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Elad I. Levy, Robert D. Ecker, James J. Thompson, Peter A. Rosella, Ricardo A. Hanel, Lee R. Guterman and L. Nelson Hopkins

Recent advances in carotid artery (CA) stent placement procedures have propelled this technology into the forefront of treatment options for both symptomatic and asymptomatic patients with CA stenosis. Until recently, endarterectomy was the only surgical option for patients with CA occlusive disease. For high-risk surgical candidates, periprocedural stroke rates remained unacceptable and were significantly higher than those associated with the natural history of the disease. Advances in stent technology and improvements in antiplatelet and antithrombotic regimens, in conjunction with distal protection devices, have significantly lowered the risk of periprocedural complications for high-risk surgical candidates requiring CA revascularization. In this paper the authors review data gleaned from the important recent CA stent trials and address questions concerning the safety, efficacy, and durability of stent-assisted angioplasty for extracranial CA occlusive disease. Additionally, they review the role of noninvasive imaging modalities for the diagnosis and surveillance of CA disease in these high-risk patients.

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Giuseppe Lanzino, Ajay K. Wakhloo, Richard D. Fessler, Mary L. Hartney, Lee R. Guterman and L. Nelson Hopkins

placed stents are currently unknown, we believe that this combined approach holds great practical promise, especially in view of the potential for device improvements. Acknowledgments We acknowledge the assistance of Chakriya D. Anunta in editing this manuscript, Paul H. Dressel in preparing the illustrations, and Dr. Scott C. Standard for providing follow-up information on Case 8. References 1. Bai H , Masuda J , Sawa Y , et al : Neointima formation after vascular stent implantation. Spatial and chronological distribution of smooth muscle cell proliferation

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Giuseppe Lanzino, Robert A. Mericle, Demetrius K. Lopes, Ajay K. Wakhloo, Lee R. Guterman and L. Nelson Hopkins

territory after a mean follow-up period of 27 months. Conclusions Revascularization of recurrent carotid artery stenosis can be safely achieved through the endovascular approach. Endoluminal revascularization for recurrent carotid artery stenosis has a satisfactory midterm patency rate and also seems to provide protection from further neurological events. Thus, carotid artery stent placement can be considered a viable alternative to surgical reexploration in patients with recurrent carotid artery stenoses. Significant potential exists for improvement of the devices used

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Yiemeng Hoi, Hui Meng, Scott H. Woodward, Bernard R. Bendok, Ricardo A. Hanel, Lee R. Guterman and L. Nelson Hopkins

: Occlusion of experimentally created fusiform aneurysms with porous metallic stents. AJNR 21: 739–745, 2000 8. Geremia G , Haklin M , Brennecke L : Embolization of experimentally created aneurysms with intravascular stent devices. AJNR 15 : 1223 – 1231 , 1994 Geremia G, Haklin M, Brennecke L: Embolization of experimentally created aneurysms with intravascular stent devices. AJNR 15: 1223–1231, 1994 9. Gonzalez CF , Cho YI , Ortega HV , et al : Intracranial aneurysms: flow analysis of their

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Demetrius K. Lopes, Robert A. Mericle, Giuseppe Lanzino, Ajay K. Wakhloo, Lee R. Guterman and L. Nelson Hopkins

embolic complications during CASP. The recent development of distal protection devices may further reduce the incidence of embolic events during CASP. 28 The minor stroke experienced by the patient in Case 29 resulted from an ICA dissection distal to the stent. It is important to avoid dissections by using shorter balloons restricted to the treated segment of the artery during posttreatment remodeling. Furthermore, it is crucial to keep the tip of the microguide-wire under constant fluoroscopic visualization throughout the procedure. Other complications that may be

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Elad I. Levy, Alan S. Boulos, Ricardo A. Hanel, Fermin O. Tio, Ronald A. Alberico, Mary Duffy Fronckowiak, Balazs Nemes, Ann Marie Paciorek, Lee R. Guterman and L. Nelson Hopkins

atherosclerotic disease has increased in popularity, yet no in vivo model has been developed to examine the response of cerebral vessels to the implantation of these devices. Although vascular response to stent implantation in the coronary and peripheral vasculature has been studied extensively in numerous in vivo models, we cannot assume that a similar response exists in the arteries of the central nervous system. Intracranial vessels differ substantially from peripheral and coronary vessels in that they lack robust adventitia. These thin-walled vessels are composed of a

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Elad I. Levy, Ricardó A. Hanel, Alan S. Boulos, Bernard R. Bendok, Stanley H. Kim, Kevin J. Gibbons, Adnan I. Qureshi, Lee R. Guterman and L. Nelson Hopkins

. Although direct stent placement in other vessels, such as those in the coronary circulation, has been shown to be safe and effective, 1, 5, 27 such a procedure undertaken in the BA may be prone to neurological complications resulting from emboli that may be dislodged when the high-profile stent-delivery device is advanced across the plaque. Additionally, snowplowing, 24 or closure of perforating side branches by plaque, may result in neurological deficits. Other complications of direct stent placement may include dissection of tortuous intracranial vessels, resulting

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Alan S. Boulos, Eric M. Deshaies, Richard D. Fessler, Shuta Aketa, Scott Standard, Lazlo Miskolczi, Lee R. Guterman and L. Nelson Hopkins

allows the surgeon to create a variety of aneurysm structures to use in testing endovascular technology and techniques and in studying the hemodynamic properties of aneurysms. For example, the wide-necked aneurysms made in this model required balloon or stent remodeling for successful treatment, thereby increasing the complexity of the embolization procedure. In addition to the practical utility of using these complex aneurysms for studying multiple endovascular techniques and devices, the aneurysms treated with this model will allow endovascular surgeons to develop

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Elad I. Levy, Ricardo A. Hanel, Bernard R. Bendok, Alan S. Boulos, Mary L. Hartney, Lee R. Guterman, Adnan I. Qureshi and L. Nelson Hopkins

) artery to the superior cerebellar or posterior cerebral arteries. Although patency rates were 79% overall, complications occurred in 55% of patients. Over the past 2 years, there has been marked advancement in stent technology. Clinicians are now able to deliver more pliable stents to the distal intracranial VB vasculature. Such devices offer practitioners an alternative intervention for the treatment of medically or surgically refractory posterior circulation stenosis. In some early series it has been suggested that the morbidity and mortality rates after VBA stent

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Stanley H. Kim, Adnan I. Qureshi, Alan S. Boulos, Bernard R. Bendok, Elad I. Levy, Abutaher M. Yahia, Lee R. Guterman and L. Nelson Hopkins

site. We believed that such a hemodynamic change might promote closure of the fistula. The S670 coronary stent is more flexible than the S7 stent. In addition, the shorter and smaller profile of the S670 device may have allowed its navigation into the cavernous segment of the ICA. We did not believe that direct stent placement over the cavernous lesion without initial angioplasty was possible because of the severe stenosis and curvature of the cavernous ICA. If the stent had failed to occlude the fistula, we would have observed the patient and considered the