Management of plaque protrusion in transcarotid artery revascularization with stent-in-stent technique

Transcarotid artery revascularization (TCAR) has emerged as a promising alternative to carotid endarterectomy as an intervention for high risk carotid artery stenosis patients. TCAR provides superior neuroprotection as compared with transfemoral carotid stenting, as well as similar outcomes to carotid endarterectomy. Plaque prolapse (PP) through the stent while rare poses a significant risk of ischemic complications during TCAR. The patient presented with a left internal carotid artery stenosis that was inaccessible surgically. During TCAR, angiography revealed PP through the stent. A second stent was deployed with excellent results. This case highlights TCAR's advantage in managing PP with flow reversal. TCAR's enhanced neuroprotection offers a valuable option for addressing this complication, providing benefits that may not be fully achieved with transfemoral carotid stenting.