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Carotid artery stenosis is a narrowing of the carotid arteries, most often caused by atherosclerotic plaque accumulation, that can significantly impair cerebral blood flow and increase the risk of ischemic stroke. Carotid artery stenting (CAS) is a minimally invasive endovascular procedure designed to re-establish cerebral perfusion by performing balloon angioplasty and placing a stent to maintain vessel patency. Use of cerebral protection devices during CAS reduces the risk of embolization and procedural stroke. The procedure can be performed via a transfemoral or transcarotid approach, with selection guided by patient anatomy, comorbidities, and risk profile. While CAS offers a less invasive alternative to carotid endarterectomy, it carries potential complications, including stroke, restenosis, and vascular injury. Success depends on careful patient selection, adherence to evidence-based protocols, and close perioperative monitoring. Collaborative management involving vascular surgeons, interventional radiologists, neurologists, and anesthesiology clinicians ensures procedural safety, reduces complications, and enhances neurological outcomes. Participants in this course develop comprehensive competence in evaluating, planning, and performing carotid artery stenting using both transfemoral and transcarotid approaches. The curriculum emphasizes understanding current indications, contraindications, device selection, and neuroprotection strategies aligned with contemporary clinical guidelines. Clinicians gain expertise in managing intraoperative and postoperative complications, optimizing antiplatelet therapy, and maintaining hemodynamic stability to improve procedural safety and long-term vessel patency. The course underscores the value of interprofessional collaboration among vascular specialists, neurologists, anesthesiology clinicians, and nursing teams to provide coordinated care throughout the perioperative period. Such teamwork enhances diagnostic accuracy, procedural efficiency, and early detection of complications, ultimately improving stroke prevention and patient recovery. Objectives: Identify patients at high risk for carotid artery stenosis who may benefit from carotid artery stenting. Differentiate between symptomatic and asymptomatic carotid artery disease and determine the appropriate timing of intervention.

Participants in this course develop comprehensive competence in evaluating, planning, and performing carotid artery stenting using both transfemoral and transcarotid approaches. The curriculum emphasizes understanding current indications, contraindications, device selection, and neuroprotection strategies aligned with contemporary clinical guidelines. Clinicians gain expertise in managing intraoperative and postoperative complications, optimizing antiplatelet therapy, and maintaining hemodynamic stability to improve procedural safety and long-term vessel patency. The course underscores the value of interprofessional collaboration among vascular specialists, neurologists, anesthesiology clinicians, and nursing teams to provide coordinated care throughout the perioperative period. Such teamwork enhances diagnostic accuracy, procedural efficiency, and early detection of complications, ultimately improving stroke prevention and patient recovery. Objectives: Identify patients at high risk for carotid artery stenosis who may benefit from carotid artery stenting. Differentiate between symptomatic and asymptomatic carotid artery disease and determine the appropriate timing of intervention. Select optimal access approach (transfemoral vs transcarotid) based on patient-specific anatomy and comorbidities. Collaborate with the interprofessional team, including radiologists, anesthesiologists, nurses, and technicians, to ensure procedural safety and optimize patient outcomes. Access free multiple choice questions on this topic.

Traditionally, carotid endarterectomy (CEA) has been the primary treatment for high-grade asymptomatic and symptomatic carotid artery stenosis. A carotid endarterectomy involves exposure of the carotid artery and removal of plaque, most typically from the carotid bulb and the proximal internal carotid artery, via a neck incision. However, in vascular surgery, as in many other surgical specialties, minimally invasive techniques have evolved over the years. These techniques offer the advantages of smaller incisions, reduced postoperative pain, reduced risk of postoperative wound complications, and a shorter hospital length of stay. Carotid artery stenting (CAS) is one such technique that can be performed via a transfemoral or transcarotid approach.[1][2][3]

Complications following CAS vary depending on the access route and patient factors, but can involve both local vascular injury and serious cerebrovascular events. For the transfemoral approach, complications are often related to femoral artery access, including bleeding, arterial perforation, dissection, thrombosis, pseudoaneurysm formation, and distal embolization. Access-site hematomas and retroperitoneal hemorrhage are also potential risks, particularly in anticoagulated patients. In both transfemoral and transcarotid approaches, procedural complications may include carotid artery dissection, thromboembolism, incomplete stent deployment, and stent fracture or migration in rare cases. Neurologic complications represent the most serious category, with stroke and transient ischemic attacks resulting from embolization of atheromatous debris during wire manipulation, balloon inflation, or stent placement. Hyperperfusion syndrome, characterized by severe headache, seizures, or intracerebral hemorrhage, may develop postrevascularization due to impaired cerebrovascular autoregulation. Careful blood pressure control is essential in the postoperative period to mitigate this risk. Hemodynamic instability, specifically bradycardia and hypotension, is typical during angioplasty or stent deployment due to carotid sinus stimulation and typically responds to atropine or vasopressors. Access-site infections, contrast-induced nephropathy, and allergic reactions to contrast agents are less frequent but essential considerations. Long-term complications include in-stent restenosis from neointimal hyperplasia (occurring in 5%–10% of cases) and stent thrombosis, underscoring the need for adherence to dual antiplatelet therapy (aspirin and clopidogrel). Prevention of complications relies on careful patient selection, meticulous procedural technique, and interprofessional coordination between surgeons, anesthesiologists, nurses, and technologists. Neuroprotection devices, close hemodynamic monitoring, and timely recognition of access or stent-related issues are critical for minimizing morbidity and optimizing patient outcomes.

Optimal outcomes in carotid artery stenting (CAS) rely on a coordinated, multidisciplinary approach that integrates the skills and strategies of clinicians, nurses, pharmacists, and allied health professionals. Interventionalists must possess expertise in endovascular techniques, imaging interpretation, and real-time management of hemodynamic instability. Advanced practitioners and nurses are essential in preprocedural assessment, patient education, and postprocedural monitoring for complications such as access-site bleeding, stroke symptoms, or hemodynamic fluctuations. Pharmacists contribute to patient safety by optimizing antiplatelet and anticoagulant therapy, monitoring for drug interactions, and ensuring appropriate perioperative medication management. Collectively, these professionals implement strategies that emphasize patient-centered decision-making, adherence to evidence-based protocols, and meticulous procedural planning to reduce risk and improve outcomes. Effective interprofessional communication and care coordination are crucial throughout all stages of CAS—from preoperative evaluation through postoperative follow-up. Clear, structured communication ensures that all team members consistently understand diagnostic findings, procedural plans, and evolving patient conditions. Regular interdisciplinary briefings, standardized checklists, and timely electronic documentation foster seamless care transitions. By collaborating across disciplines, healthcare professionals can anticipate complications early, enhance procedural safety, and deliver comprehensive care that improves stroke prevention, functional recovery, and patient satisfaction while reinforcing a culture of teamwork and continuous quality improvement.