The onset of deep vein thrombosis (DVT) and pulmonary embolism (PE) compromise the state of the patient in the intensive care unit, often leading to death. Prophylaxis with anticoagulant therapy and mechanical devices (graduated compression and/or intermittent pneumatic hosiery) is needed, as is early patient mobilization. The aim of the study is to demonstrate whether there is an association between pharmacological prophylaxis and intermittent pneumatic compression (group 1), and pharmacological prophylaxis with graduated compression stockings (group 2) that reduces thromboembolic events compared with control group. From January 2019 to March 2021, 209 patients from admission to discharge, hospitalized in the intensive care unit at University Hospital of Siena, were divided into four groups by admission class: medical, surgical, trauma, and cranial. Ultrasound monitoring was done on a weekly basis and data were analyzed with the Statistical Package for Social Science (SPSS) software, using various correlation tests and a logistic-regression model. Overall, 6.2% of patients had DVT and, of these, 0.9% had PE. In group 2, 6.8% had DVT and 1.4% has PE (total, 74). Group 1 had 5.9% DVT and 0.7% PE (total, 135). No statistical significance was found in DVT between the two groups (P = .774). Specifically, there was 2.5% DVT and no PE (total 80) in the medical class; 3.3% DVT and no PE (total, 30) in the surgical class; 11.1% DVT and 3.7% PE (total, 54) in the trauma class; and 8.9% DVT and no PE (total, 45) in the cranial class. There were no significant differences in DVT between the four groups (P = .165). The only significant correlation (P = .002) found with the Sequential Organ Failure score (SOFA) was between thromboembolic events and hospital stay. The mean number of days was 9.5 ± 9.2 in group 2 and 13.4 ± 14.1 in group 1. Group 2 had a mean SOFA score of 5.9 ± 3.0 and group 1 had a mean SOFA score of 7.3 ± 3.2. The study confirms that increasing hospital days leads to risk of thromboembolic events, although there was no significant difference of DVT in the two groups. The SOFA score identifies the increased risk of DVT and/or PE.

OPINION article Front. Surg., 14 October 2022Sec. Vascular Surgery Volume 9 - 2022 | https://doi.org/10.3389/fsurg.2022.971776

Stenosis of the internal carotid artery may be responsible for 10%–20% of all strokes or transient ischemic attacks. Stroke is the third leading cause of death and the most common cause of permanent disability in western countries. Until the introduction of carotid artery stenting (CAS), carotid endarterectomy (CEA) was the only surgical solution to the potential embolic and thrombotic load of the carotid plaque. Over the past few years, medical therapy has made enormous progress because of the introduction of new drugs and the widespread and more effective control of vascular risk factors. The choice of treatment between CEA, CAS, or medical therapy alone for any individual patient with carotid stenosis remains a controversial issue. However, a simple complete method to independently stratify the peri-interventional neurologic outcomes of patients undergoing CAS is still lacking. CEA has been used to treat carotid disease for greater than 50 years. Over this period, CEA was validated by large multicenter randomized clinical trials as an effective method for stroke prevention. Indication for CEA with defined outcomes has markedly improved and technical aspects have evolved but an ideal surgical technique has yet to be determined. Consequently, as a practical matter, most vascular surgeons use a number of technical variations for CEA in their clinical practice and adapt their preference to each particular situation. About carotid artery stenting (CAS), in the last years evolution in both stents and protection devices as well as in carotid stenting techniques, resulted in an important reduction in stroke rate in patients undergoing CAS procedure. But carotid stenting, although a mature technique regularly applied with excellent outcomes in high-volume centers by expert operators, is struggling to find the consensus of the scientific community. A key issue in limiting periprocedural events to the lowest possible is to select the appropriate device for the appropriate patient anatomy and clinical syndrome. An important element of this concept is the recognition of high-risk cases for CAS dependent primarily on the skill of the interventional vascular specialist, a factor that is substantially more relevant in the field of CAS than other areas of percutaneous intervention. Evaluation of different types of interventions, medical therapy, carotid endarterectomy (CEA) or CAS and their continuous evolutions, a tailored approach to the patient is considered now the best treatment in carotid artery stenosis.

An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta that progressively grows until it ruptures. Treatment is typically recommended when the diameter is more than 5 cm. The EVAR (Endovascular aneurysm repair) is a minimally invasive procedure that involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. For years, stent grafts' essential design was based on metallic stent frames to support the fabric. More recently, a polymer-based technology has been proposed as an alternative method to seal AAA. This review underlines the two platforms that are based on a polymer technology: (1) the polymer-filled endobags, also known as Endovascular Aneurysm Sealing (EVAS) with Nellix stent graft; and (2) the O-ring EVAR polymer-based proximal neck sealing device, also known as an Ovation stent graft. Polymer characteristics for this particular aim, clinical applications, and durability results are hereby summarized and commented critically. The technique of inflating endobags filled with polymer to exclude the aneurysmal sac was not successful due to the lack of an adequate proximal fixation. The platform that used polymer to create a circumferential sealing of the aneurysmal neck has proven safe and effective.

Objective: In cases of juxtarenal abdominal aortic aneurysm (jAAA), endovascular aneurysm repair (EVAR) involves the use of custom-made fenestrated stent grafts, which usually need large-diameter access vessels, superior costs, and a certain time between graft planning and delivery. We report our preliminary experience using the bare renal stent technique (called vent) in combination with the ultralow-profile stent graft Ovation (Endologix, Irvine, Calif) to seal jAAAs in patients evaluated to be unfit for open surgery and not suitable for fenestrated endograft. Methods: A single-center retrospective review of jAAAs treated by Ovation vent technique from January 2015 to December 2018 was conduced. The vent procedure consisted of a modified, off-label deployment of the sealing ring of the ultralow-profile Ovation stent graft close to renal orifices in combination with short bare-metal stents. The exclusion criterion was a diameter >31 mm at the level of the lowest renal artery. Early technical and clinical results, estimated midterm survival, renal artery patency, freedom from type IA endoleak, freedom from reintervention, and freedom from neck enlargement (>2 mm) were reported. Results: Overall, 38 patients had jAAA and were considered unfit for open repair and not eligible for fenestrated EVAR. The proximal neck was <5 mm in all cases (mean, 3.3 +/- 1.2 mm). Vent renal stents were implanted bilaterally in 16 patients. Primary technical success was 94.7% (36/38), with satisfactory cannulation of all renal arteries and sealing of the aneurysm in all but two cases because of type IA endoleaks that were treated immediately with success. Primary clinical success at 1 month was 100%. During amedian follow-up period of 22.4 +/- 3.6 months (range, 1-46 months), no abdominal aortic aneurysm-related deaths occurred, and no patient was lost to follow-up. The survival curve at 1 year and 2 years was, respectively, 96.4% and 91.6% (standard error, 0.57%). There were no cases of neck dilation or endograft migration. Freedom from reintervention at 12 months and 24 months was 100% and 89.5%, respectively (standard error, 0.7%); freedom from type IA endoleak was 100% and patency of the renal artery was 100% at 2 years. Conclusions: The described technique includes the use of a low-profile stent graft with a polymer ring sealing technology combined with bare renal stents that are not competing for the same room. This early experience shows that the vent technique is safe and feasible and increases the range of treatment of those patients with jAAA who are unfit for open repair and for fenestrated EVAR because of several anatomic constraints.

BACKGROUND:Cranial and cervical nerve (CCN) injury is recognized as a possible complication after carotid endarterectomy (CEA), which may result in minor local neurologic deficiencies and significant discomfort for the patient. The aim of this study is to investigate the effect of a mini-skin incision (<5 cm) on the CCN injury after CEA in comparison to standard longitudinal incision of 12-15 cm in a high volume center, and to evaluate health-related quality of life (HRQOL) outcomes in those patients who had undergone both types of the skin incision. METHODS:From January 2013 to December 2019, 446 CEAs (47.3%) were performed through a standard neck incision of 12-15 cm (group A), while 496 (52.7%) were performed through a mini-skin incision (<5 cm) (group B). Sixty-two patients underwent standard neck incision on one side and mini-skin incision on the other side (subgroup B). The main outcome measures were stroke, death, CCN injuries, cervical hematoma rates, and reinterventions. The HRQOL was assessed at baseline and after 30 days using Medical Outcomes Study Short-Form 36 and 6 disease-specific modified Likert scales. RESULTS:The stroke and death rate at 30 days was 1.12% in group A and 1% in group B (P = 1). The incidence of CCN deficits was significantly lower in group B (5.1%) in comparison to group A (13.4%) (P < 0.001). The cervical hematoma was more common after standard incision (4.9% vs. 1.2%, P = 0.02). HRQOL at 1 month showed that the outcomes after mini-skin incision were significantly better for less difficulty with eating/swallowing and neck pain (P < 0.01). CONCLUSIONS:CEA through a small incision (<5 cm) may reduce CCN complications without additional perioperative neurologic risks. As validated by patients with bilateral disease who experienced both surgical techniques, mini-skin incision is also associated with better HRQOL at 1 month, particularly with regard to eating/swallowing and neck pain.

Foot ulcers associated with Diabetes mellitus require immediate attention due to risk of amputation if left untreated. Herein we focus on the mitigating risk factors and physiopathology of the diabetic foot, recounting our own surgical approach and revascularization procedures.

Nowadays patients affected by deep vein thrombosis (DVT) and pulmonary embolism (PE) are studied widely but the challenge for physicians is when and how they are to be treated. Most patients present serious comorbidities that can potentially make treatment difficult. An increasing cohort of patients cannot be treated with systemic fibrinolysis but fortunately today, physicians can utilize a number of different instruments to resolve acute DVT and PE.

BACKGROUND:Endovascular repair of abdominal aortic aneurysm (EVAR) presents an increasing role in treatment of abdominal aortic aneurysms in patients at high and mid risk for conventional surgery. Most Vascular Surgery Units need to identify a single device as workhorse in AAA treatment. Objective of this study is to analyze midterm results of consecutive unselected patients treated with the same device in a single center series.METHODS:A retrospective analysis of a prospective database of all consecutive patients treated between January 2016 and June 2019 with the TREO device in our center. Primary outcomes of the study were AAA related mortality rate, migration rate and type 1 endoleak at 1-year follow-up.RESULTS:During the study period 71 consecutive patients (96% male) were treated with TREO device. Technical success was achieved in all patients. Mean follow-up was 19.6 months (range: 1-42 months). Procedure related mortality was 1.4% (N.=1), No AAA related mortality, migration or type 1b endoleak were recorded during follow-up. Two cases of late type 1a endoleak were recorded, both resolved with aortic cuffing. Median shrinkage of the residual sac was 10% and 18.5% at 6 and 18 months, respectively.CONCLUSIONS:EVAR using TREO device seems to be safe and effective treatment for unselected patients suffering AAA. Particularly this device seems to be suitable as workhorse device in a single center with skillness between open and endovascular techniques.

Cell angiogenic therapy performed by the implantation of autologous peripheral blood mononucleate cells has demonstrated safety and efficacy in the treatment of critical limb ischemia in patients who are not candidates for revascularization. The aim of our study was to evaluate the safety and the adjuvant validity of angiogenic therapy in unrevascularizable chronic limb-threatening ischemia. From February 2017 to May 2019, there were 35 patients with unrevascularizable chronic limb-threatening ischemia who underwent infiltration of mononuclear cells from peripheral blood. We have used the monocell selective filtration system that allows us to produce the concentrate directly in the operating room at the time of the procedure, without any manipulation, in conditions of absolute sterility. From each patient, 100 mL of peripheral blood was taken to obtain 10 mL of cellular concentrate subsequently inoculated by 30 to 45 injections, each of 0.25 mL, 1 to 2 cm deep in the ischemic muscle along the anatomic course of the main vessels of the leg. This operation was repeated three times at a distance of 30 to 45 days apart from each other. Our follow-up includes weekly clinical checks (lesion surface, resting pain, transcutaneous oxygen pressure detection, and quality of life scale evaluation). There were no adverse events (death, major cardiovascular events, anemia) or limb amputations in the observation period. In all the treated patients, there was a reduction in pain on the visual analog scale compared with the baseline mean value (−14.5% after the first cycle, −45.4% after the second cycle, −72.7% after the third cycle), a reduction in the average area of ulcers (−27% after the first cycle, −48% after the second cycle, and −68% after the third cycle), and an increase in transcutaneous oxygen pressure compared with the baseline mean value from +19% after the first cycle to +72% after the third cycle. All patients reported improved quality of life. Therapeutic angiogenesis appears to be a safe and potentially effective adjuvant strategy in patients with unrevascularizable chronic limb-threatening ischemia. Although our case series is still limited, the preliminary results encourage us to continue the ongoing program.

Introduction: The purpose of the following research was to provide a systematic survey on the use of additive manufacturing in vascular surgery. The survey focuses on applications of 3D printing in endovascular surgery like endovascular aneurysm repair (EVAR), a quite unexplored application domain. 3D printing is an additive production process of three-dimensional objects starting from a three-dimensional digital model. This kind of manufacturing process is getting great attention in the medical field and new applications have emerged in recent years especially thanks to the combination of additive printing with 3D imaging techniques. The purpose of the study is to reflect on additive manufacturing and its potential as an inclusive manufacturing practice which can provide benefits at economic and societal level. Evidence acquisition: The article first introduces the use of 3D printing in surgery by summarizing the results of previous reviews which reveal three main usages of 3D printing: anatomic models, surgical tools, implants and prostheses. These studies point out that vascular surgery is still an unexplored field of application of 3D printing. Starting from this result, a new survey was carried out in databases Pubmed, Elsevier, Research Gate and ACM Digital Library for terms related to 3D printing in vascular surgery using the following keywords: 3D printing, vascular surgery, EVAR, aneurysm. The search screened articles published up to 2019 for relevance and practical application of the technology in vascular surgery, in particular the topic is related to the treatment of complex abdominal aortic aneurysm. Evidence synthesis: Initially 437 records published up to 2019 were found, but then were narrowed down to 29 full-text articles. The findings reveal that in addition to the applications found in the previous studies, new experiments are ongoing related to the use of 3D printing in the "Off label' practice to manually fenestrate the stein to improve the accuracy of the EVAR. Conclusions: Different applications of the use of 3D printing and digital imaging in vascular surgery have been experimented with a different maturity level. Whilst the technology has increased its potential in the latest years, the number of studies documented in the literature is still quite narrow. Further research is necessary to fully test the potential of 3D printing, also in combination with other technologies (e.g. 3D imaging and CNC cutting). Early experimentations show that these technologies have the potential to radically change the vascular surgery practice in the near future, in particular in treatment like EVAR, to improve the planning and therefore the success of the surgery.

Introduction: Venous thromboembolism, which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), poses a global disease burden. New mechanical thrombus removal devices could represent a safe and effective treatment for acute PE, especially in patients with absolute contraindication to thrombolysis, resulting in high technical and clinical success of this procedure[i] . Moreover coexisting DVT could be treated with thrombus removal devices avoiding caval filter deployment. Aim of this study is to assess the feasibility of aspiration mechanical thrombectomy of massive or submassive PE and DVT, in a single session, in patients with contraindications to thrombolysis. Methods: In two centers, from April 2017 to April 2018, we prospectively enrolled all patients with contraindications to thrombolysis, suffering from DVT and massive or submassive PE according to ESC and AHA guidelines, undergone simultaneous mechanical thrombectomy of both pulmonary arteries and deep peripheral veins. All procedures were approved by our institutional review board and a written informed consent was obtained from all patients when possible. Exclusion criteria were: low risk PE and eligibility for first-line thrombolytic treatment. All patients included in the study were proved to have acute PE based on clinical and radiological findings, according to the presence of proximal arterial PE at computed tomography angiography (CTA) and DVT based on ultrasound and CTA. RV/LV ratio was measured from CTA using a four-chamber views on a dedicated workstation, before trombectomy, postoperatively and at 12 months follow-up. SpO2, Heart Rate (HR), and ultrasound venous examination were recorded at 12 months follow-up. Technical success was defined as pulmonary arterial systolic pressure reduction at 50% from the initial value for PE treatment and direct visualisation of thrombus significant reduction (> 70%) in peripheral DVT. Results: Six patients (2 male) were enrolled in our study. Mean age was 76 (55-91). All patients required before treatment high volume O2 therapy, with mean SpO2 of 85.8 (82-90), mean heart rate of 72.5 (42-100) and mean RV/LV of 1.37 (1.2-1.8). Contraindications for first-line thrombolytic treatment were: recent stroke in 4 cases, known bleeding risk in 1 case and brain metastasis in 1 case. Two patients presented popliteal residual DVT, 3 patients femoral DVT and 1 patient iliac DVT. No procedural or periprocedural complications were observed. PE technical success was achieved in all patients, peripheral venous revascularisation was effective in 4 patients, in two patients mechanical aspiration was unable to solve the subacute thrombosis and no further treatment was attempt. At 12 months follow up only 1 patient required 1L O2 therapy with mean SpO2 of 91.8 mmHg (90-94), mean heart rate of 68,3 (63-73) and mean RV/LV ratio of 0,90 (0,85-0,95). Vein ultrasound examination revealed that 4 patients still had patent veins, while in uneffective peripheral veins aspiration a chronic DVT was evident. Conclusion: In our preliminary series simultaneous treatment of DVT and PE is safe and effective. Low rate of complications encourage extensive use of this technique in selected patients, however larger prospective studies are needed to assess the feasibility of this treatment. Disclosure: Nothing ti disclose

The aim of this study was to assess the feasibility of aspiration mechanical thrombectomy of massive or submassive pulmonary embolism (PE) and deep venous thrombosis (DVT), in a single session, in patients with contraindications to thrombolysis. In two centers, from April 2017 to April 2018, we prospectively enrolled all patients with contraindications to thrombolysis, suffering from DVT and massive or submassive PE, who had undergone simultaneous mechanical thrombectomy of both pulmonary arteries and deep peripheral veins. All patients included in the study were proved to have acute PE on the basis of clinical and radiologic findings according to the presence of proximal arterial PE at computed tomography angiography (CTA) and DVT based on ultrasound and CTA. Right ventricular/left ventricular (RV/LV) ratio was measured from CTA using four-chamber views on a dedicated workstation before thrombectomy, postoperatively, and at 12 months of follow-up. Oxygen saturation as measured by pulse oximetry (Spo2), heart rate, and ultrasound venous examination were recorded at 12 months of follow-up. Technical success was defined as pulmonary arterial systolic pressure reduction at 50% from the initial value for PE treatment and direct visualization of thrombus significant reduction (>70%) in peripheral DVT. Six patients (two male) were enrolled in our study. Mean age was 76 years (55-91 years). Before treatment, all patients required high-volume oxygen therapy, with mean Spo2 of 85.8 (82-90), mean heart rate of 72.5 (42-100), and mean RV/LV of 1.37 (1.2-1.8). No procedural or periprocedural complications were observed. PE technical success was achieved in all patients, and peripheral venous revascularization was effective in four patients; in two patients, mechanical aspiration was unable to solve the subacute thrombosis, and no further treatment was attempted. At 12 months of follow-up, only one patient required 1 L of oxygen therapy with mean Spo2 of 91.8 mm Hg (90-94), mean heart rate of 68.3 (63-73), and mean RV/LV ratio of 0.90 (0.85-0.95). Vein ultrasound examination revealed that four patients still had patent veins; in ineffective peripheral vein aspiration, a chronic DVT was evident. In our preliminary series, simultaneous treatment of DVT and PE is safe and effective. A low rate of complications encourages extensive use of this technique in selected patients. However, larger prospective studies are needed to assess the feasibility of this treatment.

BACKGROUND:Acute lower limb ischemia (ALLI) poses a major threat to limb survival. For many years, surgical thromboembolectomy was the mainstay of treatment. Recent years have brought an endovascular revolution to the management of ALLI. It seems that the newly designed endovascular thrombectomy devices may shift treatment recommendations toward endovascular options. This protocol study aims to collect evidence supporting the latest hypothesis.OBJECTIVE:The devices under investigation are the Penumbra/Indigo Systems (Penumbra Inc). The objective of this clinical investigation is to evaluate, in a controlled setting, the early safety and effectiveness of the devices and to define the optimal technique for the use of these systems in patients with confirmed peripheral acute occlusions.METHODS:This study will be an interventional prospective trial of patients with a diagnosis of ALLI treated with Penumbra/Indigo devices. This project is intended to be a national platform where every physician invited to participate could register his or her own data procedure. The primary outcome is the technical success of thromboaspiration with the Indigo System. Assessment of vessel patency will be recorded using the Thrombolysis in Myocardial Infarction (TIMI) score classifications before and after use of the device. Clinical success at follow-up is defined as an improvement of Rutherford classification at 1-month follow-up of one class or more as compared to the preprocedure Rutherford classification. Secondary endpoints include the following: (1) safety rate at discharge, defined as the absence of any serious adverse events; (2) primary patency at 1 month, defined as a target lesion without a hemodynamically significant stenosis or reocclusion on duplex ultrasound (>50%) and without target lesion reintervention within 1 month; and (3) limb salvage at 1 month.RESULTS:The study is currently in the recruitment phase and the final patient is expected to be treated by the end of March 2019. A total of 150 patients will be recruited. Analyses will focus on primary and secondary endpoints.CONCLUSIONS:These new endovascular thrombectomy devices that are specifically designed for peripheral intervention in this difficult set of patients, as those under investigation in the proposed registry, may offer improved clinical outcomes with lower rates of major systemic and local complications. Following completion of this study, it is expected that the value of the Indigo Thrombectomy System in the treatment of ALLI will be better defined. As a result, a shift of treatment recommendations toward endovascular options may be observed in the near future.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/9972.

At the beginning of the endovascular aortic repair (EVAR) era, a large number of patients were denied endovascular treatment as challenging proximal neck and narrow access vessels were responsible for EVAR ineligibility in more than 50% of cases. Since then, stent-graft technology has evolved rapidly, limitations of earlier-generation devices have been overtaken, and EVAR eligibility has increased enormously. Still, in patients with complex aortic necks, proximal graft sealing remains a challenge with traditional self-expandable endograft. This chapter focuses on the evolution over the years of endografts, in terms of profile and adaptability to challenging infrarenal aortic neck. The final section of the chapter is dedicated to the VENT procedure, a particular EVAR technique that combines the Ovation endograft implantation with open bare-metal stent in the renal arteries and offers a treatment option for patients with unfit challenging neck for traditional endograft.

Objective: The objective of this study was to compare outcomes of patients with favorable neck angulation (FNA) and hostile neck angulation (HNA) treated with the Treovance stent graft (Terumo Aortic [formerly Bolton Medical], Sunrise, Fla). Methods: Patients with abdominal aortic aneurysms suitable for endovascular repair with Treovance were included in the RATIONALE postmarket surveillance registry. A post hoc subgroup analysis compared patients with infrarenal neck angles <60 degrees (FNA) and >= 60 degrees (HNA). Results: After 1 year, 179 FNA (89.5%) and 21 HNA (10.5%) patients were analyzed. Both groups were similar in terms of sex (male, 92.7% FNA and 95.2% HNA) and age (73.0 years vs 72.6 years), but the HNA group had more Asian or other race representation (7.3% vs 19.0%) and more patients assigned to American Society of Anesthesiologists class 3 and class 4 (57.6% vs 66.7%). Mean suprarenal angles (standard deviation) were 13.1 (+/- 613.5) degrees vs 29.0 (+/- 16.4) degrees; mean infrarenal angles were 23.2 (+/- 16.4) degrees vs 65.4 (+/- 4.6) degrees, respectively. Aneurysm sac size maximumdiameter was 58.1 (+/- 9.8) mm vs 62.0 (+/- 14.1) mm. There was a significant difference in unplanned adjunctive procedures (2.2% vs 19.0%; P = .01). Mean procedural duration was also significantly different for HNA patients, who underwent protracted operations (111.3 [647.3] minutes vs 153.5 [+/- 44.5] minutes; P <.0001). However, there were no significant differences in rates of clinical success (96.1% vs 95.2%). The rate of reintervention was low overall but 0% in the HNA group. Changes in sac size at 1 year were significant in both groups but not as pronounced in HNA patients (relative change of -11.8% [+/- 13.3] vs -6.6% [+/- 11.4]). Conclusions: Patients with high neck angulation treated with Treovance underwent more complex procedures but showed equally good technical success and 1-year clinical success parameters.

Spinal cord protection is still the Achilles’ heel of both open and endovascular aortic repair. The latest knowledge of the spinal cord vascular anatomy with the “collateral network concept” has led to the development of a series of adjuncts that aim to reduce the risk of spinal cord ischaemia.

Multicenter clinical trials level 1 evidence favors the application of carotid endarterectomy in symptomatic patients, especially the in the elderly cohort. Carotid artery stenting has been proposed as a possible early alternative in selected patients after onset of ipsilateral neurologic symptoms. It is well known that treatment of acute stroke is time-dependent in patients with acute ischemic stroke caused by high-grade stenosis of the internal carotid artery, but intensive medical treatment in conjunction with intervention to improve stroke severity and clinical outcomes has not been established. Two major clinical concerns exist: (1) the risk of hemorrhagic infarction after cerebral revascularization in the acute stage and (2) application of carotid stenting in the acute embolic stage, which may be associated with continued embolic risk after carotid artery stenting compared to carotid endarterectomy, which removes the symptomatic plaque. This review summarizes the indications and results of early carotid artery stenting after onset of neurologic symptoms, considering the new carotid stents and cerebral protection systems available for clinical use and enhanced stenting techniques.