Transcervical carotid artery stenting with flow reversal eliminates emboli during stenting: why does it work and what...

Carotid artery stenting (CAS) remains under scrutiny because of the controversial results of major trials that compared it with carotid endarterectomy. However, the question of how the results of carotid stenting are influenced by the access technique and cerebral protection methods has not been properly addressed in any trial. Most unresolved technical weaknesses of transfemoral carotid stenting are related to instrumentation of the arch and proximal supra-aortic trunks, crossing of the carotid lesion without protection, and use of distal filter protection devices of unproven benefit. All these problems can be avoided by using a transcervical approach with carotid flow reversal for protection. The potential advantage of transcervical carotid artery stenting (CAS) is demonstrated by the fact that it can be done in octogenarians without increased morbidity, produces a lower incidence of middle cerebral artery transcranial Doppler (TCD)-detected embolic signals during the procedure, carries a significant reduction in the incidence of ischemic brain infarcts as detected by diffusion weighted magnetic resonance imaging (MRI), when compared to transfemoral stenting with distal filter protection, and can be done with a remarkably low incidence of major adverse events.