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Purpose: To describe the evolving techniques for stent implantation in the proximal and cervical carotid arteries., Methods and Results: Percutaneous access to proximal and cervical carotid lesions is either via direct puncture of the common carotid artery or through the more familiar retrograde common femoral (RCF) artery approach. Both techniques and their variations are described in detail, along with their benefits, disadvantages, and possible complications. Dual lesions at the arch and higher up the neck can be treated either from the RCF route or, if the cervical lesion requires endarterectomy, with open exposure at the bifurcation and stenting of the proximal lesion., Conclusions: While the RCF route is more familiar to the majority of interventionists and provides adequate access in most situations, traversing the arch and negotiating acute angles at the ostia of the great vessels may render this method infeasible. The direct puncture technique is a useful alternative; however, it requires more expertise to prevent potentially disastrous access-site complications. One further caveat must be stated: regardless of the access approach selected, the opportunity for serious, debilitating-and lethal-complications is always present in cerebrovascular interventions. At this earliest phase in our experience with carotid stenting, cautious investigative methodologies must prevail.

Purpose: To demonstrate the clinical value of intravascular ultrasound (IVUS) imaging in monitoring stent deployment in the cervical carotid arteries., Methods and Results: Two-dimensional (2D) and three-dimensional (3D) IVUS imaging has been used routinely in more than 100 patients following carotid stenting and the completion angiogram to detect evidence of inaccurate stent deployment. Axial 2D views were used to measure diameters and cross-sectional areas and provide the basis for 3D reconstruction. These composited images produced single-frame views of entire vascular segments, with definition of vessel wall morphology, stent placement, and angioplasty-induced defects. This information was used in the decision to apply further treatment to the area in order to maximize luminal diameter and/or correct defects., Conclusions: IVUS imaging is an important component of carotid artery stent procedures. It more accurately visualizes stent placement and vessel wall morphology than arteriography, information critical to the intraprocedural assessment process.