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Symptomatic carotid stenosis with intraluminal thrombus is infrequent; its management remains contentious; and it carries an ominous prognosis irrespective of medical or surgical treatment. In the North American Symptomatic Carotid Endarterectomy Trial (NASCET), intraluminal thrombus tripled the medical risk and doubled the surgical risk of 30-day stroke or death, with 1-year stroke rates of 25.3% in medically treated patients and 16% in surgically treated patients.1 This has prompted recommendations for initial anticoagulation followed by delayed carotid endarterectomy (CEA).2 However, prophylaxis against recurrent stroke is greatest when CEA is performed early, with a delay >2–3 weeks after symptomatic presentation substantially diminishing the absolute risk reduction achievable.3
Recently, we and others demonstrated techniques for carotid angioplasty and stenting (CAS) in the presence of intraluminal thrombus.4,5 These methods depend primarily on a combination of proximal flow arrest followed by distal trapping, rather than distal protection alone. Early CAS could therefore be of particular importance in treating carotid stenosis with intraluminal thrombus when patients present with hemispheric stroke, because they have a higher risk of future stroke3 and also potential for hemorrhagic transformation of …
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