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Objectives: We here report our clinical experience in CAS management through common carotid artery endovascular clamping with FlowGate2 system. Methods: Forty-five patients were enrolled with de novo asymptomatic internal carotid artery stenosis ≥70%. Cerebral protection during the stenting procedure was achieved using a unique endovascular clamping technique developed in our Institution which includes: (a) the occlusion of the common carotid artery only, through inflatable balloons integrated in the FlowGate2 Balloon Guide Catheter system; (b) flow inversion connecting catheter to 16 G blood cannula previously placed in arm vein; (c) after the placement of the stent, the flow inversion is maintained for 30 s to allow debris washout. The related primary end-point was the rate of Diffusion-weighted imaging magnetic resonance (DWI) micro-embolic scattering of infarction. The patient's clinical and the neurological status were assessed prior, during and after intervention, at discharge. Results: Transient clamping intolerance was observed in two patients (2/45; 4%). One minor stroke (1/45; 2%) occurred 8 hr the procedure with DWI ipsilateral microembolic lesions. No major strokes or deaths were observed at 3 months follow-up. DWI demonstrated ipsilateral micro-embolic scattering of infarction, in one asymptomatic patient. In all patients, no worst changes in NIHSS scale assessment were recorded at 1, 3, and 6 months. Conclusions: Our data confirmed the efficacy of FlowGate2 in terms of neuroprotection during CAS. To our knowledge, these are the first published data on this innovative approach developed in our institution. A large controlled trial is ongoing to confirm preliminary evidences. 1 | INTRODUCTION Carotid artery stenosis is responsible for 20-30% of ischemic strokes. This is due to plaque rupture, arterial dissection, thrombus embolization and occlusive thrombosis. 1-3 Randomized trials showed that the carotid endarterectomy (CEA) reduces stroke risk in these patients. 4-7 Carotid artery stenting (CAS) has emerged as an alternative to CEA due to its minor invasivity. Neverthless, the efficacy and safety of both techniques appear to be not equal, due to patient's selection, operator experience and device evolution dependent. 8,9 Novel equipment technologies and advanced stents as double layer mesh technology, flow reversal with alternative types of proximal/distal emboli protecting devices (EPD), have been reported to improve CAS outcomes. However, embolic events can complicate up to 90% of CAS.

Abdominal aortic aneurysms after a kidney transplant are becoming treated more frequently owing to the extension of renal transplant in severely arteriosclerotic older patients. Renal transplant recipients with autosomal dominant polycystic kidney disease are prone to develop abdominal aortic aneurysms. We present the case of a ruptured abdominal aortic aneurysm that occurred in a renal transplant patient with autosomal dominant polycystic kidney disease. The patient was treated with emergency endovascular repair because open surgery could not be performed successfully owing to the presence of massive polycystic native kidneys and a liver that was occupying the entire peritoneal cavity. His postoperative course was uneventful without complications. The important lessons to be learned from our case are 2-fold: (1) Autosomal dominant polycystic kidney disease renal transplant recipients should be screened annually for abdominal aortic aneurysms to prevent ruptures and (2), emergency endovascular repair may be a preferred treatment in renal transplant recipients owing to its low surgical risk and success.

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