Carotid Artery Stenting (CAS)
Endovascular alternative to carotid endarterectomy for symptomatic or high-grade asymptomatic carotid stenosis. Balloon angioplasty + self-expanding stent deployment across the lesion, with embolic protection device (distal filter or proximal flow reversal) deployed before any manipulation to catch plaque debris.
Clinical pathway
- Femoral or radial access; occasionally direct carotid cutdown for difficult arches.
- Arch aortogram + selective common carotid angiography — characterize arch anatomy (Type I/II/III), lesion length, calcification, tortuosity.
- Embolic protection deployment — distal filter across lesion into distal ICA, or proximal flow reversal system (Mo.Ma, ENROUTE).
- Pre-dilation (sometimes skipped) with small balloon.
- Stent deployment — self-expanding nitinol stent sized to common carotid and ICA.
- Post-dilation with sized balloon.
- Filter retrieval + final angiography — document distal intracranial runs to rule out embolic event.
Typical systems
Single-plane usually sufficient; biplane helpful for selective arch work in Type III arches.
Room + procedure characteristics
- Procedure time: 60–120 min typical
- Team: vascular surgeon, interventional cardiologist, or neurointerventionalist depending on center; local anesthesia + conscious sedation standard
- Neurological monitoring: continuous during procedure — patient squeezes squeaky toy, responds to commands
- Dose: moderate; neck + arch fluoroscopy time drives dose