A thorough diagnostic angiogram should be performed to observe both the lesion and the collateral flow to the brain. Although the carotid artery is the immediate target for repairing flow, the overall goal is to improve cerebral perfusion; thus, the true target of the intervention is the brain. Knowing the level of diminished flow to the brain and the potential conduits for collateral flow facilitates establishment of the necessity for the procedure and the potential risks to the patient during the procedure. The Circle of Willis is not complete in all patients and may exhibit many variations with only 20% to 25% of the population having complete collateral pathways (21).

Ideally, carotid stenting should be performed under moderate sedation, allowing the team members to quickly evaluate the neurologic consequences of intervention. However, some patients will not be able to stay motionless at critical points in the procedure, which could lead to a devastating outcome. These patients would benefit from a general anesthetic technique that will allow for rapid emergence following completion of the procedure and immediate postprocedure neurologic evaluation.

The procedure is initiated with catheterization of the common carotid artery on the side of stenosis. Via an exchange over a guidewire or via direct catheterization, the equivalent of an 8-French guiding catheter is stably placed into the common carotid artery. Angiograms are performed, measurements are taken, and careful determination of the appropriate diameter is made. Then length of the balloon (stent) is selected based on the length of the stenosis and the diameter of the native vessel. After the balloon/stent system is chosen, the common carotid artery is accessed. Distal protection, usually a wire-mounted basket, can be placed over a micro-guidewire, and the balloon (stent) is placed through the lesion. Distal protection devices should be placed below the skull base in a straight segment of the carotid. The device is inflated, and deployment of the stent is performed. Angiograms are performed until the operator is satisfied with the diameter restoration. Additional balloon inflations with the same or larger balloons might be required for optimal dilation. Final angiograms are performed intracranially to document normalization of flow and transit time from the arteries to the veins, thereby ensuring no significant emboli. The system can then be removed, and the patient can emerge from anesthesia.

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