Multimarker approach in discriminating patients with symptomatic and asymptomatic atherosclerotic carotid artery stenosis.

BACKGROUND AND PURPOSE: Several circulating biomarkers have been implicated in carotid atherosclerotic plaque rupture and thrombosis; however, their clinical utility remains unknown. The aim of this study was to determine the role of a large biomarker panel in the discrimination of symptomatic (S) vs. asymptomatic (A/S) subjects in a contemporary population with carotid artery stenosis (CS). METHODS: Prospective sampling of circulating cytokines and blood lipids was performed in 300 unselected, consecutive patients with ≥50% CS, as assessed by duplex ultrasound (age 47-83 years; 110 with A/S and 190 with S) who were referred for potential CS revascularization. RESULTS: CS severity and pharmacotherapy did not differ between the A/S and S patients. The median values of total cholesterol, low-density lipoprotein cholesterol, and lipoprotein(a) did not differ, but high-density lipoprotein (HDL) cholesterol was significantly higher (p<0.001) and triglycerides were lower (p=0.03) in the A/S-CS group than in the S-CS group. Interleukin-6 (IL-6) and high-sensitivity C-reactive protein were higher (p=0.04 and p=0.07, respectively) in the S-CS group. Circulating visfatin, soluble CD 40 receptor ligand, soluble vascular cell adhesion molecule, leptin, adiponectin, IL-1ß, IL-8, IL-18, monocyte chemoattractant protein-1, myeloperoxidase, matrix metalloproteinases-8, -9, and -10, and fibrinogen were similar, but tissue inhibitor of matrix metalloproteinases-1 (TIMP) was reduced in S-CS compared to A/S-CS (p=0.02). Nevertheless, incorporation of TIMP and IL-6 did not improve the HDL-cholesterol receiver operating characteristics for S-CS status prediction. S-CS status was unrelated to angiographic stenosis severity or plaque burden, as assessed by intravascular ultrasound (p=0.16 and p=0.67, respectively). Multivariate logistic regression analysis revealed low HDL-cholesterol to be the only independent predictor of CS symptoms, with an odds ratio of 1.81 (95% confidence interval=1.15-2.84, p=0.01) for HDL <1.00 mmol/L (first quartile) vs. >1.37 (third quartile). In S-CS, osteoprotegerin and lipoprotein-associated phospholipase A2 (Lp-PLA2) were elevated in those with recent vs. remote symptoms (p=0.01 and p=0.02, respectively). CONCLUSIONS: In an all-comer CS population on contemporary pharmacotherapy, low HDL-cholesterol (but not other previously implicated or several novel circulating biomarkers) is an independent predictor of S-CS status. In addition, an increase in circulating osteoprotegerin and Lp-PLA2 may transiently indicate S transformation of the carotid atherosclerotic plaque.

Transoesophageal echocardiography can help distinguish between patients with "symptomatic" and "asymptomatic" patent foramen ovale.

BACKGROUND: Incidence of patent foramen ovale (PFO) has been estimated at 25% in the general population and 6% for larger defects. Data on the relationship between PFO morphology and the risk of stroke are limited. PFO closure has become a common practice in many centres, although recent guidelines limit indications for such treatment to patients with cryptogenic (recurrent) stroke. AIM: To investigate whether PFO morphology assessed by transoesophageal echocardiography (TOE) differed between patients with symptoms and those who had an asymptomatic PFO. METHODS: We analysed 88 consecutive patients (48 female, 40 male; mean age 36.1 ± 16.2 [range 18-59] years) who underwent TOE before transcatheter PFO closure due to a cryptogenic cerebrovascular event (Group I) and compared them to 88 consecutive patients (49 female, 39 male; mean age 35.7 ± 14.2 [range 18-57] years) with an asymptomatic PFO found incidentally on TOE (Group II). The diagnosis of stroke was based on the occurrence of a new acute focal neurological deficit, with neurological signs and symptoms persisting for >24 h, subsequently confirmed by computed tomography and/or magnetic resonance imaging. Multiplane TOE was conducted as per guidelines using commercially available instruments. The interatrial septum was viewed in the transverse midoesophageal 4-chamber view and the longitudinal biatrial-bicaval view. PFO was diagnosed with intravenous injections of agitated saline while the patient was at rest and during the Valsalva manoeuvre. We analysed PFO size (resting and maximal separation of the septum primum and secundum during the Valsalva manoeuvre), tunnel length (maximal overlap of the septum primum and secundum), presence of an atrial septal aneurysm (excursion 〉 15 mm), shunt severity (mild: 3-5, moderate: 6-25, severe 〉 25 microbubbles) and prominence of the Eustachian valve. RESULTS: The two groups did not differ with respect to age and sex distribution. Group I showed larger PFO size (maximal separation 3.9 ± 1.4 vs. 1.3 ± 1.3 mm, p 〈 0.0001), longer tunnel length (14 ± 6 vs. 12 ± 5.5 mm, p 〈 0.05) and a greater frequency of atrial septal aneurysm (55% vs. 15%, p 〈 0.0001) compared to Group II (controls). Group I was also characterised by a higher proportion of large PFOs (≤ 4 mm; 50% vs. 18%, p 〈 0.001) and severe shunt (40% vs. 2%, p 〈 0.0001). CONCLUSIONS: PFO in symptomatic patients is larger in size, has a longer tunnel and is more frequently associated with atrial septal aneurysm. Asymptomatic patients with PFO characteristics similar to that seen in stroke patients require more careful clinical evaluation. It may be debated whether such patients should be recruited to prospective trials to evaluate indications for PFO closure in stroke prevention.

Carotid artery stenting according to the tailored-CAS algorithm is associated with a low complication rate at 30 days: data from the TARGET-CAS study.

BACKGROUND: The rate of early complications of carotid artery stenting (CAS) should not exceed 3% in asymptomatic and 6% in symptomatic patients. However, some recent studies/registries failed to reach this threshold, fueling a debate on the role of CAS in the treatment of patients with carotid artery stenosis. AIM: To evaluate 30-day safety of CAS using different embolic protection devices and different stent types according to the tailored-CAS algorithm and to identify risk factors for complications. METHODS: Between 2002 and 2010, we performed 1176 CAS procedures in 1081 patients (age 38-86 years, mean 66.3 ± 8.4 years, 51.5% symptomatic) according to the tailored-CAS algorithm that included extracranial ultrasound and computed tomography angiography to select the most appropriate embolic protection device (EPD) and stent type. Proximal EPD and closed-cell (CC) stents were preferentially used for high-risk lesions (HR - soft/thrombus-containing/tight/ulcerated, 36.14% of all lesions) and in symptomatic patients. RESULTS: Procedural success rate was 99.8%. In symptomatic patients, proportion of HR lesions was higher (41.1%) than in the asymptomatic group (30.8%, p = 0.001) and the usage of CC stents (76.2% vs 71.7%, p = 0.103) and proximal EPD (P-EPD, 34.8% vs 27.7% among asymptomatic patients, p = 0.010) was more frequent. CC stents were used in 82.4% of CAS procedures involving HR lesions (vs 69.1% for non-HR lesions, p < 0.01), and P-EPD were used in 83.1% of procedures involving HR lesions (vs 2.5% for non-HR lesions, p < 0.001). In-hospital complications included 6 (0.55%) deaths, 1 (0.08%) major stroke and 19 (1.61%) minor strokes. No myocardial infarctions (MI) were noted. Among 7 (0.59%) cases of hyperperfusion syndrome, 2 were fatal. Thirty-day complication rate (death/any stroke/MI) was 2.38%. Age > 75 years was a predictor of death (p = 0.015), and prior neurological symptoms were a predictor of death/stroke (p = 0.030). There were 4 cases of periprocedural embolic cerebral artery occlusion, all treated with combined intracranial mechanical and local thrombolytic therapy. CONCLUSIONS: CAS with EPD and stent type selection on the basis of thorough non-invasive diagnostic work-up (tailored- -CAS) is safe. Advanced age was associated with an increased risk of death and the presence of prior neurological symptoms was a predictor of death/stroke at 30 days. With the tailored-CAS approach, high-risk lesion features (soft/thrombus- -containing/tight/ulcerated) are eliminated as a risk factor. Hyperperfusion syndrome is a severe CAS complication which may lead to intracranial bleeding and death. Acute, iatrogenic embolic cerebral artery occlusion is rare and may be managed by combined intracranial mechanical and local thrombolytic therapy.

Safety of embolic protection device-assisted and unprotected intravascular ultrasound in evaluating carotid artery atherosclerotic lesions.

BACKGROUND: Significant atherosclerotic stenosis of internal carotid artery (ICA) origin is common (5-10% at ≥ 60 years). Intravascular ultrasound (IVUS) enables high-resolution (120 µm) plaque imaging, and IVUS-elucidated features of the coronary plaque were recently shown to be associated with its symptomatic rupture/thrombosis risk. Safety of the significant carotid plaque IVUS imaging in a large unselected population is unknown. MATERIAL/METHODS: We prospectively evaluated the safety of embolic protection device (EPD)-assisted vs. unprotected ICA-IVUS in a series of consecutive subjects with ≥ 50% ICA stenosis referred for carotid artery stenting (CAS), including 104 asymptomatic (aS) and 187 symptomatic (S) subjects (age 47-83 y, 187 men). EPD use was optional for IVUS, but mandatory for CAS. RESULTS: Evaluation was performed of 107 ICAs (36.8%) without EPD and 184 with EPD. Lesions imaged under EPD were overall more severe (peak-systolic velocity 2.97 ± 0.08 vs. 2.20 ± 0.08 m/s, end-diastolic velocity 1.0 ± 0.04 vs. 0.7 ± 0.03 m/s, stenosis severity of 85.7 ± 0.5% vs. 77.7 ± 0.6% by catheter angiography; mean ± SEM; p<0.01 for all comparisons) and more frequently S (50.0% vs. 34.6%, p=0.01). No ICA perforation or dissection, and no major stroke or death occurred. There was no IVUS-triggered cerebral embolization. In the procedures of (i) unprotected IVUS and no CAS, (ii) unprotected IVUS followed by CAS (filters - 39, flow reversal/blockade - 3), (iii) EPD-protected (filters - 135, flow reversal/blockade - 48) IVUS + CAS, TIA occurred in 1.5% vs. 4.8% vs. 2.7%, respectively, and minor stroke in 0% vs. 2.4% vs. 2.1%, respectively. EPD intolerance (on-filter ICA spasm or flow reversal/blockade intolerance) occurred in 9/225 (4.0%). IVUS increased the procedure duration by 7.27 ± 0.19 min. CONCLUSIONS: Carotid IVUS is safe and, for the less severe lesions in particular, it may not require mandatory EPD use. High-risk lesions can be safely evaluated with IVUS under flow reversal/blockade.

Treatment strategies in severe symptomatic carotid and coronary artery disease.

Coexistent carotid artery stenosis (CS) and multivessel coronary artery disease (CAD) is not infrequent. One in 5 patients with multivessel CAD has a severe CS, and CAD incidence reaches 80% in those referred for carotid revascularization. We reviewed treatment strategies for concomitant severe CS and CAD. We performed a literature search (MEDLINE) with terms including carotid artery stenting (CAS), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), stroke, and myocardial infarction (MI). The main therapeutic option for CS-CAD has been (simultaneous or staged) CEA-CABG. This, however, is associated with a high risk of MI (in those with CEA prior to CABG) or stroke (CABG prior to CEA), and the cumulative major adverse event rate (MAE - death, stroke or MI) reaches 10-12%. With increasing adoption of CAS, a sequential strategy of CAS followed by CABG has emerged. Registries (usually single-centre) indicate an MAE rate of ≈7% for CAS followed by CABG (frequently after >30 days, due to double antiplatelet therapy). Recently, 1-stage CAS-CABG has been introduced. This involves different antiplatelet regimens and, in some centers, preferred off-pump CABG, with a cumulative MAE of 1.4-4.5%. No randomized trial comparing different treatment strategies in CS-CAD has been conducted, and thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-centre, studies are required before this can become widely applied.

Predictors of cerebral reperfusion injury after carotid stenting: the role of transcranial color-coded Doppler ultrasonography.

PURPOSE: To evaluate the possible role of transcranial color-coded Doppler ultrasonography (TCD) in predicting cerebral reperfusion injury (CRI) in patients undergoing carotid artery stenting (CAS) for internal carotid artery (ICA) stenosis. METHODS: TCD was obtained in 210 patients (149 men; mean age 64.2+/-8.4 years, range 44-83) who underwent CAS for ICA stenosis averaging 86.7%+/-8.4%. Contralateral ICA occlusion or near occlusion (stenosis >90%) was present in 67 (31.9%) patients. TCD was performed before and 24 hours after CAS with assessment of peak systolic velocities (PSVs) in the ipsilateral middle cerebral artery (iMCA) and contralateral middle cerebral artery (cMCA). PSV ratios (PSVR) in the iMCA and cMCA were calculated from the PSVs before and after CAS. RESULTS: CRI syndrome occurred in 3 (1.4%) patients (2 intracranial bleedings, 1 subarachnoid hemorrhage). The mean iMCA and cMCA PSVRs were 2.66+/-0.19 and 4.16+/-2.77, respectively, in CRI patients, while the PSVRs in CAS patients without neurological sequelae were 1.56+/-0.46 and 1.21+/-0.39, respectively (both p<0.001). The combination of iPSVR>2.4 and cPSVR>2.4 occurred in 4 patients with bilateral ICA disease; 3 (75%) of them developed CRI (100% sensitivity and 99% specificity for CRI prediction). The following independent CRI predictors were identified: combined iPSVR>2.4 and cPSVR>2.4 (RR 2.06, CI 1.89 to 2.24; p<0.001), high cMCA PSV after CAS (RR 1.23, CI 1.13 to 1.34; p<0.001), and contralateral ICA occlusion (RR 1.13, CI 1.03 to 1.23; p = 0.007). CONCLUSION: TCD is an important tool in CRI risk evaluation. The combination of iPSVR>2.4 and cPSVR>2.4 is an independent CRI risk factor, along with contralateral ICA occlusion and high cMCA PSVs after CAS.

Flow reversal for proximal neuroprotection during endovascular management of critical symptomatic carotid artery stenosis coexisting with ipsilateral external carotid artery occlusion.

PURPOSE: To report the utility of proximal brain protection by flow reversal in endovascular management of critical internal carotid artery (ICA) stenosis coexisting with ipsilateral external carotid artery (iECA) occlusion. CASE REPORT: Four patients with a symptomatic, critical ICA stenosis (in-stent restenosis in one) and iECA occlusion were admitted for carotid artery stenting (CAS). In all cases, the stenosis severity and high-risk lesion morphology precluded the use of filter protection. The "tailored" CAS algorithm indicated that a proximal anti-embolism system should be used to maximize the potential for effective neuroprotection. The flow reversal system, which consists of an independent guiding sheath balloon positioned in the common carotid artery (CCA) and an iECA balloon-wire, was employed, using the CCA balloon only. The system was well-tolerated, and the CAS procedures were uneventful. CONCLUSION: Due to a unique design with separate CCA and iECA balloons, the flow reversal system can be used for proximal neuroprotection during CAS in severe, symptomatic ICA lesions coexisting with iECA occlusion.

Carotid artery stenting with patient- and lesion-tailored selection of the neuroprotection system and stent type: early and 5-year results from a prospective academic registry of 535 consecutive procedures (TARGET-CAS).

PURPOSE: To develop and prospectively evaluate the safety and efficacy of an algorithm for tailoring neuroprotection devices (NPD) and stent types to the patient/lesion in carotid artery stenting (CAS). METHODS: From November 2002 to October 2007, 499 patients (360 men; mean age 65.2+/-8.4 years, range 36-88) were prospectively enrolled in a safety and efficacy study of tailored CAS using proximal (flow blockade or reversal) or distal (filters or occlusion) NPDs and closed- or open-cell self-expanding stents. Of the 535 lesions treated in the study, 175 (32.7%) were "high risk" by morphology. Half (50.1%) the patients were symptomatic. RESULTS: A quarter (137, 25.6%) of the procedures were performed under proximal protection and the remainder (398, 74.4%) with distal NPDs; the direct stenting rate was 66.9%. High-risk lesions were treated predominantly with a proximal NPD and closed-cell stent (77.1% and 82.9%, respectively) and less frequently by direct stenting (37.1%, p<0.0001 versus non-high-risk lesions). The in-hospital death/stroke rate was 2.0% (95% CI 0.85% to 3.23%), and the death/major stroke rate was 0.7% (95% CI 0.02% to 1.48%). There were no myocardial infarctions, but there was 1 (0.2%) further death within 30 days. With the tailored approach, symptom status and high-risk lesion morphology were not risk factors for an adverse outcome after CAS; only age >75 years (p<0.001) was a predictor of short-term death. Long-term survival (95.4% at 1 and 88.3% at 5 years) was similar for symptomatic versus asymptomatic patients, direct stenting versus predilation, and closed- vs. open-cell stent design; only coronary artery disease adversely impacted survival (p = 0.04). The rates of freedom from death/ipsilateral stroke were 94.9% at 1 year and 85.9% at 5 years. CONCLUSION: Tailored CAS is associated with a low complication rate and high long-term efficacy. CAS operators should have a practical knowledge of different NPDs, including at least one proximal type.

Subarachnoid hemorrhage after carotid artery stenting.

We describe subarachnoid hemorrhage (SAH) in a 66-year-old man, who underwent technically successful carotid stenting for a string-stenosis of the right internal carotid artery (ICA) in a presence of contralateral ICA occlusion with recurrent right hemisphere transient ischemic attacks. At 2 hours, the patient developed headache and vomiting, but no focal neurological deficits. Performed transcranial color-coded Doppler (TCCD) showed over 2.8-fold increase of the peak systolic velocity in the right middle cerebral artery. The emergent CT of the brain showed SAH with the right hemisphere edema. Patient was treated with Nimodipine in continuous infusion, diuretics i.v. and additional hypotensive therapy depending on blood pressure values. Clopidogrel was stopped for 5 days. Over next 4 weeks, a gradual cerebral velocities decrease was observed on TCCD, which was related to clinical and CT resolution.

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.

Evaluation of cerebral circulation in patients with significant carotid artery stenosis.

BACKGROUND: A significant proportion of ischaemic stroke episodes are caused by atherosclerotic lesions in extracranial arteries. Assessment of haemodynamical profile of cerebral arteries in both symptomatic and asymptomatic patients with carotid artery stenosis is of clinical importance. AIM: To assess haemodynamic changes in cerebral arteries in patients with significant internal carotid artery (ICA) stenosis. METHOD: Patients (n=109) were divided into the following groups: group I (GI) - 42 subjects (64.6+/-9.0 years) with asymptomatic ICA stenosis > or =70%; and group II (GII) - 67 subjects (63.4+/-7.1 years) after stroke. The control group consisted of 30 patients (60.3+/-8.9 years) without significant stenoses of extracranial arteries on USG and angiography. In all cases ultrasonographic evaluation of flow velocities and directions in cerebral arteries within the circle of Willis and collateral flow was performed. RESULTS: The severity of ICA stenosis did not differ significantly between GI and GII. Patients in GI had flow velocity in the middle cerebral artery (MCA) increased by 15.7% and by 40.8% in the anterior cerebral artery (ACA) contralateral to the ICA stenosis (p<0.001 and p<0.001), whereas in GII no significant changes in flow velocity in these arteries were observed in comparison with the control group. Patients in the groups I and II had lower flow velocities in MCA ipsilateral to the ICA stenosis, however values for GII patients were significantly lower than in GI patients (p<0.001). The presence of collateral circulation through the anterior and posterior communicating arteries (ACoA and PCoA) was similar in GI and GII; however, the flow velocities in the ipsilateral MCA and ACA were significantly higher in asymptomatic patients (GI). The frequency of active collateral circulation through both ACoA and PCoA increased along with the increase of ICA stenosis severity (p=0.003; p<0.001). CONCLUSIONS: Collateral flow in the circle of Willis in subjects with ICA stenosis occurs equally often in symptomatic and asymptomatic patients; however, it is more efficient in patients without symptoms. The rate of development of collateral circulation depends on ICA stenosis severity. The important role in maintaining collaterals within the circle of Willis is played by ACoA, although in some patients MCA may also be supplied by PCoA.

Use of the Parodi Anti-Emboli System and transient subclavian steal for cerebral protection during emergent vertebral artery recanalization.

PURPOSE: To report the use of the Parodi Anti-Emboli System (PAES) for cerebral protection during emergent vertebral artery recanalization. CASE REPORT: A 56-year-old chimney sweep was referred with recurrent episodes of vertigo and gait ataxia. Left vertebral artery (LVA) flow was barely detectable on duplex Doppler, and brain computed tomography revealed a small infarct in the posterior inferior cerebellar artery territory. Angiography showed subtotal ostial stenosis of the LVA with poor distal flow and possible thrombus. Due to a high risk of distal embolization with percutaneous treatment, anticoagulation was initiated, and the lesion was to be re-evaluated in 2 to 3 weeks. However, 2 days later, the patient developed severe, aggravating headache, gait and left-limb ataxia, horizontal nystagmus, and vomiting. Emergent angiography showed a total ostial LVA occlusion. The PAES was employed to elicit a temporary subclavian steal during percutaneous LVA recanalization, thus protecting the brain from embolization. The ostial LVA was successfully recanalized and stented, with immediate symptom cessation. CONCLUSIONS: The PAES can be successfully applied in the subclavian artery to prevent distal embolization during emergent vertebral artery recanalization. Since a significant proportion of vertebral strokes are embolic, PAES may play a novel role in the treatment of acute cerebellar stroke.

[Carotid artery stenting with proximal or distal brain protection: early outcome]. / Wczesne wyniki stentowania tetnic szyjnych z zastosowaniem systemów czasowej protekcji mózgu.

BACKGROUND: Stroke is the third cause of death and a leading cause of disability. Significant atherosclerotic carotid artery stenosis is associated with as many as one in five strokes. Recent randomized trials have shown that percutaneous carotid artery stenting (CAS) is at least as effective and safe as surgery. AIM: To evaluate the early outcome of CAS performed with brain protection systems in a large series of consecutive patients. METHODS: From January 2001 to April 2004, 132 patients (age 63 +/- 8 years, 99 symptomatic and 90 with co-existing coronary artery disease, 36 women) with carotid artery stenosis were treated in our Institution. All patients underwent independent neurological assessment and non-invasive imaging (extra- and intracranial duplex Doppler and CT angiography, brain CT) before the procedure to tailor the brain protection system to the patient and lesion. Proximal (Parodi Anti-Emboli System, Mo.Ma) or distal (Percusurge/Guardwire, filters i.e. Angioguard, EPI FilterWire, Accunet, Spider, NeuroShield) neuroprotection was applied respectively in 42 (31%) and 93 (69%) cases. Clinical evaluation was performed on discharge and at 30 days. RESULTS: Procedural success rate was 130/132 (98.6%). The degree of stenosis (expressed as % diameter reduction, QCA) decreased from 76.3 +/- 10.6 to 16.9 +/- 9.1 (p < 0.001) while the minimal lumen diameter increased from 1.48 +/- 0.67 to 3.72 +/- 0.71 mm (p < 0.001). In the peri-procedural period, 5 (3.7%) patients had TIA and 1 (0.7%) had hyperperfusion syndrome with a small haemorrhagic stroke, but with a complete clinical recovery. There were no deaths, myocardial infarctions nor any major strokes. On discharge no patients had neurological deterioration as compared to the admission status. At 30 days there were no new cardiac or neurological events. CONCLUSIONS: Our results show that percu-taneous CAS--when performed with brain protection--has a high success rate and a very low complication rate. It is conceivable that the patient/lesion-tailored application of a particular neuroprotection system importantly contributes to the favourable early outcome of CAS.