Carotid artery stenosis causes up to 20% of ischemic strokes. Stenting is used as an alternative to endarterectomy in symptomatic patients. Each commercially available stent offers numerous stent diameters/lengths. Most centers thus carefully match each individual stenosis to a specific stent length/diameter stent size. However, this process can be time-consuming and costly while the relative benefit of a custom stent sizing versus one-size-fits-all approach has not been well evaluated yet. We hypothesized that a ‘one-size-fits-all’ default approach to carotid stenting results in comparable results to a customized approach.

We conducted a descriptive retrospective cohort study on 154 patients who presented to our academic carotid revascularization clinic with symptomatic carotid artery stenosis who underwent carotid artery stenting for peri- and postprocedural carotid artery stenting complications. The primary outcomes were periprocedural (within 24 hours of the procedure) or postprocedural (within 30 days of the procedure) TIA, stroke, or death. The secondary outcome was the estimated degree of stenosis on follow-up ultrasound performed within 6 months of the procedure.

The complication rate within the first 24 hours was 4.5% while that during the first 30 days postprocedure was 6.5%. Age over 80 and degree of stenosis on postprocedural cerebral angiogram were associated with an increased risk of complications. Severe restenosis was reported in 16.8% of patients within 6 months postprocedure.

Our study suggests that using a simplified, one-size-fits-all, approach to carotid stenting results in safe and effective outcomes, suggesting an alternative to simplify a complex medical procedure.

Cerebral emboli are generated by every step of standard carotid angioplasty and stenting. Primary carotid stenting (PCS) is a technique in which the use of balloon angioplasty (BA) is minimized to decrease the embolic load. The primary aim of this study is to establish the number of emboli generated by each step of primary stenting and determine the relationship to new diffusion (DWI) lesions on subsequent magnetic resonance imaging (MRI).

Eighty-five patients with severe, symptomatic carotid stenosis were prospectively recruited and underwent carotid stenting. Intraoperative transcranial Doppler was performed in 77 patients. The number and size of microemboli for each of seven procedural steps were recorded. Correlation was made with the number and location of new DWI lesions.

PCS was performed in 73 patients. BA was required in 12 patients. The mean number of microemboli was 114, and most microemboli were generated by stent deployment, followed by BA. Balloon techniques generated significantly more emboli than primary stenting (p = 0.017). There was a significant relationship between total microemboli and new DWI lesions (p = 0.009), and between new DWI lesions in multiple territories and the severity of pretreatment stenosis (p = 0.002).

During PCS, more emboli are generated by stent deployment than during any other stage of the procedure. When BA is necessary, more malignant emboli are generated but total emboli are unchanged and there is no difference in new diffusion lesions on MRI. PCS is safe and is not inferior to historical controls for the generation of new DWI lesions.