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Distal embolization occurs routinely during carotid artery stenting (CAS), and some of these debris may result in devastating neurologic complications. The use of an emboli protection device (EPD) is crucial to reduce distal embolization, and has been shown in nonrandomized studies to decrease stroke or death event rates by two to three times during CAS. This chapter reviews both the filter and balloon occlusion EPD.

It is important for operators of carotid artery stenting (CAS) to have a thorough understanding of potential complications associated with CAS, and strategies to prevent and manage these complications. With improvements in technology and equipments, periprocedural complications related to CAS has progressively diminished, especially since the introduction of emboli protection devices. The most devastating complications of CAS are stroke and death. In this chapter, potential complications associated with each step of CAS are reviewed, including delayed postprocedural complications.

Intracranial large vessel atherosclerosis is believed to account for approx 5-10% of all ischemic strokes in the United States. Compared with extracranial artery atherosclerosis, the natural history of intracranial atherosclerosis, and the effectiveness of medical therapy and revascularization in modifying the natural history of the disease, are poorly defined. This chapter summarizes our current understanding of intracranial atherosclerosis and describes the emerging practice of endovascular revascularization for the treatment of this disease.

Approximately 25% of ischemic strokes involve the posterior or vertebrobasilar circulation, which is associated with a mortality of 20-30%. Posterior circulation strokes are predominantly due to embolism and large artery disease. This chapter focuses on the percutaneous management of patients with significant atherosclerotic stenosis of the extracranial and intracranial vertebral artery.

Acute ischemic stroke is caused by a variety of mechanisms including cardiac embolism, atherosclerosis/thrombosis, intracranial atherosclerosis, or penetrating artery disease. The highly complex clinical manifestations of ischemia, which are often unique to the individual patient, the wide variety of medical conditions that often accompany stroke, and diverse anatomical and technical factors all combine to make each patient unique in terms of the endovascular approach to treatment.

A 65-yr-old man underwent left endarterectomy 2 yr ago for symptomatic left carotid artery stenosis. Upon follow-up with duplex ultrasound, he was found to have asymptomatic restenosis 80-99% involving the left common carotid artery (CCA). His past medical history includes long-standing hypertension, hyperlipidemia, and prior three-vessel coronary artery bypass surgery. On physical examination, he had a left carotid bruit, and normal neurologic examination. Given his prior history of left endarterectomy, he was felt to be at high risk for redo endarterectomy for restenosis. Thus, he was referred for left carotid stenting.

A 56-yr-old man presented with a history of transient ischemic attacks suggesting left mid-cerebral artery (MCA) territory. He had symptoms of right arm and leg weakness, as well as slurred speech. His past medical history included hypertension and hyperlipidemia, as well as three-vessel coronary artery disease. A head computed tomography (CT) scan was performed urgently and reported to be normal. A carotid duplex ultrasound revealed a 60-79% stenosis of the left internal carotid artery (ICA). After neurologic evaluation, he was referred for carotid artery stenting because he was thought to be at high risk for carotid endarterectomy given his coronary anatomy.

A 60-yr-old man presented with a history of transient ischemic attack (TIA) 2 mo ago, in which he experienced aphasia lasting 6 h. He also had a history of long-standing hypertension, hyperlipidemia, and a 14 pack-year smoking history. On physical examination, he had a soft right carotid bruit and a normal neurologic exam. A noncontrast head CT showed no abnormality. However, carotid duplex ultrasound demonstrated that his right internal carotid artery (ICA) had a 60-79% stenosis, and his left ICA was occluded. After evaluation by a neurologist and a vascular surgeon, it was felt that carotid revascularization was appropriate. However, he was considered to be at high risk for right carotid endarterectomy because of the contralateral occlusion, and also because of the high location of the right ICA stenosis. Therefore, he was referred for carotid artery stenting.

A 60-yr-old woman with a history of right carotid artery endarterectomy (CEA) 4 yr ago and a repeat CEA 2 yr ago developed restenosis of the proximal and distal clamp sites requiring carotid stent 1 yr ago. She received a 6 x 20 mm Precise(tm) (Cordis, Warren, NJ) stent to the distal CEA site and an 8 x 20 mm Precise(tm) stent to the proximal CEA site. At the time of that intervention, the venous patch used for the CEA was noted to be mildly dilated and ectatic. She subsequently developed re-restenosis and a pulsatile mass in the right neck with compression of the right internal jugular artery 1 yr later.

A 77-yr-old man with asymptomatic severe left internal carotid artery (ICA) stenosis detected by carotid duplex ultrasound. He had a history of three-vessel coronary artery disease, coronary artery bypass graft surgery in 1971, and several percutaneous coronary interventions. He also had systemic hypertension and hyperlipidemia. The patient had persistent exertional anginal symptoms despite prior coronary interventions, and thus he was felt to be at high risk for surgical carotid endarterectomy. Therefore, he was referred for carotid artery stenting.