CAS has proven effective in preventing recurrent ischemic events in carefully selected patients with symptomatic cervical carotid artery stenosis. However, several RCTs have shown an elevated risk of distal embolic stroke in CAS compared to carotid endarterectomy. We attempt to minimize this perioperative stroke risk through the replacement of large-diameter balloon angioplasty with the deployment of two self-expanding stents, one within the other, without balloon assistance. Our approach hopes to minimize embolic risk by avoiding initial plaque fracture from rapid balloon distension, increasing atherosclerotic plaque coverage (ergo minimizing plaque protrusion between stent struts) and improving luminal gains via gradual post-surgical stent expansion.

Our case series compares patients seeking CAS for symptomatic cervical carotid artery stenosis at SLU Hospital from January 2016 to May 2019. Data were retrieved from patient records retrospectively. Patients undergoing balloon angioplasty (BA, n=18) versus double-stenting without angioplasty (DS, n=20) are compared regarding pre-surgical, post-surgical and follow-up stenosis when available (NASCET criteria), peri-procedural complications (MI, stroke, death), recurrence of stroke/TIA, and mRS scores.

Patients undergoing either procedure had no significant difference in the median pre-surgical stenosis (DS=80%, BA=86%, p=0.15). Balloon angioplasty resulted in better immediate post-surgical stenosis improvement (DS=-60%, BA=-75%, p=0.009). Double-stented patients had improved net luminal gains on follow-up, whereas balloon angioplasty showed no improvement and some evidence of restenosis (DS=-10%, BA=0%, p=0.38). There was no significant difference in peri-procedural complication rate (DS=5%, BA=11.1%, p=0.6), recurrence of stroke/TIA (DS=7.1%, BA=6.7%, p=1) or median mRS discharge score (DS=1, BA=2, p=1).

These data support the view that our double-stenting technique may be noninferior to conventional balloon angioplasty for symptomatic carotid artery stenosis treatment and may even improve long-term luminal gains, thus warranting further investigation.