(Circulation. 2001;103:532.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Immediate and Late Clinical Outcomes of Carotid Artery Stenting in Patients With Symptomatic and Asymptomatic Carotid Artery Stenosis
A 5-Year Prospective Analysis
Presented in part at the 72nd Scientific Sessions of the American Heart Association, Atlanta, Ga, November 7–10, 1999, and published in abstract form (Circulation. 1999;100[suppl I]:I-674).
From Lenox Hill Heart and Vascular Institute, New York, NY (G.S.R., G.N., S.S.I., J.J.V., N. Al-M.); Division of Cardiovascular Disease, Department of Medicine and Department of Neurology, University of Alabama at Birmingham, Birmingham (M.W.L., C.G.); Cleveland Clinic, Cleveland, Ohio (J.Y.); and Brigham and Women’s Hospital, Boston, Mass (R.E.K.).
Correspondence to Gary S. Roubin, MD, PhD, Director, Endovascular Therapy, Lenox Hill Heart and Vascular Institute, 130 E 77th St, New York, NY 10021. E-mail 110775.2410{at}compuserve.com
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionReferences |
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Background—Carotid stenting is a less invasive percutaneous procedure than carotid endarterectomy for the treatment of carotid stenosis. Reports suggest that it can be performed with periprocedural complication rates similar to those of carotid endarterectomy. The purpose of this study was to determine short- and long-term outcomes in the largest prospective cohort of carotid stenting patients.
Methods and
Results—This study followed 528 consecutive
patients (604 hemispheres/arteries) undergoing carotid stenting. There
was a 0.6% (n=3) fatal stroke rate and 1% (n=5) nonstroke death rate
at 30 days. The major stroke rate was 1% (n=6), and the minor stroke
rate was 4.8% (n=29). The overall 30-day stroke and death rate was
7.4% (n=43). Over the 5-year study period, the 30-day minor stroke
rate improved from 7.1% (n=7) for the first year to 3.1% (n=5) for
the fifth year (P<0.05 for
trend). The best predictor of 30-day stroke and death was age 
80
years. After the 30-day period, the incidence of fatal and nonfatal
stroke was 3.2% (n=31). On Kaplan-Meier analysis, the 3-year freedom
from ipsilateral or fatal stroke was
92±1%.
Conclusions—Experience from a single group of operators demonstrates that carotid stenting can be performed with an acceptable 30-day complication rate. Late follow-up also demonstrates a low rate of fatal and nonfatal stroke. These results suggest that carotid stenting may be comparable to carotid endarterectomy, and it underscores the clinical equipoise and premise for the National Institute of Health–supported, randomized Carotid Revascularization Endarterectomy Versus Stent Trial comparing carotid stenting with carotid endarterectomy.
Key Words: stents • stenosis • stroke
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Approximately 600 000 people suffer a stroke each year in the United States. This leads to nearly 160 000 deaths and leaves many more people with major disability.1 The advantage of carotid endarterectomy (CEA) over medical therapy in patients with significant carotid stenoses has been established in recent randomized studies.2 3 4 Carotid stenting (CS) is a less invasive percutaneous procedure that has been under investigation in the United States since 1994.5 CS may allow avoidance of some of the perioperative complications of CEA. The National Institute of Health/National Institute of Neurological Disorders and Stroke recently approved funding for the Carotid Revascularization Endarterectomy Versus Stent Trial (CREST), a multicenter, randomized trial, to compare these 2 techniques.6 The success of recruitment in this trial will depend on evidence for "clinical equipoise—genuine uncertainty within the expert medical community about the preferred treatment." 7 Preliminary reports suggest that CS can be performed with an acceptable 30-day complication rate.8 9 10 11 12 13 14 15 16 Whether CS is a reasonable alternative to CEA and thus should be compared directly depends on more definitive evidence. This prospective study on outcomes after CS was undertaken to better define the incidence of immediate and late stroke in a large series of patients.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Patient Population
From September 8, 1994, through September 8, 1999, 528 consecutive patients (604 hemispheres/arteries) underwent CS at the University of Alabama at Birmingham Hospital and subsequently at Lenox Hill Hospital (performed by G.S.R., S.S.I., and J.J.V.). The outcomes in the first 107 patients in this report have been published previously.8 Small analyses in various subgroups have also been reported.17 18 19 Carotid stenosis was located at the extracranial internal carotid artery (ICA) at the bifurcation (n=565), proximal common carotid artery (CCA; n=34), separate stenoses of the ICA (at the bifurcation) and proximal CCA artery (n=3), or a functional external carotid artery (Fx-ECA; ie, occluded ICA and patent ECA that supplies ipsilateral middle cerebral artery via ophthalmic collaterals; n=2). Although not strictly bifurcational disease and not commonly treated by CEA, CCA and Fx-ECA lesions were included because the procedure may have a similar clinical sequel.
Patients were required to have either symptomatic (50%
diameter) or asymptomatic (60% diameter) stenosis of the carotid
artery. "NASCET ineligible" patients were defined as those
symptomatic patients who were ineligible for enrollment according to
the exclusion criteria of the North American Symptomatic Carotid
Endarterectomy Trial (NASCET; >79 years of age, prior CEA, atrial
fibrillation, etc).20
Patients were excluded if they had a major neurological deficit or any
other illness impeding informed consent, severe renal insufficiency
(serum creatinine >3.0 mg/dL), or peripheral vascular disease
precluding femoral artery access. Over the study period, selection
criteria and techniques were modified as immediate outcomes were
analyzed. Patients with severe diffuse atherosclerosis of the CCA,
chronic total occlusions, and long preocclusive lesions ("string
sign" lesions) were excluded. All patients were studied under
Institutional Review Board–approved protocols at the above
institutions, and all patients gave written informed consent to
participate. The risks and benefits of CS were explained. The operator
informed patients that they were undergoing an investigational
procedure, told them about the proven efficacy of CEA in randomized
trials, and offered them this treatment as an
alternative.
CS Technique
Preprocedural Protocol
Patients were referred to our institutions after a
carotid stenosis was suspected on screening. A CT scan or MRI of the
brain was performed to establish a baseline. All patients were
premedicated with aspirin 325 mg BID and a thienopyridine derivative
(ticlopidine 250 mg BID or clopidogrel 150 mg BID) for 2 days before
the procedure. Patients had a history, an examination, and laboratory
investigations performed. An NIH Stroke Scale was performed before and
within 24 hours after the procedure by a board-certified
neurologist.
Angiography and CS Technique
No sedation was given before or throughout the
procedure. Neurological assessment was performed at predetermined
intervals throughout the procedure. Hemodynamics and oxygen saturation
were continuously monitored. Nitroglycerin, atropine, metaraminol, and
dopamine were administered as required to manage hypertension,
bradycardia, and hypotension.
Cervical-cerebral angiography was performed according to standard techniques. Intracranial views determined the patency of the circle of Willis. This allowed us to anticipate those patients who had a contralateral occlusion and/or an "isolated hemispheric blood supply" and therefore may not tolerate carotid artery occlusion. The principles of CS have been described.21 Patients were usually discharged the next day after examination by a neurologist and were prescribed ticlopidine or clopidogrel and aspirin 325 mg BID for 4 weeks and aspirin thereafter for the rest of their lives.
Data Collection and Patient Follow-Up
Quantitative carotid angiography was performed on all
arteries before and after stenting. Diameter stenosis was determined
according to NASCET
criteria.20
Clinical follow-up (mean±SD, 17±12 months) was available on 518 (99.6%) of the 520 patients who survived the periprocedural period. Follow-up phone interviews were conducted at 1 month and at 6-month intervals thereafter by a dedicated research coordinator. Patients were instructed to notify the coordinator if symptoms suggestive of a neurological event occurred. When a neurological event occurred, CT of the head was performed, and the physician was contacted to accurately document the episode. Hospital discharge diagnoses were also reviewed to adjudicate events. When a death occurred, the cause of death was obtained from the death certificate or postmortem.
A board-certified neurologist performed an NIH Stroke Scale
24 hours after the procedure. A transient ischemic attack was
defined as a focal retinal or hemispheric event from which the patient
made complete recovery within 24 hours. A minor nonfatal stroke was
defined as a new neurological deficit that either resolved completely
within 30 days or increased the NIH Stroke Scale by 
3. A major
nonfatal stroke was defined as a new neurological deficit that
persisted >30 days and increased the NIH Stroke Scale by 4.
Long-term outcomes are reported as neurological events and deaths. A
fatal stroke was defined as death attributed to an ischemic stroke or
intracerebral hemorrhagic stroke and did not include brain tumors or
death resulting from head trauma.
Statistical Analysis
Data are expressed as mean±SD. All probability
values were 2 tailed, and values of
P<0.05 were considered
statistically significant. Comparisons of 30-day outcomes included men
versus women, <80 versus 80 years of age, and symptomatic versus
asymptomatic patients (
2 analysis).
Logistic regression analysis was performed to determine predictors of
30-day stroke and death. A 2 test of
trend was performed on the 30-day death and stroke rates by calendar
year to evaluate differences in outcomes over the study period. Time to
treatment failure was analyzed by Kaplan-Meier methods and a log-rank
statistic for symptomatic versus asymptomatic patients, patients 80
versus patients <80 years of age, and male versus female
patients.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Patient Characteristics
The clinical characteristics of all the patients are shown in Table 1
.
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Angiographic and Stenting Results
Two hundred seventy patients had bilateral carotid
artery disease (50% stenosis), with 61 arteries (10%) having an
occlusion of the contralateral ICA. Seventy-six patient (15%) had
bilateral carotid artery stenting, with 30 being performed in the same
procedure.
The mean stenosis before stenting was 74±14%. Seven arteries were total occlusions. The mean stenosis after stenting was 5±9%. On average, 1.2±0.6 stents were used per vessel, with 424 (70%) being self-expanding and the remainder being balloon-expandable stents. There was significant compromise of the origin of the ECA in 11 arteries that required treatment with angioplasty in the same procedure (not considered separate arteries). There were 12 technically unsuccessful procedures (2%) in which a carotid stent was unable to be delivered: 9 resulting from inadequate guiding sheath placement, 2 from air embolism, and 1 from inability to cross the lesion with a wire. One patient (0.2%) had a minor stroke after an air embolism. One patient (0.2%) had a major ipsilateral nonfatal stroke after a failed attempt to deliver a stent.
Thirty-Day Outcomes
Thirty-day stroke and death rates are listed in
Table 2. There was 1 periprocedural acute non–Q-wave
myocardial infarction. Symptomatic and asymptomatic patients had
similar 30-day outcomes (8.2% versus 6.3%, respectively;
P=0.47). Male and female
patients also had similar periprocedural complication rates (8.0%
versus 5.9%, respectively;
P=0.4). However, patients 80
years of age had higher rates of major nonfatal stroke compared with
those <80 years old (see
Table 3).
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|
Table 4 shows the reduction in periprocedural events over
the 5 years of this study. There was a decreasing trend in the minor
nonfatal stroke rate from the first through the fifth year of the study
(P<0.05 for trend). On
logistic regression analysis, age 80 years (OR, 3.64; 95% CI, 1.7 to
7.69) and a history of hypertension (OR, 3.45; 95% CI, 1.17 to 10.10)
were the only predictors of 30-day events.
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Late Follow-Up
After the 30-day periprocedural period, the incidence
of late fatal and nonfatal stroke was 3.2% (see
Table 5). In this series, 16 patients (3%) required
repeated angioplasty for restenosis. Two patients (0.3%) required CEA,
1 for a failed attempt at CS and 1 for restenosis. There were 75 late
nonneurological deaths (mainly attributed to cardiac disease and
cancer), and 2 deaths of indeterminate cause.
|
The 3-year freedom from all fatal and nonfatal strokes was
88±2% (mean±SE;
Figure 1A). Among those who survived the 30-day
periprocedural period, the 3-year freedom from all fatal and nonfatal
strokes was 95±2%;
Figure 1B). Similarly, the 3-year freedom from all fatal and
ipsilateral nonfatal strokes with and without the inclusion of 30-day
periprocedural period was 92±1% and 99±1%, respectively
(Figure 2). The 3-year freedom from all fatal and nonfatal
strokes including and excluding 30-day periprocedural period for <80
versus 80 years of age was 90±2% versus 73±4%
(P<0.0001) and 95±2% versus
91±1% (P<0.01), respectively
(Figure 3). There were no differences in freedom from stroke
between men and women and symptomatic and asymptomatic
patients.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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CS may provide an alternative to CEA, especially in those patients deemed to be at higher risk for endarterectomy. The short-term results derived from the largest series reported to date confirm other reports that suggest that the procedure can be performed with an acceptable complication rate.8 9 10 11 22 The long-term durability of CS, however, has not been previously examined. In this large series by a single group of operators, the high freedom from ipsilateral stroke at 3 years suggests that CS is durable and efficacious.
CS is now being performed in many centers around the world with low complication rates.9 10 11 Data from a worldwide registry reported a technical success rate of 98.4%, an overall minor stroke rate of 2.72%, a major stroke rate of 1.49%, and a mortality rate of 0.86%.22 Although techniques vary slightly between operators and centers, these results are concordant with the findings of this study, which suggest that CS can be carried out with acceptable procedural outcomes.
The only randomized study to date, the Carotid and
Vertebral Artery Transluminal Angioplasty Study (CAVATAS), comparing
carotid angioplasty (with bailout stenting in 26%) and CEA,
demonstrated similar periprocedural stroke rates for the 2 groups (10%
and 9.9%, respectively).23
Meaningful comparison of the results of this present study with
complication rates from published CEA studies is limited by differences
in case mix, completeness of neurological evaluation, and
nonstandardized end points. In particular, a large proportion of
symptomatic patients in this study were NASCET
ineligible.20 Nonetheless,
stroke rates after CS appear to be in a range similar to those observed
in randomized trials of CEA for symptomatic patients. In NASCET, the
30-day minor stroke rate was 4.0%, major stroke rate was 1.6%,
mortality rate was 1.2%, and overall stroke and death rate was 6.7%
in patients with symptomatic carotid stenosis (50% diameter
stenosis) randomized to the CEA
arm.4 The Veterans Affairs
Cooperative Study (VACS) also reported a 6.5% 30-day stroke and death
rate,24 and the European
Carotid Stent Trial (ECST) reported an overall 7.0% major stroke and
death rate in patients with symptomatic carotid
stenosis.2 For asymptomatic
patients, comparison is particularly difficult. The Asymptomatic
Carotid Atherosclerosis Study (ACAS) reported a periprocedural stroke
and death rate of 2.3% in a lower-risk
subset,3 and the asymptomatic
surgical group in VACS suffered a 4.7% permanent stroke and death
rate.25
This study demonstrated that symptomatic patients and asymptomatic patients had similar periprocedural complication rates after CS. The results in asymptomatic patients appear to be higher than that reported in ACAS. However, although criteria for symptom status are the same, differences may exist in other criteria, such as patient age and comorbidity, between the asymptomatic patients in this series and the patients in the CEA trials.3 25 26 In the latter part of the present study, complication rates for symptomatic patients fell within American Heart Association/Society of Vascular Surgery guidelines,27 whereas procedural outcomes for asymptomatic patients exceeded the recommended 3% upper limit based on ACAS results.26 During the last 2 years of the study, asymptomatic patients <80 years of age had a periprocedural complication rate of 3.5%. Again, these results cannot be directly compared with results of CEA. Whether future technical improvements, such as the use of distal-protection devices10 during stenting, will improve periprocedural outcomes for both asymptomatic and symptomatic patients remains to be determined. The potential advantages of CS over CEA include avoidance of neck wound complications and cranial nerve palsies and a reduction in periprocedural myocardial infarction. In the present study, 1 patient (0.2%) experienced a myocardial infarction. In contrast, the NASCET study reported a 3.9% myocardial infarction rate, an 8.9% wound complication rate, and a 7.6% cranial nerve palsy rate.20
Long-term survival curves in the symptomatic patients in this present series demonstrate an 11% fatal and nonfatal stroke rate estimated at 3 years. In CAVATAS, in which 96% of patients were symptomatic, the 3-year freedom from ipsilateral stroke and death was similar between the angioplasty and CEA groups.23 NASCET, on the other hand, reported a 15.8% 2-year any stroke or death rate and an 8.0% major stroke or death rate.
Long-term survival curves in the asymptomatic group in this study demonstrated a 14% fatal and nonfatal stroke rate at 3 years. In asymptomatic patients, ACAS reported a 5-year stroke or death rate of 20.7%. Moreover, in this study, symptom status was not a predictor of periprocedural or late neurological events. Of importance, the need for repeated intervention was low in this cohort. This is consistent with the low angiographic restenosis rates reported by our group and that of others.8 10 11
Similar periprocedural and late outcomes were observed for men and women in this study. This is in contrast to randomized and observational reports of CEA, which have consistently demonstrated poorer outcomes for women.2 3 4 28 Much of the sex difference can be attributed to the higher periprocedural complication rate rendering the long-term risk benefit ratio not in favor of surgical treatment for females. Perhaps CS may eliminate this sex dimorphism commonly observed in cardiovascular disease.
This study included patients who were 80 years of age. Age
80 years was a predictor of periprocedural events and late stroke. No
comparison from randomized CEA trials can be made because age 80
years was one of the exclusion
criteria.2 3 29
Observational data reported for CEA, however, concur with our results
and demonstrate an increased risk of stroke for patients >75 years of
age.30 The use of distal
protection devices may improve periprocedural outcomes in this
high-risk
group.10 31 Since
this analysis was completed, we have performed CS in patients 80
years of age only with the aid of distal neuroprotection
devices.
Study Limitations
This prospective study cannot be comparable to reported
trials and series of CEA because of confounding factors that may make
patients at higher or lower risk. This will ultimately be tested in
randomized trials. In this study, stroke rate was calculated using the
number of hemispheres/arteries treated, rather than the number of
patients, as the denominator. Although this is a departure from the
conventional method of reporting strokes in trials of CEA, it may be a
more accurate reflection of outcomes from this procedure. Seventy-six
patients had bilateral stenting, with the potential for bilateral
neurological complications to occur. This is in contrast to CEA trials
in which patients were usually excluded if a bilateral procedure was
required, thereby reducing the possibility of bilateral neurological
events.3 20 We
have, however, shown both methods for calculating periprocedural events
in
Table 2
. Similarly, Kaplan-Meier survival curves were
analyzed in terms of fatal and nonfatal strokes rather than strokes and
all-cause deaths as reported in trials of CEA. Selection criteria in
these trials typically precluded patients with any serious illness
deemed to be life
limiting.3 20 32
The present study did not exclude patients with other life-threatening
diseases, such as cancer, lung disease, and coronary ischemia.
Therefore, long-term survival analyses in terms of all-cause deaths may
reflect the level of comorbidity of the study population more than
efficacy of this technique.
Conclusions
This large cohort of patients undergoing CS
demonstrates acceptable 30-day periprocedural complications and a low
incidence of late stroke. These results underscore the need to validate
this less invasive procedure against CEA, the current "gold
standard," surgically proven treatment for carotid artery disease.
The National Institute of Neurological Disorders and Stroke–sponsored,
multicenter, randomized CREST study will begin recruitment of patients
at the end of 2000. The immediate and late results from the present
study support the "clinical equipoise" necessary to begin
randomization.
|
Acknowledgments |
|---|
We would like to thank Thomas Brott, MD, for his critique of the manuscript and acknowledge Virginia Yates, Diana Alred, Kimberley Kretzer, and Emily Lawrence for their assistance.
|
Footnotes |
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Drs Roubin and New contributed equally to this article.
Received July 24, 2000; revision received September 7, 2000; accepted September 13, 2000.
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C. Setacci, E. Chisci, F. Setacci, F. Iacoponi, and G. de Donato Grading Carotid Intrastent Restenosis: A 6-Year Follow-Up Study Stroke, April 1, 2008; 39(4): 1189 - 1196. [Abstract] [Full Text] [PDF]
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M. K. Eskandari Preventable Complications of Carotid Stenting Perspectives in Vascular Surgery and Endovascular Therapy, March 1, 2008; 20(1): 17 - 25. [Abstract] [PDF]
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H.W. Pyun, D.C. Suh, J.K. Kim, J.S. Kim, Y.J. Choi, M.-H. Kim, H.R. Yang, Y.M. Jang, M.-S. Ko, E.Y. Cha, et al. Concomitant Multiple Revascularizations in Supra-Aortic Arteries: Short-Term Results in 50 Patients AJNR Am. J. Neuroradiol., November 1, 2007; 28(10): 1895 - 1901. [Abstract] [Full Text] [PDF]
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J. Van der Heyden, M. J. Suttorp, E. T. Bal, J. M. Ernst, R. G. Ackerstaff, J. Schaap, J. C. Kelder, M. Schepens, and H. W. Plokker Staged Carotid Angioplasty and Stenting Followed by Cardiac Surgery in Patients With Severe Asymptomatic Carotid Artery Stenosis: Early and Long-Term Results Circulation, October 30, 2007; 116(18): 2036 - 2042. [Abstract] [Full Text] [PDF]
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E. R Mohler III Carotid stenting for atherothrombosis Heart, September 1, 2007; 93(9): 1147 - 1151. [Full Text] [PDF]
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M. Maynar, S. Baldi, R. Rostagno, T. Zander, M. Rabellino, R. Llorens, J. Alvarez, and F. Barajas Carotid Stenting without Use of Balloon Angioplasty and Distal Protection Devices: Preliminary Experience in 100 Cases AJNR Am. J. Neuroradiol., August 1, 2007; 28(7): 1378 - 1383. [Abstract] [Full Text] [PDF]
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R. Hofmann, A. Niessner, A. Kypta, C. Steinwender, J. Kammler, K. Kerschner, M. Grund, F. Leisch, and K. Huber Risk Score for Peri-Interventional Complications of Carotid Artery Stenting Stroke, October 1, 2006; 37(10): 2557 - 2561. [Abstract] [Full Text] [PDF]
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A. Cremonesi, C. Setacci, A. Bignamini, L. Bolognese, F. Briganti, G. Di Sciascio, D. Inzitari, G. Lanza, L. Lupattelli, S. Mangiafico, et al. Carotid Artery Stenting: First Consensus Document of the ICCS-SPREAD Joint Committee Stroke, September 1, 2006; 37(9): 2400 - 2409. [Abstract] [Full Text] [PDF]
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D. J. Clark, S. Lessio, M. O'Donoghue, C. Tsalamandris, R. Schainfeld, and K. Rosenfield Mechanisms and Predictors of Carotid Artery Stent Restenosis: A Serial Intravascular Ultrasound Study J. Am. Coll. Cardiol., June 20, 2006; 47(12): 2390 - 2396. [Abstract] [Full Text] [PDF]
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P. L. Faries, R. A. Chaer, S. Patel, S. C. Lin, B. DeRubertis, and K. C. Kent Current Management of Extracranial Carotid Artery Disease Vascular and Endovascular Surgery, May 1, 2006; 40(3): 165 - 175. [Abstract] [PDF]
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G. S. Roubin, S. Iyer, A. Halkin, J. Vitek, and C. Brennan Realizing the Potential of Carotid Artery Stenting: Proposed Paradigms for Patient Selection and Procedural Technique Circulation, April 25, 2006; 113(16): 2021 - 2030. [Abstract] [Full Text] [PDF]
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M.D. Hill, W. Morrish, G. Soulez, A. Nevelsteen, G. Maleux, C. Rogers, K.E. Hauptmann, A. Bonafe, R. Beyar, L. Gruberg, et al. Multicenter evaluation of a self-expanding carotid stent system with distal protection in the treatment of carotid stenosis. AJNR Am. J. Neuroradiol., April 1, 2006; 27(4): 759 - 765. [Abstract] [Full Text] [PDF]
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M. Rosenkranz, J. Fiehler, W. Niesen, C. Waiblinger, B. Eckert, O. Wittkugel, T. Kucinski, J. Rother, H. Zeumer, C. Weiller, et al. The Amount of Solid Cerebral Microemboli during Carotid Stenting Does Not Relate to the Frequency of Silent Ischemic Lesions AJNR Am. J. Neuroradiol., January 1, 2006; 27(1): 157 - 161. [Abstract] [Full Text] [PDF]
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C. H. Timaran Clinical Predictors of Transient ischemic Attack, Stroke, or Death Within 30 Days of Carotid Angioplasty and Stenting Perspectives in Vascular Surgery and Endovascular Therapy, December 1, 2005; 17(4): 384-1 - 385. [Abstract] [PDF]
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Y. P. Liew and J. R Bartholomew Atheromatous embolization Vascular Medicine, November 1, 2005; 10(4): 309 - 326. [Abstract] [PDF]
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M. Cosottini, M. C. Michelassi, M. Puglioli, G. Lazzarotti, G. Orlandi, F. Marconi, G. Parenti, and C. Bartolozzi Silent Cerebral Ischemia Detected With Diffusion-Weighted Imaging in Patients Treated With Protected and Unprotected Carotid Artery Stenting Stroke, November 1, 2005; 36(11): 2389 - 2393. [Abstract] [Full Text] [PDF]
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K. I. Paraskevas, S. S. Daskalopoulou, M. E. Daskalopoulos, and C. D. Liapis Secondary Prevention of Ischemic Cerebrovascular Disease. What Is the Evidence? Angiology, September 1, 2005; 56(5): 539 - 552. [Abstract] [PDF]
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R. Moftakhar, A. S. Turk, D. B. Niemann, S. Hussain, S. Rajpal, T. Cook, M. Geraghty, B. Aagaard-Kienitz, P. A. Turski, and G. C. Newman Effects of Carotid or Vertebrobasilar Stent Placement on Cerebral Perfusion and Cognition AJNR Am. J. Neuroradiol., August 1, 2005; 26(7): 1772 - 1780. [Abstract] [Full Text] [PDF]
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M. J. Alberts, R. E. Latchaw, W. R. Selman, T. Shephard, M. N. Hadley, L. M. Brass, W. Koroshetz, J. R. Marler, J. Booss, R. D. Zorowitz, et al. Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition Stroke, July 1, 2005; 36(7): 1597 - 1616. [Abstract] [Full Text] [PDF]
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R. Zahn, T. Ischinger, B. Mark, S. Gass, U. Zeymer, W. Schmalz, K. Haerten, K. E. Hauptmann, E.-R. von Leitner, W. Kasper, et al. Embolic Protection Devices for Carotid Artery Stenting: Is There a Difference Between Filter and Distal Occlusive Devices? J. Am. Coll. Cardiol., June 7, 2005; 45(11): 1769 - 1774. [Abstract] [Full Text] [PDF]
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P. H. Lin, R. L. Bush, E. Peden, W. Zhou, P. Kougias, E. Henao, I. Mohiuddin, and A. B. Lumsden What Is the Learning Curve for Carotid Artery Stenting With Neuroprotection? Analysis of 200 Consecutive Cases at an Academic Institution Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2005; 17(2): 113 - 123. [Abstract] [PDF]
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P. L. Faries Expert Commentary Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2005; 17(2): 123-1 - 125. [PDF]
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J. J. Vitek, N. Al-Mubarak, S. S. Iyer, and G. S. Roubin Carotid Artery Stent Placement with Distal Balloon Protection: Technical Considerations AJNR Am. J. Neuroradiol., April 1, 2005; 26(4): 854 - 861. [Abstract] [Full Text] [PDF]
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A. Kastrup, K. Groschel, J. B. Schulz, T. Nagele, and U. Ernemann Clinical Predictors of Transient Ischemic Attack, Stroke, or Death Within 30 Days of Carotid Angioplasty and Stenting Stroke, April 1, 2005; 36(4): 787 - 791. [Abstract] [Full Text] [PDF]
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L. J. Coward, R. L. Featherstone, and M. M. Brown Safety and Efficacy of Endovascular Treatment of Carotid Artery Stenosis Compared With Carotid Endarterectomy: A Cochrane Systematic Review of the Randomized Evidence Stroke, April 1, 2005; 36(4): 905 - 911. [Abstract] [Full Text] [PDF]
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H. G. Roh, H. S. Byun, J. W. Ryoo, D. G. Na, W.-J. Moon, B. B. Lee, and D.-I. Kim Prospective Analysis of Cerebral Infarction After Carotid Endarterectomy and Carotid Artery Stent Placement by Using Diffusion-Weighted Imaging AJNR Am. J. Neuroradiol., February 1, 2005; 26(2): 376 - 384. [Abstract] [Full Text] [PDF]
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K Rosenfield SCAI/SVMB/SVS Clinical Competence Statement: SCAI/SVMB/SVS Clinical Competence Statement on carotid stenting: training and credentialing for carotid stenting - multispecialty consensus recommendations Vascular Medicine, February 1, 2005; 10(1): 65 - 75. [PDF]
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K. Groschel, A. Riecker, J. B. Schulz, U. Ernemann, and A. Kastrup Systematic Review of Early Recurrent Stenosis After Carotid Angioplasty and Stenting Stroke, February 1, 2005; 36(2): 367 - 373. [Abstract] [Full Text] [PDF]
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K. Rosenfield, J. D. Babb, C. U. Cates, M. J. Cowley, T. Feldman, A. Gallagher, W. Gray, R. Green, M. R. Jaff, K. C. Kent, et al. Clinical competence statement on carotid stenting: Training and credentialing for carotid stenting--multispecialty consensus recommendations: A report of the SCAI/SVMB/SVS Writing Committee to develop a clinical competence statement on carotid interventions J. Am. Coll. Cardiol., January 4, 2005; 45(1): 165 - 174. [Full Text] [PDF]
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J. S. Yadav, M. H. Wholey, R. E. Kuntz, P. Fayad, B. T. Katzen, G. J. Mishkel, T. K. Bajwa, P. Whitlow, N. E. Strickman, M. R. Jaff, et al. Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients N. Engl. J. Med., October 7, 2004; 351(15): 1493 - 1501. [Abstract] [Full Text] [PDF]
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R. P. Cambria Stenting for Carotid-Artery Stenosis N. Engl. J. Med., October 7, 2004; 351(15): 1565 - 1567. [Full Text] [PDF]
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W. Theiss, P. Hermanek, K. Mathias, R. Ahmadi, L. Heuser, F.-J. Hoffmann, R. Kerner, F. Leisch, H. Sievert, S. von Sommoggy, et al. Pro-CAS: A Prospective Registry of Carotid Angioplasty and Stenting Stroke, September 1, 2004; 35(9): 2134 - 2139. [Abstract] [Full Text] [PDF]
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G. M. Biasi, A. Froio, E. B. Diethrich, G. Deleo, S. Galimberti, P. Mingazzini, A. N. Nicolaides, M. Griffin, D. Raithel, D. B. Reid, et al. Carotid Plaque Echolucency Increases the Risk of Stroke in Carotid Stenting: The Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) Study Circulation, August 10, 2004; 110(6): 756 - 762. [Abstract] [Full Text] [PDF]
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M. K. Eskandari, G. M. Longo, J. D. Vijungco, M. D. Morasch, and W. H. Pearce Does Carotid Stenting Measure Up to Endarterectomy?: A Vascular Surgeon's Experience Arch Surg, July 1, 2004; 139(7): 734 - 738. [Abstract] [Full Text] [PDF]
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M. A. Bettmann, M. D. Dake, L. N. Hopkins, B. T. Katzen, C. J. White, A. C. Eisenhauer, W. H. Pearce, K. A. Rosenfield, R. W. Smalling, T. A. Sos, et al. Atherosclerotic Vascular Disease Conference: Writing Group VI: Revascularization Circulation, June 1, 2004; 109(21): 2643 - 2650. [Full Text] [PDF]
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R. T. Higashida, P. M. Meyers, C. C. Phatouros, J. J. Connors III, J. D. Barr, D. Sacks, and for the Technology Assessment Committees of the Am Reporting Standards for Carotid Artery Angioplasty and Stent Placement Stroke, May 1, 2004; 35(5): e112 - e134. [Full Text] [PDF]
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S. Sabeti, M. Schillinger, W. Mlekusch, T. Nachtmann, W. Lang, R. Ahmadi, and E. Minar Contralateral High-Grade Carotid Artery Stenosis or Occlusion Is Not Associated with Increased Risk for Poor Neurologic Outcome after Elective Carotid Stent Placement Radiology, January 1, 2004; 230(1): 70 - 76. [Abstract] [Full Text] [PDF]
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J. P. Broderick William M. Feinberg Lecture: Stroke Therapy in the Year 2025: Burden, Breakthroughs, and Barriers to Progress Stroke, January 1, 2004; 35(1): 205 - 211. [Abstract] [Full Text] [PDF]
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R. D. Ecker, M. A. Pichelmann, I. Meissner, and F. B. Meyer Durability of Carotid Endarterectomy Stroke, December 1, 2003; 34(12): 2941 - 2944. [Abstract] [Full Text] [PDF]
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J. D. Barr, J. J. Connors III, D. Sacks, J. C. Wojak, G. J. Becker, J. F. Cardella, B. Chopko, J. E. Dion, A. J. Fox, R. T. Higashida, et al. Quality Improvement Guidelines for the Performance of Cervical Carotid Angioplasty and Stent Placement: Developed by a Collaborative Panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology AJNR Am. J. Neuroradiol., November 1, 2003; 24(10): 2020 - 2034. [Full Text] [PDF]
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G. Dangas Editorial Comment--Hypotension After Carotid Revascularization Stroke, November 1, 2003; 34(11): 2581 - 2582. [Full Text] [PDF]
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P. H. Lin, R. L. Bush, and A. B. Lumsden Carotid Artery Stenting: Current Status and Future Directions Vascular and Endovascular Surgery, September 1, 2003; 37(5): 315 - 322. [Abstract] [PDF]
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F. Liistro and C. Di Mario Carotid artery stenting Heart, August 1, 2003; 89(8): 944 - 948. [Full Text] [PDF]
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A. Cremonesi, R. Manetti, F. Setacci, C. Setacci, and F. Castriota Protected Carotid Stenting: Clinical Advantages and Complications of Embolic Protection Devices in 442 Consecutive Patients Stroke, August 1, 2003; 34(8): 1936 - 1941. [Abstract] [Full Text] [PDF]
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B. Eckert and H. Zeumer Editorial Comment--Carotid Artery Stenting With or Without Protection Devices? Strong Opinions, Poor Evidence! Stroke, August 1, 2003; 34(8): 1941 - 1943. [Full Text] [PDF]
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D. F. Denny Jr Prediction of Restenosis after Carotid Artery Stent Implantation Radiology, May 1, 2003; 227(2): 316 - 318. [Full Text] [PDF]
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M. Schillinger, M. Exner, W. Mlekusch, H. Rumpold, R. Ahmadi, S. Sabeti, W. Lang, O. Wagner, and E. Minar Acute-Phase Response after Stent Implantation in the Carotid Artery: Association with 6-month In-Stent Restenosis Radiology, May 1, 2003; 227(2): 516 - 521. [Abstract] [Full Text] [PDF]
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S. Taylor, F. Alcocer, and W. D. Jordan Jr Controversies in Carotid Stenting Vascular and Endovascular Surgery, March 1, 2003; 37(2): 79 - 87. [Abstract] [PDF]
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A. Kastrup, K. Groschel, H. Krapf, B. R. Brehm, J. Dichgans, and J. B. Schulz Early Outcome of Carotid Angioplasty and Stenting With and Without Cerebral Protection Devices: A Systematic Review of the Literature Stroke, March 1, 2003; 34(3): 813 - 819. [Abstract] [Full Text] [PDF]
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Z. Kaposzta, A. Clifton, J. Molloy, J. F. Martin, and H. S. Markus S-Nitrosoglutathione Reduces Asymptomatic Embolization After Carotid Angioplasty Circulation, December 10, 2002; 106(24): 3057 - 3062. [Abstract] [Full Text] [PDF]
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P. Faries, N. J. Morrissey, V. Teodorescu, E. C. Gravereaux, J. A. Burks JR, A. Carroccio, K. C. Kent, L. H. Hollier, and M. L. Marin Recent Advances in Peripheral Angioplasty and Stenting Angiology, November 1, 2002; 53(6): 617 - 626. [Abstract] [PDF]
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E.J. Cunningham, R. Bond, Z. Mehta, M.R. Mayberg, C.P. Warlow, and P.M. Rothwell Long-Term Durability of Carotid Endarterectomy for Symptomatic Stenosis and Risk Factors for Late Postoperative Stroke Stroke, November 1, 2002; 33(11): 2658 - 2663. [Abstract] [Full Text] [PDF]
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G Stankovic, F Liistro, S Moshiri, C Briguori, N Corvaja, G Gimelli, A Chieffo, M Montorfano, L Finci, V Spanos, et al. Carotid artery stenting in the first 100 consecutive patients: results and follow up Heart, October 1, 2002; 88(4): 381 - 386. [Abstract] [Full Text] [PDF]
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T. G. Brott Angioplasty and Stenting Should Be Performed Only in the Setting of a Clinical Trial Stroke, October 1, 2002; 33(10): 2519 - 2520. [Full Text] [PDF]
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G. S. Roubin Angioplasty and Stenting Should Not Be Restricted to Clinical Trials Stroke, October 1, 2002; 33(10): 2520 - 2522. [Full Text] [PDF]
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M. Schluter, T. Tubler, D. G. Mathey, and J. Schofer Feasibility and efficacy of balloon-based neuroprotection during carotid artery stenting in a single-center setting J. Am. Coll. Cardiol., September 4, 2002; 40(5): 890 - 895. [Abstract] [Full Text] [PDF]
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A. M. Abou-Zamzam Jr, G. L. Moneta, G. J. Landry, R. A. Yeager, J. M. Edwards, D. B. McConnell, L. M. Taylor Jr, and J. M. Porter Carotid Surgery Following Previous Carotid Endarterectomy Is Safe and Effective Vascular and Endovascular Surgery, July 1, 2002; 36(4): 263 - 270. [Abstract] [PDF]
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J. L. Kaufman, W.A.J. Hoefnagels, G. S. Roubin, G. New, and R. L. Sacco Extracranial Carotid Stenosis N. Engl. J. Med., May 16, 2002; 346(20): 1590 - 1591. [Full Text] [PDF]
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W. A. Gray, H. J. White Jr, D. M. Barrett, G. Chandran, R. Turner, and M. Reisman Carotid Stenting and Endarterectomy: A Clinical and Cost Comparison of Revascularization Strategies Stroke, April 1, 2002; 33(4): 1063 - 1070. [Abstract] [Full Text] [PDF]
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F. Masuhr and M. Busch Ambulatory Carotid Stenting in Patients With Asymptomatic Carotid Artery Stenosis Stroke, April 1, 2002; 33(4): 1168 - 1169. [Full Text] [PDF]
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N. Al-Mubarak, A. Colombo, P. A. Gaines, S. S. Iyer, N. Corvaja, T. J. Cleveland, S. Macdonald, C. Brennan, and J. J. Vitek Multicenter evaluation of carotid artery stenting with a filter protection system J. Am. Coll. Cardiol., March 6, 2002; 39(5): 841 - 846. [Abstract] [Full Text] [PDF]
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R. Hofmann, K. Kerschner, C. Steinwender, A. Kypta, D. Bibl, and F. Leisch Abciximab Bolus Injection Does Not Reduce Cerebral Ischemic Complications of Elective Carotid Artery Stenting: A Randomized Study Stroke, March 1, 2002; 33(3): 725 - 727. [Abstract] [Full Text] [PDF]
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A. Angelini, B. Reimers, M. D. Barbera, S. Sacca, G. Pasquetto, C. Cernetti, M. Valente, P. Pascotto, and G. Thiene Cerebral Protection During Carotid Artery Stenting: Collection and Histopathologic Analysis of Embolized Debris Stroke, February 1, 2002; 33(2): 456 - 461. [Abstract] [Full Text] [PDF]
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T. Tubler, M. Schluter, O. Dirsch, H. Sievert, I. Bosenberg, E. Grube, J. Waigand, and J. Schofer Balloon-Protected Carotid Artery Stenting: Relationship of Periprocedural Neurological Complications With the Size of Particulate Debris Circulation, December 4, 2001; 104(23): 2791 - 2796. [Abstract] [Full Text] [PDF]
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E. Ballotta, G. S. Roubin, G. New, S. S. Iyer, J. J. Vitek, N. Al-Mubarak, M. W. Liu, J. Yadav, C. Gomez, and R. E. Kuntz Immediate and Late Clinical Outcomes of Carotid Artery Stenting in Patients With Symptomatic and Asymptomatic Carotid Artery Stenosis: A 5-Year Prospective Analysis Response Circulation, November 27, 2001; 104 (22): e121 - e122. [Full Text] [PDF]
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C. J. White Another nail in the coffin of carotid endarterectomy J. Am. Coll. Cardiol., November 15, 2001; 38(6): 1596 - 1597. [Full Text] [PDF]
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N. Al-Mubarak, G. S. Roubin, J. J. Vitek, S. S. Iyer, G. New, and M. B. Leon Effect of the Distal-Balloon Protection System on Microembolization During Carotid Stenting Circulation, October 23, 2001; 104(17): 1999 - 2002. [Abstract] [Full Text] [PDF]
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 C. J White Non-surgical treatment of patients with peripheral vascular disease Br. Med. Bull., October 1, 2001; 59(1): 173 - 192. [Abstract] [Full Text] [PDF]
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N. Al-Mubarak, G. S. Roubin, J. J. Vitek, G. New, S. S. Iyer, and D. Pelz Procedural Safety and Short-Term Outcome of Ambulatory Carotid Stenting Editorial Comment Stroke, October 1, 2001; 32(10): 2305 - 2309. [Abstract] [Full Text] [PDF]
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D. O. Williams Carotid Filters : New Additions to the Interventionist's Toolbox Circulation, July 3, 2001; 104(1): 2 - 3. [Full Text] [PDF]
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B. Reimers, N. Corvaja, S. Moshiri, S. Sacca, R. Albiero, C. Di Mario, P. Pascotto, and A. Colombo Cerebral Protection With Filter Devices During Carotid Artery Stenting Circulation, July 3, 2001; 104(1): 12 - 15. [Abstract] [Full Text] [PDF]
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