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Objective Over the years where stents have been used to treat carotid lesions, a great deal has been learned about which anatomic characteristics lead to adverse outcomes. This review summarizes the anatomic and morphologic characteristics of the carotid vasculature that can help guide patient selection and clinical decision-making. Methods Each of the carotid artery anatomy and lesion characteristics that are relevant to carotid stenting is described in detail. These are accompanied with evidence-based outcomes and results. Results Data on the prevalence of carotid artery lesions that are unsuitable for stenting are summarized and the implications of these data for practice are discussed, especially as they pertain to transcarotid artery revascularization. Conclusions Carotid artery stenting can be a viable option for carotid revascularization, but the lesion must be acceptable and safe for stent placement. There should be thorough assessment to rule out the presence of severe tortuosity, long-segment disease, severe calcification (circumferential or exophytic), mobile plaque, swollen internal carotid artery sign, and carotid diameters outside the acceptable range. In carefully chosen lesions with the absence of the unfavorable characteristics described, transcarotid artery revascularization may offer improved periprocedural success and carotid artery stenting may attain better long-term durability.

In Case 1, A 65-year-old man with a family history of carotid body paraganglioma and no other risk factors was referred to the noninvasive vascular laboratory for a carotid duplex with complaints of left eye amaurosis fugax. In Case 2, an 84-year-old woman with a history of hypertension and hyperlipidemia presented to the noninvasive vascular laboratory for carotid duplex under the suspicion of a right hemisphere transient ischemic attack. Duplex sonography of both cases recorded minimal

Background Previously, the Stenting and Angioplasty with Protection of Patients with High Risk for Endarterectomy (SAPPHIRE) randomized trial showed that carotid artery stenting (CAS) was not inferior to carotid endarterectomy (CEA) in the treatment of high-surgical risk patients. Objective The primary objective of the SAPPHIRE Worldwide Registry is to evaluate 30-day major adverse events (MAE) after CAS performed by physicians with varied experience and utilizing a formal training program. Data will be analyzed on the overall patient population and by high-risk inclusion criteria. Methods SAPPHIRE Worldwide is a multicenter, prospective, postapproval registry to evaluate CAS with distal protection in patients at high-risk for surgery using the Cordis PRECISE Nitinol Stent and ANGIOGUARD™ XP/RX Emboli Capture Guidewire. Participating physicians are encouraged to treat patients according to their standard of practice and consistent with current Food and Drug Administration-approved labeling. Results Enrollment began in October 2006. Data are available on the first 2,001 patients enrolled and followed to 30 days. Of these patients, the mean age was 72.2 ± 9.75 yr; 62% were male; and 27.7% were symptomatic. Entry criteria for surgical high-risk included anatomic (n = 716), physiologic (n = 918), or both risk factors (n = 327). At 30-day follow-up, the MAE was 4.4% (death 1.1%, stroke 3.2%, MI 0.7%) for the overall population. Patients with anatomic risk had a significantly lower 30-day MAE than patients with physiologic risk (2.8% vs. 4.9%, P = 0.0306), respectively. Conclusions While the number of physicians performing CAS continues to increase, MAE rates seen in this registry (4.4%) are well within an acceptable range, as was first seen in the SAPPHIRE randomized trial (4.8%). A significant decrease in MAE was seen in patients with anatomic risk compared with physiologic risk factors. The SAPPHIRE Worldwide Registry supports the use of CAS as an alternative to CEA in patients who are at high-risk for surgery due to anatomic risk factors. © 2008 Wiley-Liss, Inc.