renal, mesenteric, and peripheral atherosclerotic disease".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading https://www.uptodate.com/contents/percutaneous-carotid-artery-stenting/print 12/24 7/5/23, 11:43 AM Percutaneous carotid artery stenting - UpToDate level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topics (see "Patient education: Carotid artery disease (The Basics)") SUMMARY AND RECOMMENDATIONS Carotid revascularization to treat carotid atherosclerotic disease can be accomplished using open surgery (carotid endarterectomy) or using a carotid artery stent (CAS), with the most common CAS approach using a percutaneous approach. Transfemoral carotid artery stenting (TF-CAS) involves accessing the femoral artery percutaneously to place the necessary guidewires and sheaths, traversing the aortic arch to gain access to the carotid artery, deployment of an embolic protection device, and subsequently dilation of the artery and placement of the stent. (See 'Introduction' above and 'Carotid revascularization' above.) For patients in whom CAS is scheduled or anticipated, dual antiplatelet therapy (DAPT) using aspirin and clopidogrel is recommended. Furthermore, periprocedural statin therapy is also recommended. (See 'Patient preparation' above and "Overview of carotid artery stenting", section on 'Summary and recommendations'.) For percutaneous CAS (transfemoral or other percutaneous approach), we use the following regimen, which is generally consistent with multidisciplinary guidelines: For those patients not on chronic aspirin therapy, we start aspirin (325 mg twice daily) at least 48 hours before the procedure, or, if within 48 hours of the procedure, we give a loading dose of aspirin 650 mg four or more hours before the procedure. For those patients not on chronic clopidogrel therapy, we start clopidogrel 75 mg twice daily at least 48 hours before the procedure, or if within 48 hours of the procedure, we give a loading dose of clopidogrel 450 mg four or more hours before the procedure. For those patients not on chronic statin therapy, we start atorvastatin 40 mg daily for seven days before the procedure or we give a loading dose of 80 mg 12 hours before the procedure. https://www.uptodate.com/contents/percutaneous-carotid-artery-stenting/print 13/24 7/5/23, 11:43 AM Percutaneous carotid artery stenting - UpToDate Following percutaneous access and sheath placement, the patient is systemically anticoagulated, typically using heparin. Whether to reverse heparin with protamine is left to the discretion of the operator and generally based on issues pertaining to the percutaneous access site. For those in whom a vascular closure device will not be used at a femoral access site, we suggest reversal of anticoagulation (Grade 2C). Reversal of anticoagulation reduces sheath dwell time and duration of bedrest. (See 'Anticoagulation' above.) Following the CAS procedure, DAPT with aspirin (325 mg once daily) plus clopidogrel (75 mg once daily) is continued for at least four weeks. For patients with a history of neck irradiation, we continue DAPT indefinitely. For all other patients, after clopidogrel is discontinued, we continue aspirin 325 mg daily indefinitely. (See "Overview of carotid artery stenting", section on 'Dual antiplatelet therapy'.) Several types of embolic protection devices (EPDs) are available and are intended to prevent embolic complications of angioplasty and stenting. Filter devices are used in most percutaneous CAS procedures. Although a benefit for EPDs has not been definitively established, many consider the use of an EPD to be standard of care. In the United States, the use of an EPD is mandatory for reimbursement for CAS. (See 'Embolic protection devices' above.) The most serious acute complication associated with CAS is stroke, which can occur due to thromboembolism, hypoperfusion, hyperperfusion syndrome, or hemorrhage. The overall stroke rate for TF-CAS is 3 to 4 percent and has steadily decreased with improvements in device technology and operator experience. Other complications associated with CAS include access-related issues (eg, hematoma, bleeding, pseudoaneurysm formation, and distal atheroembolization), myocardial infarction, contrast-related renal failure, restenosis of the target lesion, and carotid stent fracture. (See 'Complications' above and "Overview of carotid artery stenting", section on 'Complications'.) ACKNOWLEDGMENT The editorial staff at UpToDate acknowledges Ronald M Fairman, MD, who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Terms of Use. 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Topic 127412 Version 6.0 https://www.uptodate.com/contents/percutaneous-carotid-artery-stenting/print 21/24 7/5/23, 11:43 AM Percutaneous carotid artery stenting - UpToDate GRAPHICS Angiographic criteria for internal carotid near-occlusion The figures illustrate the four criteria for internal carotid near-occlusion on conventional angiography. In all figures, the intravenous contrast (gray color) is shown emanating from a catheter positioned in the CCA. (A) Delayed filling (B) Evidence of intracranial collaterals when the contralateral side is examined (C) Ipsilateral distal ICA diameter less than the contralateral distal ICA diameter (D) Ipsilateral distal ICA diameter equal to or less than the ipsilateral ECA diameter CCA: common carotid artery; ICA: internal carotid artery; ECA: external carotid artery. Modi ed with permission of the American Society of Neuroradiology, from: Johansson E, Fox AJ. Carotid Near- Occlusion: A Comprehensive Review, Part 1 De nition, Terminology, and Diagnosis. AJNR Am J Neuroradiol 2016; https://www.uptodate.com/contents/percutaneous-carotid-artery-stenting/print 22/24 7/5/23, 11:43 AM Percutaneous carotid artery stenting - UpToDate 37:2; permission conveyed through Copyright Clearance Center, Inc. Copyright 2016. Graphic 129242 Version 1.0 https://www.uptodate.com/contents/percutaneous-carotid-artery-stenting/print 23/24 7/5/23, 11:43 AM Percutaneous carotid artery stenting - UpToDate Contributor Disclosures Jeffrey Jim, MD, MPHS, FACS Consultant/Advisory Boards: Endospan [Aortic interventions]; Medtronic [Aortic interventions]; Silk Road Medical [Carotid stent]. All of the relevant financial relationships listed have been mitigated. John F Eidt, MD Grant/Research/Clinical Trial Support: Syntactx [Clinical events, data/safety monitoring for medical device trials]. All of the relevant financial relationships listed have been mitigated. Joseph L Mills, Sr, MD No relevant financial relationship(s) with ineligible companies to disclose. Kathryn A Collins, MD, PhD, FACS No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/percutaneous-carotid-artery-stenting/print 24/24