应用脑保护装置实施颈动脉支架成形术的临床经验

目的探讨脑保护装置在颈动脉支架成形术中的价值。方法自2000年10月至2006年8月对65例颈动脉狭窄患者实施了颈动脉支架成形术。共植入支架75个,其中颈内动脉支架68个,颈总动脉支架2个,同时植入锁骨下动脉支架2个,椎动脉支架3个,4例术前安装了临时起搏器。结果65例中2例脑保护装置置放失败,63例成功。63例脑保护装置中26例可见斑块碎片,1例术中出现一过性脑缺血,1例同时置入椎动脉支架后发生椎动脉血栓形成;9例术中出现一过性低血压、心动过缓,4例术前安装临时起搏器者未发生术中低血压。5例出现术后低血压,1例术后原有神经系统症状加重。1例双颈动脉支架成形术后出现高血压。结论颈动脉支架成形术是治疗颈动脉狭窄的有效手段,在有脑保护装置的条件下,正规熟练的操作和严格的预防措施能有效提高安全性,减少并发症。     

颈动脉滤伞下颈动脉支架成形术的并发症分析

目的 初步总结颈动脉滤伞保护下行颈动脉支架成形术的应用和并发症的处理体会.方法 对35例颈动脉硬化性狭窄患者的38处病变(无症状的狭窄超过70%,有症状的狭窄超过50%)行颈动脉滤伞保护下颈动脉支架成形术,对操作过程及并发症发生、处理和预后进行分析.使用超声、CTA和MRA进行随访.结果 本组38处病变成功完成所有操作,支架后即时造影示病变处管径明显改善(残余狭窄<20%),血流通畅.21例(55.3%)回收后的栓塞防护装置中可见拦截的斑块碎片,其中3例斑块甚至填满保护装置.并发症包括术后脑出血死亡者1例(2.6%);术中出现脑梗塞,一侧肢体运动障碍者1例(2.6%);出现一过性TIA表现,收伞后症状消失者2例(5.3%);出现一过性术中术后心率、血压下降者10例(26.3%).平均随访32个月(6～54个月),颈动脉支架处血流通畅,除1例使用覆膜支架患者支架处闭塞外,其他病例均无明显再狭窄.随访期无新的TIA或脑梗塞出现.结论 初步应用显示颈动脉滤伞下颈动脉支架成形术是安全、有效的.精细、轻柔的操作可减少并发症的发生.     

腔内支架成形术治疗颈动脉狭窄(附64例报告)

目的：介绍颈动脉腔内支架成形术的基本方法，总结64例经验体会，探讨该术式治疗颈动脉狭窄的操作和并发症的预防。方法：64例颈动脉狭窄病人行腔内支架成形术，共放支架66个，其中Wallstent支架41个，Smart支架22个．OptiMed支架3个。应用脑保护装置26例。结果：术中出现较重卒中2例：1例术出现左眼视野缺损．3个月后仍有残余症状：1例术中出现意识丧失、右侧肢体偏瘫，经救治神志恢复。出现轻度卒中3例。10例出现一过性血压降低、心动过缓，其后逐渐恢复。1例术后出现原有神经系统症状加重。神经系统并发症发生率为7．88％，严重卒中是3.13％。循环系统并发症是15．63％。应用脑保护装置的病人仅有1例发生一过性神经系统并发症。结论：颈动脉腔内支架成形术是治疗颈动脉狭窄的有效手段，在有经验的医师操作下，治疗是安全的。使用脑保护装置可明显减少神经系统并发症。     

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目的探讨颈动脉支架成形术治疗高危颈动脉狭窄的可行性、安全性及短期疗效一方法自200l年8月至2003年7月，共采用颈动脉支架成形术治疗高危颈动脉狭窄8例，术前平均狭窄程度分别为(74.13=13.38)％，均为症状性病人结果狭窄位于颈内动脉6例，位于颈总动脉2例，所有病人均成功地植入支架术后狭窄程度均≤10％。全部病人无临床并发症，5例临床症状消失，3例临床症状不同程度好转随访3～27个月，无短暂性脑缺血发作(TIA)等缺血性神经损害发生；影像学检查无显著再狭窄。结论颈动脉支架成形术治疗颈动脉狭窄安全有效，尤其适合于颈动脉内膜切除术高危的病人，脑保护装置可以有效减少因硬化斑块或血枪引起的并发症     

颈动脉支架术中脑保护措施的应用

颈动脉狭窄是造成脑卒中的主要原凼.颈动脉支架置人术治疗颈动脉狄窄对患者创伤小、痛苦少,已逐渐成为治疗颈动脉狭窄的首选术式.而术中脑保护装置的应用更大大提高了其疗效.本文对颈动脉成形术中应用脑保护的有关问题进行概述.相信随着许多大规模、多中心临床实验的完成,脑保护下的颈动脉支架置入术将在颈动脉狭窄患者的卒中预防和治疗中发挥重要作用.     

应用脑保护装置的颈动脉支架成形术治疗颈动脉狭窄

目的 总结应用脑保护装置的颈动脉支架成形术的体会,并探讨其围手术期处理要点.方法 2002年1月至2007年12月共收治122例(125侧)颈动脉狭窄性病变患者,成功完成颈动脉支架成形术123侧,均使用了脑保护装置,共置人支架124枚.结果 技术成功率为98.4%(123/125).围手术期发生一过I生脑缺血6例(4.9%),小卒中2例(1.6%),完伞性卒中1例(O.8%),严重脑缺血再灌注损伤2例(1.6%),其余113例次(91.9%)无神经系统并发症发生.无围手术期死亡.总卒中/死亡率为2.4%.86例患者术后获随访,平均随访时间为18.5(3～36)个月,超声检查提示50%～70%狭窄5例(5.8%),70%以上狭窄1例(1.2%),均无临床症状.非相关原因死亡2例.其余78例(90.7%)支架通畅,无神经系统并发症发生.结论 颈动脉支架成形术是治疗颈动脉狭窄性病变安全、有效的方法.不断提高围手术期处理水平是进一步提高疗效、降低并发症发生率的重要保证.     

颈动脉再通术后重度再狭窄病变的诊治策略

目的评估颈动脉支架成形术(CAS)和颈动脉内膜切除术(CEA)治疗颅外颈动脉狭窄后重度再狭窄的诊断和治疗策略。方法回顾性分析2012年1月至2017年1月在复旦大学附属中山医院接受颈动脉再通手术治疗后发生严重再狭窄而二次手术治疗的15例患者资料,其中CEA术后再狭窄3例,CAS术后再狭窄12例,均通过血管多普勒超声检查和数字减影血管造影明确诊断。结果对于CEA术后再狭窄的患者,治疗包括脑保护下CAS手术(2例)、球囊扩张(1例);对于CAS术后再狭窄的患者,治疗包括再次行CEA及补片血管成形术(7例)、球囊扩张(3例)、再次行脑保护下CAS术(2例)。患者围术期无脑卒中或死亡发生。1例CAS术后再狭窄患者采用单纯球囊扩张治疗后,6个月随访再次发生颈动脉再狭窄且伴有短暂性脑缺血发作的症状,接受CEA及补片血管成形术,术后随访1年显示颈动脉血流通畅。其余患者在术后随访过程中未见脑卒中或再狭窄发生。结论血管多普勒超声检查和数字减影血管造影是诊断颅外颈动脉再通术后再狭窄的重要手段。对于重度再狭窄的患者,需注意个体化治疗方式,围术期疗效及中期再狭窄复发率较满意,但仍需密切随访,注意再狭窄复发的风险。     

Mo.Ma脑保护装置的临床应用（附2例报告）

随着神经介入技术和材料科学的迅猛发展，颈动脉支架成形术（carotid angioplasty and stenting，CAS）已成为治疗颈动脉狭窄的重要手段，但术中斑块脱落导致的栓塞引起了广泛关注。脑保护装置可将术中斑块脱落所导致的栓塞性并发症降低到3％左右。我院对2例患者应用意大利Mo．Ma脑保护装置（Mo．Ma Cerebral Protection Device），效果较好，现报道如下。     

颈动脉斑块稳定性影像学评估的研究进展

动脉粥样硬化斑块引起的颈动脉狭窄是脑卒中的主要病因之一,严重的脑卒中会导致残疾甚至死亡。研究表明,颈动脉狭窄在老年人(>65岁)中的发病率大约为6.9%[1]。对于此类疾病的治疗主要有药物治疗和外科手术治疗,外科手术治疗以颈动脉内膜剥脱术(carotid endarterectomy,CEA)和颈动脉支架成形术(carotid artery stenting,CAS)两种方法为主,患者年龄、颈动脉狭窄程度、斑块稳定性、心     

国家级医学继续教育项目第七期颈动脉硬化狭窄外科治疗及进展学习班第二轮通知

国家级继续医学教育项目“第七期颈动脉硬化狭窄外科治疗及进展学习班”将于2010年9月15日-9月18日在复旦大学附属华山医院举办。本次学习班将安排国内知名专家教授系统讲解颈动脉硬化狭窄外科治疗的应用解剖、流行病学研究、影像学检查、不同颈动脉内膜切除术的手术技巧、术中监护、围手术期处理、并发症防治、颈动脉狭窄的腔内治疗等专题;进行应用转流管及血管补片的颈动脉内膜切除术及外翻式颈动脉内膜切除术手术演示;进行不同脑保护装置下颈动脉支架成型术的手术演示。     

Initial experience with cerebral protection devices to prevent embolization during carotid artery stenting

OBJECTIVE: Carotid artery stenting (CAS) for treatment of carotid stenosis has not received wide acceptance because of the availability of carotid endarterectomy (CEA) with its excellent results and because of the risk of embolic stroke associated with CAS. The feasibility and efficacy of cerebral protection devices that may prevent such embolic complications have yet to be shown. We report our initial results with CAS performed with cerebral protection. METHODS: For a period of 28 months, 31 patients with carotid artery stenosis, most of whom were considered at high risk for CEA (87%), underwent treatment with CAS in conjunction with either the PercuSurge GuardWire (n = 19; Medtronic, Minneapolis, Minn), the Cordis Angioguard filter (n = 7; Cordis, Warren, NJ), or the ArteriA Parodi Anti-embolization catheter (n = 4; ArteriA, San Francisco, Calif) with US Food and Drug Administration-approved investigational device exemptions. Factors that made CEA high risk included restenosis after CEA (n = 6), hostile neck (n = 6), high or low lesions (n = 4), and severe comorbid medical conditions (n = 11). Preoperative neurologic symptoms were present in 58%, and the mean stenosis was 85% +/- 12%. Data were prospectively recorded and analyzed on an intent-to-treat basis. Neurologic evaluation was performed before and after CAS by a protocol neurologist. RESULTS: CAS was performed with local anesthesia with the Wallstent (n = 23; Boston Scientific Corp, Natick, Mass) or the PRECISE carotid stent (n = 7; Cordis) in conjunction with one of the protection devices in an operating room with a mobile C-arm. Each patient received dual antiplatelet therapy before surgery. The overall technical success rate was 97% (30/31). In one patient, the lesion could not be crossed with a guidewire because of a severely stenosed and tortuous lesion. This patient was not a candidate for CEA and was treated conservatively. In the remaining 30 cases, CAS had a good angiographic result (residual stenosis, <10%). All patients tolerated the protection device well, and no intraprocedural neurologic complications occurred. Macroscopic embolic particles were recovered from each case. One patient (3%) with a severely tortuous vessel had a major stroke immediately after CAS, and no deaths occurred. The combined 30 day stroke/death rate was 3%. During a mean follow-up period of 17 months, one subacute occlusion of the stent occurred but did not result in a stroke. Three other patients had duplex scan-proven in-stent restenosis, and two underwent treatment with repeat percutaneous transluminal angioplasty with a good result. No patient had a stroke during the follow-up period. CONCLUSION: CAS with cerebral protection devices can be performed safely with a high technical success rate. Although many patients who underwent treatment with CAS were at high risk, the neurologic complication rate was low and CAS appears to be an acceptable treatment option for select patients at high risk for CEA. Tight lesions and tortuous anatomy may make the use of distal protection devices difficult. Further study is warranted.     

Transcervical carotid stenting with flow reversal protection: experience in high-risk patients

BACKGROUND: Carotid angioplasty and stenting (CAS) with cerebral embolic protection is a safe alternative to carotid endarterectomy in high-risk patients. Among the various systems proposed for cerebral protection, transcervical CAS avoids crossing the lesion without protection and eliminates the complications associated with transfemoral access. This study analyzes our experience and the results obtained with a transcervical stenting technique for carotid revascularization. METHODS: From January 2005 to June 2006, 62 CAS were performed in our center in high-risk patients with >70% stenosis (38.7% had a previous neurologic event and 61.3% were asymptomatic). The indications for CAS were severe heart disease (45.1%), severe pulmonary disease (6.4%), paralysis of the contralateral laryngeal nerve (6.4%), recurrent stenosis (3.2%), and high carotid lesion (1.6%). Twenty-one patients were >80 years old. A complete neurologic examination was performed by a stroke neurologist in all patients before and after stenting. The protection system used was carotid flow reversal by transcervical access. Transcranial Doppler monitoring was done during the procedure in 35 patients. We analyzed technical success, the presence of high-intensity transient signals during the procedure, neurologic morbidity and mortality at 30 days and 6 months, and stent patency at 6 months (range, 1 to 18 months). Technical success was 96.8%. Perioperative high-intensity transient signals were observed in two patients (5.7%). In the immediate postoperative period, one patient had a transient ischemic attack of the anterior cerebral artery and another had a stroke, with contralateral hemiplegia. At 48 hours after discharge, a third patient returned to the hospital with a severe cerebral hemorrhage that required surgical drainage; hence, neurologic morbidity was 4.9%. There were no deaths at 6 months. Among the total, 98.4% of the stents remained patent, two showed restenosis of 50% to 70%, and one restenosis of >70%. No patients presented a neurologic event during the follow-up. CONCLUSIONS: Transcervical carotid artery stenting with flow reversal cerebral protection is a relatively simple, safe technique that avoids instrumentation of the aortic arch and crossing the target lesion without protection. It is less expensive than techniques requiring a filter device and provides excellent outcome with an acceptable incidence of complications.     

Initial 200 cases of carotid artery stenting using a reversal-of-flow cerebral protection device

AIM: Because embolic complications can occur during carotid angioplasty and stenting (CAS), a new device, the Parodi Anti-Emboli System (PAES) was developed to protect the brain from embolization. We describe our initial experience with this device. METHODS: Between September 1999 and December 2003, CAS was performed in 200 consecutive patients (146 men; mean age, 70.4 years) with symptomatic (52%) or asymptomatic (48%) severe carotid artery stenosis (>70%). De novo lesions were present in 169 patients, restenosis in 18, and radiation-induced stenosis in 13. Wallstents were inserted in all cases, with selective predilatation, and the PAES was employed during all CAS procedures. Patients were evaluated by a neurologist before and after CAS. Minor strokes, major or fatal strokes, and myocardial infarctions that occurred within 30 days of the procedure were recorded. RESULTS: The overall technical success rate for CAS using the PAES (with the PAES placed in position percutaneously) was 99%. The overall perioperative stroke and death rate was 1.5%. There were four transient neurologic events after CAS, three of which were related to hemodynamic instability and one to postoperative embolization. CONCLUSIONS: Our experience indicates that CAS using the PAES is safe and effective. The protection device may prevent the debris released by angioplasty from entering the cerebral circulation. Additional studies of this device are warranted.     

A comparison of carotid artery stenting with neuroprotection versus carotid endarterectomy under local anesthesia

BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce the risk of stroke in patients with high-grade carotid artery stenosis. Despite the known impact of type of anesthesia on outcome after CEA, none of the current studies comparing CEA with CAS addresses the effect of anesthetic choice on perioperative events. In this study, we compare our results of distally protected CAS versus CEA under local anesthesia. METHODS: Clinical data of 345 patients who underwent 372 procedures for carotid artery occlusive disease over a 36-month were retrospectively collected for this analysis. Distal embolic protection was used in CAS procedures. All procedures, both CEA (n = 221, 59%) and CAS (N = 152, 41%), were performed under local anesthesia. The primary outcome measure was aggregate 30-day major ipsilateral stroke and/or death. Follow-up serial Duplex ultrasound examinations were performed. RESULTS: Both patient cohorts were similar in terms of demographic and risk factors, with the exception of a higher incidence of coronary artery disease in the CAS group (59% versus 30%, P <.05). The 30-day stroke and death rates were 3.2% (CAS) and 3.7% (CEA) (P = not significant). Cranial nerve injury only occurred in the CEA patients (2.3%). Perioperative hemodynamic instability was more common among patients in the CAS group (11.9% versus 4.1%, P <.05). CONCLUSIONS: Percutaneous carotid stenting with neuroprotection provides comparable clinical success to CEA performed under local anesthetic. Further studies are warranted to validate the long-term efficacy of CAS and to elucidate patient selection criteria for endovascular carotid revascularization.     

Cerebral protection during carotid stenting using flow reversal

BACKGROUND: Carotid angioplasty and stenting can be used in stroke prevention in high-risk patients. As embolic complications can occur during carotid angioplasty and stenting, a device was developed to protect from cerebral embolization. METHODS: Between September 1999 and May 2002, carotid angioplasty and stenting was performed in 100 patients (84 men; mean age, 69.2 years) with symptomatic (26%) or asymptomatic (74%) severe carotid artery stenosis. Wallstents were used in all cases with selective pre-dilatation. Cerebral protection devices (Parodi Anti-Emboli System [PAES], ArteriA, San Francisco, Calif) were used in all patients. All patients were evaluated by a neurologist, both before and after the procedure. According to the criteria set forth by the large trials, the occurrence of minor, major or fatal stroke and myocardial infarction (end points) within 30 days and follow-up were determined as end points. Data were collected prospectively. RESULTS: The overall perioperative stroke and death rate was 3% (1 noncorresponding minor stroke, 1 hemorrhagic stroke, and 1 cardiac event). Four patients developed postoperative transient neurologic events (three related to hemodynamic instability and the fourth due to postoperative embolization). The overall technical success rate for carotid angioplasty (protection device placed in position percutaneously) was 99%. CONCLUSION: The efficacy and safety of carotid angioplasty and stenting with PAES are confirmed. This innovative protection device may prevent the debris released by angioplasty from entering the cerebral circulation. Further investigation is warranted.     

脑保护装置在颈部动脉狭窄扩张和支架置入术中的初步应用

目的：报告脑保护装置在颈动脉和椎动脉粥样硬化性狭窄血管内扩张和支架置入术中的初步应用结果。方法：应用脑保护装置filterwire（滤网导丝）,或angioguard（血管保护伞）,对18例21处颈动脉和椎动脉粥样硬化性狭窄行血管内扩张和（或）支架置入术,并总结其临床使用结果。结果：应用脑保护装置成功施行21例次颈动脉和椎动脉狭窄血管内扩张和（或）支架置入术,介入操作方便易行,无术中和术后并发症发生。结论：脑保护装置有助于降低颈动脉和椎动脉狭窄血管内扩张和支架置入术中动脉粥样斑块或附壁血栓脱落性脑梗死的发生,提高其治疗安全性。     

Comparison of embolization protection device-specific technical difficulties during carotid artery stenting

BACKGROUND: Embolic protection devices (EPDs) consisting of an internal carotid artery (ICA) filter or balloon occlusion are typically used during carotid artery stenting (CAS). This study compares the technical difficulties encountered using these two types of EPD. METHODS: A retrospective review was conducted of patients undergoing CAS using a balloon occlusion EPD (balloon group: PercuSurge GuardWire) or filter EPD (filter group: Accunet, AngioGuard, or FilterWire). Complications were defined as minor stroke, National Institutes of Health (NIH) stroke scale <3; major stroke, NIH stroke scale > or =3; transient ischemic attack (TIA), reversible focal neurologic impairment; technical, reversible neurologic compromise during EPD deployment, inability to cross lesion, ICA spasm requiring treatment, EPD-related factors that prolonged CAS. RESULTS: CAS (n = 141) was performed in 133 patients (82% men) with a mean age of 72 of years. Comorbidities included diabetes, 35%; coronary artery disease, 75%; hypertension, 82%; and renal insufficiency, 15%. Indication was previous cerebrovascular accident in 10%, TIA in 29%, and asymptomatic >80% stenosis in 61%. Primary lesions were treated in 83% vs restenosis in 17%. The 30-day event rate was 1.4% major stroke, 2.1% minor stoke, 1.4% myocardial infarction, and 0.7% death. The overall combined 30-day stroke, death, and myocardial infarction rate was 5.6%. The 30-day stroke and death rate was 4.0% in the balloon group (n = 99) and 4.6% in the filter group (n = 42, P = .51). EPD-related technical difficulties occurred in 15% of the balloon group and 31% of the filter group (P < .05). Technical difficulties included a 10% incidence of reversible neurologic compromise during balloon deployment compared with 0% in the filter group (P = .002) and 12% incidence of inability to cross the lesion before predilation in the filter group compared with 0% in the balloon group (P = .001). CONCLUSIONS: During CAS, both balloon occlusion and filter devices provide acceptable results and appear complimentary. Filters can be used preferentially to avoid a 10% incidence of reversible neurologic compromise associated with balloon occlusion, except in critically narrowed or tortuous lesions when balloon occlusion may be preferred because of a 12% need for unprotected predilatation with filters.     

Carotid artery stenting using the proximal or dual protection method for near occlusion of the cervical internal carotid artery

The treatment for patients with near occlusion of the cervical internal carotid artery (ICA) is controversial. The aim of this study was to examine the results of carotid artery stenting (CAS) as a surgical treatment for ICA near occlusion. Between April 2008 and September 2012, 14 patients (all men; mean age, 75.4 years) with ICA near occlusion were treated with CAS. This represents 5.2 % of a total of 267 patients treated with CAS during the study period. All patients were treated with CAS using an embolic protection device. The proximal balloon protection method was performed in five patients, and the dual protection method using a proximal balloon and distal filter protection was used in nine patients. We examined the change of stenotic lesion, hyperintensity spot in diffusion-weighted imaging (DWI), and perioperative complications after CAS. All near occlusions were successfully dilated. Among 2 of 14 patients, DWI showed 1 and 4 hyperintensity spots. Transient and persistent complications, including neurological deficits, did not occur in any patients. In this small number of cases, CAS using the proximal or dual embolic protection method seems to be a safe and beneficial treatment for ICA near occlusion.     

Angiographic lesion characteristics can predict adverse outcomes after carotid artery stenting

BACKGROUND: Carotid artery angioplasty and stenting (CAS) is an evolving and increasingly common endovascular treatment for carotid artery stenosis. Risk factors associated with an increased incidence of adverse periprocedural neurologic outcomes are being recognized. The goal of this study was to determine if certain angiographic lesion characteristics were predictive of higher risks of adverse outcomes. METHODS: A total of 421 patients who underwent 429 carotid artery stenting procedures between June 1996 and June 2005 for symptomatic or asymptomatic carotid stenosis, and in whom preoperative carotid angiograms and follow-up records were available for review, were selected from a prospectively maintained database. Demographic data and procedural variables were recorded, including the presence or absence of the use of a cerebral protection device. Angiograms were reviewed for the following carotid lesion characteristics: length of lesion, percentage of stenosis, ostial involvement, lesion ulceration, calcification, and presence of contralateral carotid occlusion. Periprocedural stroke and 30-day adverse event rates (stroke, myocardial infarction, and death) were recorded for each patient. RESULTS: The periprocedural all-stroke rate was 3.7%. Octogenarians had a higher incidence of 30-day adverse events at 10.0% vs 3.8% (P = .029). The incidence of periprocedural stroke was increased in lesions > or =15 mm long, at 17.0% (8 of 47) vs 2.1% (8 of 382; P < .001), and in ostial centered lesions, 7.1% (11 of 154) vs 1.8% (5 of 275; P = .007). Multivariate regression also identified these two variables as independently associated with 30-day stroke rate: lesion length > or =15 mm (odds ratio [OR], 6.38; 95% confidence interval [CI], 35 to 17.29) or ostial involvement (OR, 3.12; 95% CI, 3.12 to 8.36). Other variables, including lesion calcification, ulceration, degree of stenosis, or presence of contralateral occlusion, were not associated with adverse outcomes. When studied separately, the use of cerebral protection devices in 241 patients (56%) did not change our observed correlations between angiographic characteristics and adverse procedural events. CONCLUSIONS: Certain lesion characteristics on angiography, such as length and ostial location, can predict adverse outcomes. The indication for CAS should be carefully evaluated in these cases.     

Accuracy and utility of three-dimensional contrast-enhanced magnetic resonance angiography in planning carotid stenting

BACKGROUND: Contrast-enhanced magnetic resonance angiography (CE-MRA) is a proven diagnostic tool for the evaluation of carotid stenosis; however, its utility in planning carotid artery stenting (CAS) has not been addressed. This study assessed the accuracy of three-dimensional CE-MRA as a noninvasive screening tool, compared with digital subtraction angiography (DSA), for evaluating carotid and arch morphology before CAS. METHODS: In a series of 96 CAS procedures during a 2-year period, CE-MRAs and DSAs with complete visualization from the aortic arch to the intracranial circulation were obtained before CAS in 60 patients. Four additional patients, initially considered potential candidates for CAS, were also evaluated with CE-MRA and DSA. The two-by-two table method, receiver operating characteristic curve, and Bland-Altman analyses were used to characterize the ability of CE-MRA to discriminate carotid and arch anatomy, suitability for CAS, and degree of carotid stenosis. RESULTS: The sensitivity and specificity of CE-MRA were, respectively, 100% and 100% to determine CAS suitability, 87% and 100% to define aortic arch type, 93% and 100% to determine severe carotid tortuosity, and 75% and 98% to detect ulcerated plaques. CE-MRA had 87% sensitivity and 100% specificity for the detection of carotid stenosis >/=80%. The accuracy of CE MRA to determine optimal imaging angles and stent and embolic protection device sizes was >90%. The operative technique for CAS was altered because of the findings of preoperative CE-MRA in 22 procedures (38%). The most frequent change in the operative plan was the use of the telescoping technique in 11 cases (18%). CAS was aborted in four patients (5%) due to unfavorable anatomy identified on CE-MRA, including prohibitive internal carotid artery tortuosity (n = 1), long string sign of the internal carotid artery (n = 2), and concomitant intracranial disease (n = 1). Among patients considered suitable for CAS by CE-MRA, technical success was 100%, and the 30-day stroke/death rate was 1.6%. CONCLUSIONS: Contrast-enhanced magnetic resonance angiography of the arch and carotid arteries is accurate in determining suitability for CAS and may alter the operative technique. Certain anatomic contraindications for CAS may be detected without DSA. Although CE-MRA is less accurate to estimate the degree of stenosis, it can accurately predict imaging angles, and stent and embolic protection device size, which may facilitate safe and expeditious CAS.