Introduction  The coexistence of carotid artery stenosis and a concomitant downstream ipsilateral unruptured intracranial aneurysm requires unique treatment considerations to balance the risk of thromboembolic complications from carotid artery stenosis and the risk of subarachnoid hemorrhage from intracranial aneurysm rupture. These considerations include the selection of optimal treatment modalities, the order and timing of interventions, and potential management of antiplatelet agents with endovascular approaches. We present strategies to optimize treatment in such a case. Case Report  We discuss the case of a 69-year-old woman with 90% stenosis of the right internal carotid artery and an ipsilateral, wide-necked, 4.8-mm, irregular-appearing right A1-2 junction aneurysm with an associated daughter sac. Open, endovascular, and mixed treatment strategies were considered. The patient selected and underwent a staged, open treatment approach with a carotid endarterectomy followed by a right craniotomy for microsurgical clipping of the aneurysm 5 days later. Both procedures were performed on daily full-dose aspirin without complications. On follow-up, the right carotid artery was widely patent, the aneurysm was secured, and the patient remained at her neurologic baseline. Discussion  The presented strategy for ipsilateral carotid artery stenosis and an unruptured intracranial aneurysm initially optimized cerebral perfusion to mitigate ischemic risks while permitting timely aneurysm intervention without a need for dual antiplatelet therapy or to traverse an earlier procedure site.

Syncope is a common clinical entity with variable presentations and often an elusive causal mechanism, even after extensive evaluation. In any case, global cerebral hypoperfusion, resulting from the inability of the circulatory system to maintain blood pressure (BP) at the level necessary to supply blood to the brain efficiently, is the final pathway for syncope. Steno-occlusive carotid artery disease, even if bilateral, does not usually cause syncope. However, the patient presented here had repeated syncope attacks and underwent a thorough examination for suspected cardiac disease, but no abnormality was found. Since there was severe stenosis in the right unilateral internal carotid artery (ICA), but no stenosis in the left ICA or vertebrobasilar artery (VBA), and transient left mild hemiparesis associated with syncope, carotid revascularization surgery for the right ICA was performed, and the repeated syncope attacks completely disappeared after the surgery. The patient\'s condition improved markedly, and no further episodes of syncope have been reported. We report the relationship between carotid artery stenosis and syncope and discuss its pathomechanism.

The first objective of this case series was to describe the case of a patient with severe symptomatic left internal carotid artery stenosis after a recent stroke. Several days after stent placement by transcarotid artery revascularization, the patient developed a left-sided subdural hematoma. The patient then underwent embolization of the left middle meningeal artery (MMA) despite blocked access to the left MMA because of an internal carotid stent. The external carotid artery was accessed by passing a guiding catheter through the stent wall. We describe this method as \"intrawall access.\" This allowed a coaxial system to deliver polyvinyl alcohol particles to the MMA for embolization. Embolization was successfully performed, with the stent integrity and blood flow through it remaining uncompromised. Overall, we demonstrated a new method of access through a previously placed internal carotid stent to gain neurointerventional access to the external carotid artery, which was jailed by a stent, for treating an acute subdural hematoma via MMA embolization. The second objective of this case series was to demonstrate the first MMA embolization in literature carried out in the acute or acute-on-subacute setting, in this case, and in four others.

Minor non-aneurysmal subarachnoid hemorrhage (SAH) following carotid artery stenting (CAS) is exceedingly rare and less described, with its underlying mechanism elusive. Here, we present the case of a 75-year-old female who underwent CAS for progressive asymptomatic severe stenosis of the internal carotid artery. Her post-procedural course remained uneventful, with no intracranial hemorrhage detected on the following day\'s magnetic resonance imaging (MRI). However, a routine MRI on the seventh post-procedural day identified a small amount of SAH in the central sulcus on the operative side. In the absence of symptoms, the patient was discharged home after a computed tomography (CT) scan revealed no signs of hemorrhagic enlargement the following day. In this report, we document the rare occurrence of localized SAH post-CAS. There are limited reports of minor SAH following CAS, with the underlying mechanisms remaining unclear. In this report, the localization of SAH aligns with the most critical ischemic sites, indicating that the mechanism of focal SAH after CAS is associated with blood-brain barrier (BBB) disruption due to a rapid increase in blood flow to small vessels with impaired vascular autoregulation. Focal convexity SAH is an easily overlooked finding, and the medical team performing carotid artery revascularization procedures should be aware of the potential for such SAH postoperatively and exercise caution during postoperative imaging interpretation.

OBJECTIVE: To investigate the effects of yearly institutional case volume for carotid endarterectomy (CEA) and stenting (CAS) among symptomatic carotid stenosis patients on the rates of postoperative stroke and inpatient mortality.
METHODS: Patients with prior stroke (\"symptomatic\") undergoing CEA or CAS during an inpatient stay were identified from the National Inpatient Sample for years 2012-2015. The primary variable was volume of CEA or CAS performed annually by each institution. The primary outcome was a composite variable for in-hospital death or postoperative stroke.
RESULTS: A total of 5,628 patients with symptomatic carotid stenosis underwent CEA, while 245 underwent CAS. In the symptomatic CEA population, 519 (9.2 %) patients experienced postoperative stroke or mortality, and were more likely to be treated at centers with a lower yearly institutional volume (median 10 [IQR 5-15] versus 10 [7-20] cases, p < 0.001). In the symptomatic CAS population, 32 (13.1 %) patients experienced stroke or mortality, and these patients were also more likely to undergo treatment at hospitals with a lower yearly institutional volume (median 5 [IQR 5-7] versus 5 [5-10] cases, p = 0.044). Thresholds for yearly institutional volume found differences in adverse outcome between 0-9, 10-29, and ≥30 cases/year (11.7 % vs 8.4 % vs 6.0 %, p < 0.001) for CEA, and differences in postoperative stroke between 0-9 and ≥10 cases/year for CAS (11.0 % vs 1.4 %, p = 0.028).
CONCLUSIONS: Hospitals performing higher volumes of CEA or CAS have fewer postoperative strokes. The threshold reported herein is ≥30 CEA procedures or ≥10 CAS procedures annually for appreciably improved outcomes.

UNASSIGNED: Cerebral hyperperfusion syndrome (CHS) is the most severe complication of carotid artery stenting (CAS) or endarterectomy (CEA). Staging treatment can effectively reduce the risk of CHS without increasing the risk of ischemic stroke. The first stage of balloon dilatation is critical for staged treatment. However, the successful criterion of the first stage balloon dilatation is still inconsistent.
UNASSIGNED: In the current study presents a case of a 61-year-old male with bilateral internal carotid subtotal occlusion, transcranial doppler (TCD) was used to measure middle cerebral artery (MCA) flow rate on the narrow side of surgery and the results are promising.
UNASSIGNED: Intraoperative TCD monitoring is expected to be an evaluation criterion for staged angioplasty for carotid artery stenosis.
UNASSIGNED: The approach of blood flow velocity in the brain based on intraoperative measurement of TCD during the treatment of this patient is a new idea for staging treatment in the future.

BACKGROUND: One of the major perioperative complications for coronary artery bypass graft (CABG) is stroke. The risk of perioperative stroke after CABG is approximately 2%. Carotid stenosis (CS) is considered an independent predictor of perioperative stroke risk in CABG patients. The optimal management of such patients has been a source of controversy. One of the possible surgical options is synchronous carotid endarterectomy (CEA) and CABG. Here, we have presented 4 cases of successful synchronous CEA and CABG.
METHODS: Our center\'s experience with 4 cases of significant carotid artery stenosis, which were successfully managed with combined CEA and CABG, are detailed. The first case was a female who presented for CABG after a ST-elevation myocardial infarction. She had right internal carotid artery (ICA) occlusion and 90% left ICA stenosis. The second case was a male who was electively admitted for CABG. It was discovered that he had left ICA occlusion and 90% right ICA stenosis. The third case was a male with a history of stroke, two months prior to admission. He presented with non-ST-elevation myocardial infarction. Preoperatively, it was discovered that he had > 90% right ICA stenosis. The final case was a male who was electively admitted for CABG. It was discovered that he had bilateral > 90% ICA stenosis. We have also reviewed the current evidence and guidelines for managing CS in patients undergoing CABG.
CONCLUSIONS: Our case series demonstrated that synchronous CEA and CABG was safe. A multicenter study with additional patients is needed. It is necessary for clinicians to screen for CS in high-risk patients with features.

Neuroendovascular treatment via transradial access (TRA) has gained popularity as a minimally invasive technique. However, the flow reversal (FR) system, reported useful in carotid artery stenting (CAS), cannot be applied via TRA because it requires an access route of more than 8 F. Herein, we report the utility of a modified FR system applied via TRA using a sheathless 8-F balloon guide catheter and a 2.6-F balloon catheter.
In a retrospective analysis of a single-center consecutive case series, patients with CAS and vulnerable plaques who were treated with CAS via TRA using a modified FR system from June 2022 to August 2022 were examined. High-intensity spots were assessed on postprocedural diffusion-weighted magnetic resonance images. Puncture site complications at discharge and cardiovascular events for 1 year after CAS were also evaluated.
Ten patients were included in this study. There were no high-intensity spots on diffusion-weighted magnetic resonance images after CAS. No procedure-related complications, including radial artery occlusion or cardiovascular events, were observed.
This study suggests that CAS with FR using our modified system is feasible via TRA and may be an effective technique with a low rate of vascular complications.

UNASSIGNED: To report a case of coronary-subclavian steal syndrome (CSSS) due to a history of a left internal mammary artery (LIMA) to left anterior descending (LAD) artery coronary bypass (CABG) and a heavily calcified ostial left subclavian artery (LSA) occlusion, that was treated with intravascular lithotripsy (IVL) technique and to summarize the current trends of IVL treatment for supra-aortic vessels.
UNASSIGNED: A 64-year-old woman with progressive intermittent angina pectoris and a history of LIMA to LAD bypass underwent coronary angiography which demonstrated complete ostial occlusion of the LSA. Via brachial access, the patient underwent Shockwave IVL balloon treatment of the LSA and stent-graft implantation. At 9 months follow-up, the patient showed symptoms resolution, and duplex ultrasound (DUS) demonstrated a patent LSA.
UNASSIGNED: The Shockwave IVL system was demonstrated to be a feasible treatment and justified for selective cases of highly calcified lesions in supra-aortic vessels. The present case report and the literature review, in a total of 47 patients resulted in a high technical procedural success rate, with a low rate of complications. Future studies with larger cohorts are warranted to confirm these findings and standardize this technology in this particular vascular field.
CONCLUSIONS: The present study exemplifies a case of recanalization of the left subclavian artery in a patient with coronary-subclavian steal syndrome with a heavily calcified ostial lesion treated with intravascular lithotripsy (IVL). In this paper, for the first time, a review of the contemporary literature on the use of IVL in supra-aortic vessels is reported, elucidating the feasibility of this technique in this vascular territory. Despite the heterogeneous features of the reported cases and the lack of a standardized protocol for the use of IVL in the management of highly calcified lesions of supra-aortic vessels, it was demonstrated to be a feasible technique, with a high technical success rate, being an advantageous tool for heavily calcified supra-aortic lesions.

Carotid artery stenting (CAS) for carotid stenosis has been widely used as an alternative treatment in patients not eligible for surgery. The shortening of a carotid stent rarely occurs. We report a case of early shortening of CAS in a patient with radiation-induced carotid stenosis and discuss the potential pathophysiology and strategies for prevention. This case presents a 67-year-old man who underwent radiotherapy for oral cavity squamous cell carcinoma 7 years ago and subsequently developed severe stenosis in the left proximal internal carotid artery. The patient underwent CAS for symptomatic severe carotid stenosis. Follow-up CT angiography revealed shortening of the carotid stent, and additional carotid stenting was performed. We speculate that the possible mechanism of early complication of CAS could be slippage and shortening of the stent due to weak anchoring between the stent strut and the fibrotic arterial wall in radiation-induced carotid stenosis.