Feasibility of simultaneous bilateral carotid artery stenting.

Due to the progressive aging of the population, severe bilateral carotid stenosis has become a more frequent condition. On occasion, simultaneous revascularization may be appropriate. There is increased evidence that for these high-risk patients, a percutaneous revascularization may be the best approach. However, there are concerns that simultaneous bilateral carotid stenting may be associated with cerebral hyperperfusion, excessive bradycardia, and hypotension. We report a series of 10 consecutive patients who underwent simultaneous bilateral carotid stenting. All of these patients were not deemed to be surgical candidates due to high-risk comorbidities. All but one of the lesions were successfully stented. There were no procedural deaths, myocardial infarctions, or strokes. Thus, among carefully selected patients, simultaneous bilateral carotid artery stenting is a promising, technically feasible option.     

Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: risk factors, prevention, and treatment

OBJECTIVES: The study defined the incidence of cerebral hyperperfusion syndrome and intracranial hemorrhage (ICH) and the risk factors for their development following carotid artery stenting (CAS). BACKGROUND: Hyperperfusion syndrome and ICH can complicate carotid revascularization, be it endarterectomy or CAS. Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion and ICH following CAS. METHODS: We retrospectively reviewed the prospective database of 450 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or ICH. RESULTS: The mean age of the patients was 72.7 +/- 10.9 years, and the mean diameter narrowing was 84 +/- 12.8%. Five (1.1% [95% confidence interval 0.4% to 2.6%]) patients developed hyperperfusion. Three (0.67%) of the five developed ICH. Two of these patients died (0.44%). Symptoms developed within a median of 10 h (range, 6 h to 4 days) following stenting. All five patients had correction of a severe internal carotid stenosis (mean 95.6 +/- 3.7%) with a concurrent contralateral stenosis >80% or contralateral occlusion and peri-procedural hypertension. These same risk factors are involved in cerebral hyperperfusion following carotid endarterectomy. The use of platelet glycoprotein IIb/IIIa receptor blockers did not appear to increase the risk ICH. CONCLUSIONS: The hyperperfusion syndrome occurs infrequently following CAS, and ICH occurs in 0.67% of patients. Patients with severe bilateral carotid stenoses may be predisposed to ICH, particularly if there is concurrent arterial hypertension. Patients with these factors may require more intensive hemodynamic monitoring after CAS, including prolongation of hospitalization in some cases.     

经桡动脉途径行颈动脉支架置入术

目的 探讨经桡动脉途径行颈动脉支架治疗的可行性及安全性.方法 2011年2月至2011年12月邵逸夫医院心内科行颈动脉造影明确颈动脉狭窄≥70％患者12例通过桡动脉途径行颈动脉支架置入术.探讨手术成功率和并发症情况.结果 经桡动脉途径行颈动脉支架12例,左侧颈内动脉6例,右侧颈内动脉6例,均成功置入.平均手术时间(45 ± 11) min.1例术中出现TIA,2小时后恢复,2例术中出现血压、心率下降,予对症处理后,立即恢复,无桡动脉闭塞及前臂血肿等并发症.结论 经桡动脉途径行颈动脉支架治疗初步证明是安全可行的.     

颈动脉支架置入术后过度灌注综合征的危险因素分析

目的探讨颈动脉支架置入术(CAS)后发生过度灌注综合征(CHS)的危险因素。方法纳入419例患者的临床资料,其中48例同时行双侧CAS,共计行467次CAS。根据是否发生CHS分为CHS组15例和无CHS组404例。采用分层分析法分析术后发生CHS的危险因素。结果与无CHS组比较,CHS组糖尿病、术后高血压比例明显升高,差异有统计学意义(P<0.05,P<0.01)。单因素分析显示,术前糖尿病、术后高血压与CHS相关(P<0.05)。经分层分析显示,术前糖尿病(OR=3.168,95%CI:1.008～9.222,P=0.025)及术后高血压(OR=5.033,95%CI:1.733～14.646,P=0.001)为术后发生CHS的主要危险因素。结论 CAS术前糖尿病及术后伴高血压的患者更容易出现CHS。临床上对于术前有糖尿病史及术后出现高血压的CAS患者必须加以重视,尽早发现和处理CHS。     

颈动脉血管成形和支架置入术的并发症及其处理

颈动脉狭窄是导致脑梗死的重要原因之一。颈动脉血管成形和支架置入术(CAS)已被证实能够预防卒中发生,临床应用越来越广。尽管CAS是一种微创治疗方法,但仍然有许多潜在的并发症,如血流动力学异常、过度灌注综合征、脑梗死和再狭窄等。文章对CAS的并发症及其处理方法进行了综述。     

Safety and efficacy of simultaneous bilateral carotid angioplasty and stenting

In this study, we aimed to evaluate the safety and feasibility of simultaneous bilateral carotid artery stenting (BCAS) compared with staged BCAS in patients with bilateral atherosclerotic carotid stenosis (BCS). From January 2004 to March 2012, 68 patients who underwent BCAS were identified from the Nanjing Stroke Registry Program. Of these patients, 42 (61.8 %) underwent simultaneous BCAS (simultaneous group), and 26 (38.2 %) underwent staged BCAS (staged group). We compared demographic data, major vascular risk factors, procedural parameters, and 30 day outcomes between the simultaneous and staged groups. No significant differences were detected in baseline data between the groups. Patients in the simultaneous group had a lower post-operative systolic pressure compared with the staged group (119.1 ± 16.1 vs. 130.2 ± 17.5 mmHg, P = 0.009). Technical success was 100 % of patients in the simultaneous group and 98.1 % in the staged group. Hemodynamic depression was observed in 57.4 % of procedures, with no significant difference between groups in the rate of HD. Four (5.9 %) patients had neurological complications within 30 days, including two cases of hyperperfusion syndrome in the simultaneous group, and two ischemic events in the staged group. There was no significant difference in the 30 day complication rate between the simultaneous and staged groups (4.8 vs. 7.7 %, P = 0.633). Simultaneous BCAS may be safe and feasible for most patients with BCS, with a similar 30 day complication rate to staged BCAS. Multicenter randomized control studies with larger sample sizes are warranted to further explore the safety and efficacy of simultaneous BCAS.     

Percutaneous internal carotid artery angioplasty with stenting: early and long-term results

BACKGROUND. Cerebro-vascular accidents are the third most common cause of death. The most frequent localisation of lesions responsible for stroke are bifurcation of the common carotid artery or the proximal internal carotid artery (ICA). Surgical carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the non-pharmacological methods used to treat carotid artery stenosis. AIM. To assess the efficacy and safety of CAS of ICA. METHODS. CAS was performed in 75 patients (49 males, 26 females) with a mean age of 65.2+/-9.1 years. Twenty (26.7%) patients underwent CAS with the use of the central nervous system (CNS) protective devices. The immediate, mid-term, and long-term results were analysed. RESULTS. In total, 84 stents were implanted to 80 ICA in 73 patients. In two patients stent implantation was not possible. In 7 (9%) patients with a stenosis of both ICA, a bilateral procedure was performed. In two patients concomitant dilatations of the vertebral artery, and in the other two - of subclavian artery, were performed. In 38 patients coronary angiography was performed directly before CAS; one patient underwent coronary angioplasty. In 20 patients protective CNS devices were used. During the procedure four patients developed ischaemic stroke on the side of CAS. In one patient neurological symptoms completely disappeared within 48 hours. The type of technique used during CAS did not influence the frequency of ischaemic complications. Four patients developed hyperperfusion syndrome which disappeared after a few days. There were fire deaths during follow-up: three due to myocardial infarction (MI), one - after urgent CABG, and one due to pulmonary embolism. There were no deaths due to stroke. No new ischaemic changes in CNS nor significant changes in the neurological status, using the UNSS or Barthel scales, were observed. Asymptomatic restenosis was documented in six patients whereas one patient developed symptomatic restenosis due to stent deformation. CONCLUSIONS. Percutaneous angioplasty of an internal carotid artery carries a risk not exceeding that of surgical endarterectomy. In our study, a one-year follow-up revealed a minor risk of ischaemic stroke. Percutaneous angioplasty with the use of protective devices should be tested in larger groups of patients in order to establish the real clinical usefulness and improved safety of this technique.     

Feasibility of carotid artery stenting in patients with angiographic string sign

Background : Treatment of angiographic string sign (SS) of the carotid artery with carotid endarterectomy or carotid artery stenting (CAS) has been associated with a high incidence of periprocedural neurological events. We describe our experience with CAS in a case series of symptomatic patients with severe carotid stenosis and angiographic SS. Methods : We performed a retrospective review from 1999 to 2009 using our cardiac cath laboratory database and identified nine patients with the angiographic SS who underwent CAS. All patients were referred for carotid angiography by a neurologist due to symptoms (stroke or transient ischemic attack (TIA)). All lesions were predilated and treated with self‐expanding stents. Distal protection devices were utilized (six patients) once they became available. Periprocedural outcomes and long‐term follow‐up was reviewed when available. Results : The average time from onset of symptoms to CAS was 45 days. All CAS procedures were technically and clinically successful without acute complications. One year follow‐up was available in eight patients. One patient had a possible TIA, and the remaining seven patients did not report any events (death, stroke, TIA or myocardial infarction). Carotid ultrasound evaluation at 12 months was available in six patients and showed no evidence of restenosis. Conclusions : In our experience, CAS in patients with severe symptomatic carotid stenosis and angiographic SS is feasible, with an acceptably low periprocedural complication rate. © 2010 Wiley‐Liss, Inc.     

高危症状性颈动脉狭窄支架成形术的疗效分析

目的分析颈动脉支架成形术治疗高危症状性颈动脉狭窄的有效性和安全性。方法对20例高危症状性颈动脉狭窄患者进行颈动脉支架成形术治疗,其中男12例,女8例;年龄为62～76岁,平均69岁。其中短暂性脑缺血发作11例,脑梗死9例。对所有患者均行全脑血管造影,显示颈动脉狭窄率均〉70％,其中一侧颈动脉重度狭窄9例（2例为颈动脉剥脱术后再狭窄）;双侧颈动脉重度狭窄6例;一侧颈动脉闭塞,另--N重度狭窄5例（1例为鼻咽癌放疗术后）。对所有患者使用脑保护装置,并均采用预扩张,预扩张后均使用自膨式支架。结果技术成功率为100％,残余狭窄率均〈30％。所有患者术中均出现不同程度的短暂性心率、血压下降,1例患者出现了微栓子栓塞,无其他严重并发症;其余患者围手术期内无缺血性卒中发作。术后复查颈动脉超声见,显示狭窄明显改善。结论颈动脉支架治疗高危症状性颈动脉狭窄创伤小,围手术期并发症少,是安全、有效的。     

脑保护装置下的血管成形和支架置入术治疗颈动脉狭窄

目的探讨颈动脉狭窄患者颈动脉血管成形和支架置入术(CAS)中应用脑保护装置的有效性和安全性。方法颈动脉狭窄患者CAS治疗时,12例应用脑保护装置(滤网型),16例未使用脑保护装置。结果28例颈动脉狭窄患者成功释放31枚自膨式支架。未使用脑保护装置组球囊预扩1次(6·2%),无一例后扩;使用脑保护装置组球囊预扩4次(33·3%),后扩6次(50%)。CAS治疗中,7例(25·0%)患者出现短暂性心率减慢和低血压。回收的脑保护装置中2例(16·7%)肉眼可见组织碎片。使用脑保护装置组在围手术期和随访期无神经并发症;未使用脑保护装置组围手术期发生1例(6·3%)脑梗死,随访期发生1例(6·3%)脑梗死。结论脑保护装置的使用有助于减少颈动脉狭窄患者CAS治疗的神经并发症。     

老年症状性颈动脉狭窄患者的临床干预研究

目的探讨老年症状性颈动脉狭窄患者的支架成形术和(或)内科治疗的安全性和短期疗效。方法选择我院经数字减影血管造影术(DSA)证实有颈动脉狭窄且有相关临床症状的老年患者85例,均给予内科治疗,其中58例行颈动脉支架成形术,分析其临床、影像学、治疗和随访观察资料。结果68例患者临床症状改善或消失;住院及随访期间6例(7.1%)发生脑卒中,无脑卒中相关死亡。本组中58例患者共置入支架67个,支架成形术成功率为100%,动脉狭窄率由术前(86.8±9.3)%降至(10.9±2.5)%(t=21.1,P=0.000);术后30天内2例发生支架相关脑卒中;58例支架成形术患者平均随访28.3个月,50例(86.2%)症状改善或消失,2例发生同侧颈内动脉供血区域脑卒中;36例复查颈部血管超声,2例显示支架内再狭窄;10例复查DSA均未发现支架内再狭窄。结论老年症状性颈动脉狭窄患者的综合临床干预短期疗效良好;狭窄的支架成形术方法可行,相对安全。     

Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital.

OBJECTIVES: The goal of this study was to determine whether carotid angioplasty and stenting (CAS) is equivalent to carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis >70% by a randomized, controlled trial in a community hospital. BACKGROUND: Carotid angioplasty and stenting has been suggested to be as effective as CEA for treatment of symptomatic carotid artery stenosis. METHODS: A total of 104 patients presenting with cerebrovascular ischemia ipsilateral to carotid stenosis were selected randomly for CEA or carotid stenting and followed for two years. RESULTS: Stenosis decreased to an average of 5% after CAS. The patency of the reconstructed artery remained satisfactory regardless of the technique as determined by sequential ultrasound. One death occurred in the CEA group (1/51); one transient ischemic attack occurred in the CAS group (1/53); no individual sustained a stroke. The perception of procedurally related pain/discomfort was similar. Hospital stay was similar, although the CAS group tended to be discharged earlier (mean = 1.8 days vs. 2.7 days). Complications associated with CAS prolonged hospitalization when compared with those sustaining a CEA-related complication (mean = 5.6 days vs. 3.8 days). Return to full activity was achieved within one week by 80% of the CAS group and 67% of the patients receiving CEA. Hospital charges were slightly higher for CAS. CONCLUSIONS: Carotid stenting is equivalent to CEA in reducing carotid stenosis without increased risk for major complications of death/stroke. Because of shortened hospitalization and convalescence, CAS challenges CEA as the preferred treatment of symptomatic carotid stenosis if a reduction in costs can be achieved.     

The treatment of carotid artery bifurcation stenoses with systematic stenting: experience of first 100 consecutive cardiological procedures

Carotid endarterectomy still represents the gold standard treatment of carotid artery bifurcation stenosis but percutaneous angioplasty with stenting is rapidly growing as a non-invasive alternative. In this paper we report the results of systematic application of carotid stenting performed in a cardiological setting, particularly as regards clinical management of patients and technical approach. One-hundred (100) procedures of carotid artery stenting (CAS) on 94 consecutive patients, both symptomatic and asymptomatic, with a carotid stenosis > 70%, were performed over a period of 30 months. The technical approach was directly derived from coronary angioplasty with use of large lumen guiding catheters, 0.014 in. intravascular guidewires and distal protection devices usually employed in coronary interventions. In 3 cases, a post-carotid endarterectomy restenosis and in 97 cases, a de-novo lesion, were treated respectively; in 71 cases, the degree of stenosis was 71-89% and in 29 cases, 90-99%. Cerebral protection was obtained with a distal to the lesion endovascular filter in 63 cases. Immediate technical success, i.e. residual stenosis of the treated vessel < 30% and no significant pathologic acceleration of blood flow (< 1.5 m/sec) at the Doppler ultrasound evaluation, was achieved in all procedures (100%). Ninety-six (96) procedures were totally uncomplicated; in-hospital cerebral complications were 1 TIA, 2 minor and 1 major strokes; at 30-day follow-up one additional major stroke occurred. Despite a particularly high incidence of comorbidities, neither unfavorable cardiological complications nor neurologic deaths were reported. Systematic CAS is a feasible treatment of the carotid artery bifurcation stenosis with high procedural success and low perioperative and short term complications. Its performance in a cardiological setting can combine satisfying procedural results and potentially successful handling of cardiovascular complications.     

Staged carotid artery stenting and coronary artery bypass graft surgery: initial results from a single center.

The objective of this study was to assess the clinical course of patients undergoing planned percutaneous carotid stenting followed by staged coronary artery bypass grafting (CABG). Coexisting carotid and coronary atherosclerotic disease is relatively common. A combined or staged surgical approach has a composite stroke, myocardial infarction, or death rate of > 10%. We performed a retrospective search of our single-institution database to identify all patients scheduled to undergo staged carotid stenting followed by CABG. Twenty-three such patients (17 males, 6 females) were identified, with 3/23 (13%) requiring bilateral carotid stenting. Most carotid lesions were asymptomatic (18/26; 69.2%) and severe (mean stenosis, 82.9% 6+/- 8.6%). Stents were successfully placed in 26/26 carotid arteries (100%). One stent procedure (1/26; 3.8%) resulted in a minor stroke, but full recovery occurred within 1 week. There were no other peri-stenting complications. Three patents (3/23; 13%), none of whom suffered an adverse event at carotid stenting, elected not to undergo CABG. The mean interval from last carotid stent to CABG was 69.6 6 +/- 39.6 days (range, 8-157 days). Antiplatelet therapy was ceased > 3 days prior to CABG in 10/20 patients (50%), but continued until surgery in the remainder. There were no peri-CABG bleeding or neurological complications, but one myocardial infarction occurred (1/20; 5%). Therefore, of the 20 patients who underwent planned carotid stenting followed by CABG, our overall rate of death, stroke, or myocardial infarction was 10%. However, our rate of death, persistent stroke or myocardial infarction was 5%. Planned carotid stenting followed by staged CABG is a viable method of treatment for patients with coexistent carotid and coronary atherosclerosis.     

Synchronous carotid stenting and cardiac surgery: an initial single-center experience.

Concurrent severe carotid and cardiac disease is a challenging situation where staged surgery is probably the most common strategy, although it is still controversial. We report in-hospital and midterm outcome of 30 patients who received carotid stenting and synchronous cardiac surgery. All received carotid stenting under aspirin and regular unfractioned heparin (UFH) and were immediately transferred to the operating room for coronary and/or cardiac valve surgery. All patients received aspirin and clopidogrel once bleeding was ruled out, after surgery. In-hospital complications were: three surgical related deaths, one TIA, and no patient suffered stroke or myocardial infarction. Hospital stay was 14 +/- 11.8 days. Survivors were followed for 18.4 +/- 14 months. There were two non-related deaths, but no stroke nor cardiac or carotid reinterventions. In conclusion, this small series showed that synchronous carotid stenting and cardiac surgery was feasible with an acceptable complication rate in a high-surgical-risk population which could not undergo staged procedures.     

Early recognition of cerebral hyperperfusion syndrome after carotid stenting--a case report

The hyperperfusion syndrome is a recognized complication of carotid endarterectomy. Reports of cerebral hyperperfusion injury following internal carotid artery angioplasty and stenting are few We report a case of 76-year-old hypertensive man who was admitted to our hospital for assessment 2 years after experiencing an ischemic stroke of right hemisphere. Angiography confirmed 60% stenosis of left internal carotid artery (ICA). Percutaneous transluminal stenting of left internal carotid artery was performed without any immediate complications. Two hours after the procedure, the patient suddenly deteriorated. Computed tomography (CT) of the brain revealed extensive intracerebral hemorrhage and he died 5 days later. There was precipitating migranous headache, and his blood pressure was moderately elevated at the time of deterioration. Sentinel headache could solely indicate the early sign of hyperperfusion injury after carotid stenting, especially in the presence of arterial hypertension. Patients with sentinel headache after angioplasty should be recognized early and they deserve intensive study for other features of cerebral hyperperfusion injury and prompt early management.     

Assessment of flow changes in the circle of Willis after stenting for severe internal carotid artery stenosis.

PURPOSE: To assess flow velocities in the cerebral arteries after carotid artery stenting (CAS) in patients with unilateral versus bilateral lesions and analyze velocities in patients with neurological complications after CAS. METHODS: Ninety-two patients (68 men; mean age 63.2 +/- 8.4 years, range 44-82) with internal carotid artery (ICA) stenoses were divided according to unilateral (group I, n = 72) or bilateral (group II, n = 20) disease. Fifty age- and gender-matched patients without lesions in the extra- or intracranial arteries served as a control group. Transcranial color-coded Doppler ultrasound was performed prior to and within 24 hours after CAS in the test groups; systolic velocities were assessed ipsilateral (i) and contralateral (c) to the CAS site in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). RESULTS: Collateral flow via the anterior communicating artery (ACoA) was found in all group-II patients and 90% of group-I patients. After CAS, collateral flow through the ACoA ceased, and the velocity increased by 26% in the iMCA in group I compared to controls (p < 0.001). In group II, iMCA flow increased by 30% (p < 0.001) and flow via the ACoA (p < 0.001) increased, resulting in normalization of cMCA velocities (p = 0.928). In 89 (96.7%) subjects, CAS was uncomplicated. Hyperperfusion syndrome occurred in 2 (2.2%) patients, both with bilateral ICA stenoses; 1 (1.1%) transient ischemic attack was seen in a patient with unilateral disease. In the patients with hyperperfusion syndrome, the MCA velocities were 2.7- and 7.4-fold higher, respectively, versus before CAS and 2-fold higher than in controls. CONCLUSION: Uncomplicated CAS results in an iMCA velocity increase >25% compared to controls. MCA velocities in hyperperfusion syndrome were greatly increased versus before CAS and in controls.     

Carotid stenting: acute results and complications]

The treatment of carotid stenoses with balloon angioplasty and stenting is a new and not generally established method.During a one year period 65 patients (22 female, 43 male, mean age: 73 years, 47 with neurologic symptoms, 8 with contralateral carotid occlusion) with significant (>70%) carotid stenosis were treated with balloon angioplasty and balloon expandable stents. The primary technical success rate was 98% (65/66 patients) respectively 99% (69/70 stenoses). A combined procedure was performed in 11 /17%) patients with stenting in both carotid arteries in 4 patients with additional coronary interventions in 6 patients and stenting of the origin of the common carotid artery in one patient.Severe neurologic complications occurred in 4 (6.2%) patients (1 death, 1 major stroke, 2 minor strokes) and short lasting neurologic deficits in additional 4 (6.2%) patients. Cardiovascular complications were not observed. Local (inguinal) problems occurred in 3 (4.5%) patients (2 aneurysma spuria, 1 transfusion for hematoma). Frequently, balloon insufflation was associated with bradycardia (40%) and additional hypotension (11%).In summary, carotid stenting can be performed with technically high success rates (99%), but it is adversely influenced by not infrequent thromboembolic cerebral events (12.4%). The possibility to perform combined procedures with interventions in other vessels (both carotid arteries, coronary arteries, aortic arch arteries) is advantageous.     

Is carotid artery stenting in octogenarians really dangerous?

PURPOSE: To evaluate (1) whether carotid artery stenting (CAS) performed in octogenarians increases the procedure-related risk and (2) the incidence of complex anatomy of the aortic arch and supra-aortic vessels in patients >80 years old, which can increase the technical difficulty of CAS. METHODS: Between December 2000 and September 2005, 1053 patients (903 men; mean age 72+/-2.2 years, range 46-90) underwent 1222 CAS procedures in 2 centers for de novo (n=1192) and restenotic (n=30) lesions (139 staged bilateral procedures). Indications for treatment were the presence of a symptomatic carotid artery stenosis >/=70% (n=798, 65.3%) or an asymptomatic stenosis of at least 80%. The patients were separated into 2 age categories: under 80 (n=1078 procedures, 88.2%) and 80 or older (n=144 procedures, 11.8%) for this analysis. Data analysis included death and stroke rate at discharge and at 30 days. Anatomical characteristics evaluated were aortic arch elongation, arch and supra-aortic vessel calcification and tortuosity, anatomical tortuosity of the lesion, and carotid plaque composition. RESULTS: Three lesions in octogenarians could not be treated because of failure to access the vessel in 1 case and extremely tortuous arteries in 2. The overall death and stroke rate at 30 days was 2.12% in the older group (2 fatal strokes, 1 minor stroke) and 1.11% in the younger group (3 deaths, 3 major strokes, 6 minor strokes); the difference was not statistically significant (p=0.40). Significantly higher frequencies of tortuosity and calcification of the arch and supra-aortic vessels and of type III aortic arch were observed in the older group (p<0.001). CONCLUSION: In our experience, CAS has proven to be safe and effective in elderly patients. Different age-related anatomical features can represent an adjunctive technical challenge, but these difficulties can be successfully managed without increased perioperative risk if CAS is performed in high-volume centers by highly skilled operators.     

Hypotension during carotid artery stenting with severe aortic stenosis: the intra-aortic balloon pump option

This case highlights the importance of intra-aortic balloon pump (IABP) during carotid artery stenting (CAS) in patients with severe aortic stenosis. We report the case of a patient with severe carotid artery disease and aortic stenosis who first underwent CAS using IABP and subsequently underwent aortic valve replacement. We conclude that IABP could be helpful in the staged treatment of patients with concomitant severe carotid artery disease and aortic valve disease.