The North American Symptomatic Carotid Endarterectomy Trial (NASCET) has thus far demonstrated conclusive benefit for carotid endarterectomy for patients with symptomatic 70% to 99% internal carotid artery (ICA) stenosis. In the NASCET, ICA stenosis was classified angiographically: % ICA stenosis = (1-[narrowest ICA diameter/diameter normal distal cervical ICA]) x 100%. However, widely used duplex scan criteria for ICA stenosis correlate with different angiographic categories of high-grade stenosis (50% to 79%, > 80%) and were developed on the basis of estimated bulb diameter. We therefore blindly evaluated with separate observers carotid angiograms from 100 patients who also underwent carotid duplex scanning in our vascular laboratory. Methods: "Angiographic stenosis" was calculated as in NASCET. Duplex scan measurements of ICA peak systolic velocity (PSV), ICA end-diastolic velocity, and the ratio of ICA PSV to common carotid artery (CCA) PSV were analyzed for sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy to identify a 70% to 99% ICA stenosis. Results: Analysis of the data revealed that an ICA PSV/CCA PSV ratio of 4.0 provided the best combination of sensitivity (91%), specificity (87%), positive predictive value (76%), negative predictive value (96%), and overall accuracy (88%) for detection of a 70% to 99% stenosis. Conclusion: We conclude duplex scan determination of 70% to 99% stenosis as defined in the NASCET requires the adoption of duplex criteria modified from those in current use in most vascular laboratories.

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Biologic patches that undergo active remodeling in the carotid artery require greater thickness than was anticipated to decrease wall stress and suture hole elongation. Patches exceeding this minimum thickness will be required to ensure the safety of new SIS patch designs for vascular operations.

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These results support an aggressive attempt to obtain a complete or optimal ICA endpoint with reconstruction techniques based on operative findings. Recognition of patients at risk for and treatment of hyperperfusion syndrome after CEA remains a clinical challenge.

Aggressive treatment of post-TRAX hypertension, limitation of TRAX duration, delay of postprocedure anticoagulation, and use of alternative sites for arterial puncture in female patients or patients undergoing catheter-based intervention may reduce the incidence of TRAX-related complications. In patients who have neurologic deficits prompt surgical exploration of the puncture site with decompression of the involved nerve(s) may reduce the incidence of prolonged deficits.

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Case report: A 47-year-old man was admitted with recurrent symptoms of dysarthria, diplopia, vertigo, and drop attacks. Workup revealed Ͼ90% stenosis of the left vertebral artery at its origin with poststenotic dilatation (Fig 1). The vertebral artery was 4 mm in diameter. The plaque appeared to have significant embolic potential. The right common femoral artery was accessed with short 9F sheath, and patient was anticoagulated with intravenous heparin (100 U/kg body weight). The left subclavian artery was cannulated using headhunter catheter. The catheter was advanced over the wire to mid brachial artery. Wire exchanged to stiff wire. MoMa flow reversal guide catheter (Medtronic, Minneapolis, Minn) was advanced over the stiff wire until the trailing balloon was engaged in the left subclavian artery. The leading balloon was positioned in left subclavian artery and kept deflated. The trailing balloon in left subclavian artery was inflated after