the specialty organization then composed primarily of neuroradiologists and neurosurgeons most involved with cervico-cerebral angiography and cervical and intracranial endovascular intervention, published a review and analysis of the current literature on carotid atherosclerosis and its treatment (5). Since that time, continued progress has been made in further understanding the nature of carotid atherosclerosis, improving surgical techniques, advancing the pharmaceutical armamentarium, and refining a potential endovascular therapy: carotid artery angioplasty and stent placement. Three medical societies that include training in cervico-cerebral angiography as part of their ACGME defined residency programs, the ASITN, the American Society of Neuroradiology (ASNR), and the Society of Interventional Radiology (SIR), recognize the importance of carotid atherosclerosis and its appropriate management. In this issue of the Journal of Vascular and This article also appears in J Vasc Interv Radiol 2003; 14:1095–1097. From the Miami Cardiac and Vascular Institute, Miami, FL (J.J.C., G.J.B.), Department of Radiology, Reading Hospital and Medical Center, Reading PA (D.S.), and Mid-South Imaging and Therapeutics, Memphis, TN (J.D.B.). Received July 3, 2003; accepted August 6. Address correspondence to J.J.C., MCVI, 8900 Kendall Dr, Miami, FL 33176. E-mail budmancon@aol.com

Quality Improvement Guidelines for the Performance of Cervical Carotid Angioplasty and Stent Placement: Developed by a Collaborative Panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology

John D. Barr, MD, John J. Connors, III, MD, David Sacks, MD, Joan C. Wojak, MD, Gary J. Becker, MD, John F. Cardella, MD, Bohdan Chopko, MD, PhD, Jacques E. Dion, MD, Allan J. Fox, MD, Randall T. Higashida, MD, Robert W. Hurst, MD, Curtis A. Lewis, MD, MBA, Terence A.S. Matalon, MD, Gary M. Nesbit, MD, J. Arliss Pollock, MD, Eric J. Russell, MD, David J. Seidenwurm, MD, and Robert C. Wallace, MD, for the ASITN, ASNR, and SIR Standards of Practice Committees

Platelets: Is aspirin sufficient or must we know how to pronounce abciximab?

Although vascular disease may present with symptoms that are representative of a focal exacerbation of atherosclerosis, it is inherently a systemic disease. Consequently, vascular surgeons must be capable of recommending to their patients pharmacologic approaches that will decrease future risk of cardiovascular-related morbidity and death. Antiplatelet treatments, in particular, have been shown to reduce future cerebrovascular and coronary events. Moreover, these medications have utility in maintaining peripheral vessel and graft patency after surgical bypass, endarterectomy, or percutaneous translumenal angioplasty. The future of optimal antiplatelet therapy will consist of strategies that block multiple platelet activation pathways simultaneously. Moreover, the use of directed antiplatelet medications promises more effective control of platelet physiology with a concomitant increase in safety. The authors review herein current recommendations for the use of aspirin, thienopyridines, and GP llb/llla inhibitors in patients with peripheral vascular disease.

Platelets: is aspirin sufficient or must we know how to pronounce abciximab?

Although vascular disease may present with symptoms that are representative of a focal exacerbation of atherosclerosis, it is inherently a systemic disease. Consequently, vascular surgeons must be capable of recommending to their patients pharmacologic approaches that will decrease future risk of cardiovascular-related morbidity and death. Antiplatelet treatments, in particular, have been shown to reduce future cerebrovascular and coronary events. Moreover, these medications have utility in maintaining peripheral vessel and graft patency after surgical bypass, endarterectomy, or percutaneous translumenal angioplasty. The future of optimal antiplatelet therapy will consist of strategies that block multiple platelet activation pathways simultaneously. Moreover, the use of directed antiplatelet medications promises more effective control of platelet physiology with a concomitant increase in safety. The authors review herein current recommendations for the use of aspirin, thienopyridines, and GP IIb/IIIa inhibitors in patients with peripheral vascular disease.

Carotid artery stenting in a vascular surgery practice

We tested the clinical applicability, technical results, and morbidity of carotid angioplasty-stenting (CAS) in the treatment of severe stenosis of the internal carotid artery (ICA) in patients deemed to be high-risk candidates for carotid endarterectomy (CEA). After an initial series (1994-1997) of 52 interventions, we adopted the use of a transfemoral access technique and self-expanding stents in late 1997. From Dec 1, 1997, to Mar 31, 2001, 135 CAS procedures were performed on 132 patients with more than 70% (symptomatic) or more than 80% (asymptomatic) stenoses of the ICA. Sixty percent of the patients had no symptoms, and 40% of patients had symptoms. The interventional technique was standardized with the use of a 7F long interventional sheath, balloon pre-dilatation of the stenotic lesion, placement of a self-expanding stent (Wallstent in 12 patients and a SMART stent in 120 patients), and post-balloon dilatation when necessary. Brain protection devices were not used. Patients were given clopidogrel and aspirin before and after the procedure and heparin during the intervention. All procedures except two were completed as planned, with access failure in three patients (2.2%). Residual in-stent stenosis of less than 20% was detected in 14 of 132 stented vessels (11%) and accepted as a satisfactory angiographic outcome. Neurologic complications included one patient with a single-episode transient ischemic attack (TIA; motor-sensory deficit of the hand) occurring 2 hours after CAS. One patient sustained a major stroke after thrombosis of the stented ICA, which occurred 3 days after the CAS procedure and 24 hours after open-heart surgery. A third patient sustained a minor stroke that began intraprocedurally after post-balloon dilatation of the stent, and a fourth patient had another minor stroke with transient aphasia (beginning during the procedure and resolving after 4 hours) and monoparesis of the hand, which resolved after 1 week. All stented vessels remained patent during the follow-up period (range, 2-41 months; mean, 16 plus minus 9 months), with four instances of hemodynamically significant in-stent restenosis. Re-intervention with balloon angioplasty was undertaken successfully at 4 months in one patient with restenosis. The periprocedural mortality rate was 0. Carotid stenting can be performed with acceptable safety on carefully selected patients by using meticulous, standardized interventional techniques. It may offer a possibly superior therapeutic alternative for non-CEA candidates. Evolving technological improvements and brain protection devices are likely to enhance its role in the treatment of carotid artery disease in the future. Surgical endarterectomy remains the standard of care for most patients at the present time.