1. Introduction

Carotid artery stenosis is an important and preventable cause of ischemic stroke and transient ischemic attack [1]. Timely carotid revascularisation plays a key role in reducing the risk of recurrent neurologic events in both symptomatic and selected high-grade asymptomatic patients [2]. Carotid endarterectomy has traditionally been the standard treatment; however, carotid artery stenting has emerged as a minimally invasive alternative, particularly in patients who are poor surgical candidates or have high operative risk [3]. With advances in endovascular techniques, CAS is increasingly being performed worldwide, yet real-world data from Indian tertiary care centers remain limited [4]. Institutional experiences are valuable in assessing procedural feasibility, safety, and early clinical outcomes.

This case series was undertaken to report the clinical presentation and short-term results of carotid artery stenting in patients treated at a tertiary care hospital in South India.

2.1 Aim

To evaluate the feasibility, safety, and short-term clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis treated at a tertiary care center.

2.2 Objectives

To describe the clinical profile and presenting symptoms of patients undergoing carotid artery stenting.

• To assess procedural success and immediate peri-procedural complications associated with carotid artery stenting.
• To evaluate short-term outcomes, including 30-day major adverse cardiac or cerebrovascular events.
• To document the occurrence of new ipsilateral ischemic lesions detected within 48 hours following the procedure.
• To contribute institutional real-world experience regarding carotid artery stenting as an alternative revascularisation strategy in selected patients.

3. Materials and methods

3.1 Study Design And Patient Selection

This single-center case series included eight consecutive patients who underwent carotid artery stenting (CAS) between 2021 and 2023 at KG Hospital Center, Coimbatore. Patients aged ≥18 years with de novo atherosclerotic carotid artery stenosis were eligible. Symptomatic patients had experienced transient ischemic attack or ischemic stroke within the preceding six months with ipsilateral carotid stenosis ≥50% [5]. It was assessed by angiography using NASCET criteria. Asymptomatic patients had carotid stenosis ≥80% deemed suitable for revascularisation by a vascular specialist and an independent neurologist[6].Patients with stage III renal insufficiency, acute stroke within 30 days, recent myocardial infarction (within 72 hours), atrial fibrillation, non-carotid causes of stroke, total carotid occlusion, severe circumferential calcification, lesion length >30 mm, or prior stent extension into the aortic arch were excluded.

3.2 Procedure Technique

All procedures were performed under standard protocol with embolic protection device (EPD) placement [7]. Temporary pacemaker insertion was routinely performed. Predilatation using a 2.5–3 mm balloon was performed when indicated, with atropine available for bradycardia. Self-expanding nitinol or Elgiloy stents were deployed to fully cover the lesion, extending from the common carotid artery to the internal carotid artery when necessary. Post-dilatation was performed selectively if residual stenosis resulted in a luminal diameter <5 mm. Following stent deployment, the EPD was removed and completion angiography was performed to assess residual stenosis and intracranial flow.

3.3 Outcome Measures

Primary outcomes included procedural success and peri-procedural complications [8]. Secondary outcomes included 30-day major adverse cardiac or cerebrovascular events and the incidence of new ipsilateral ischemic lesions detected at 48 hours.

4.1 Baseline Characteristics And Clinical Presentation

A total of eight patients underwent carotid artery stenting between 2021 and 2023. The mean age was approximately 61 years (range: 48–68 years). There were five females (62.5%) and three males (37.5%). Six patients (75%) were symptomatic at presentation with either stroke or transient ischemic attack. Stroke was the most common presentation, observed in four patients (50%), while two patients (25%) presented with recurrent or recent transient ischemic attacks. One patient presented with isolated upper limb weakness without documented infarct at presentation. Two patients (25%) presented with non-focal symptoms, including giddiness and headache.Comorbid conditions were common. Type 2 diabetes mellitus was present in three patients (37.5%), hypertension in two patients (25%), dyslipidemia in one patient (12.5%), and hypothyroidism in one patient (12.5%). Two patients had a prior history of cerebrovascular accident.Digital subtraction angiography demonstrated high-grade carotid stenosis in all cases, ranging from 70% to 99%. The right internal carotid artery involved five patients (62.5%), while left-sided lesions were noted in three patients (37.5%).

4.2 Case Summaries

Table 1: Clinical Characteristics and Outcomes of the Reported Case(s)

Figure 1: Case 1 – Pre- and Post-Stenting Images left: Pre-stenting DSA showing 90% stenosis of left ICA. right: Post-stenting angiogram showing good flow across the stent.

Figure 2: Case 2 – Pre- and Post-Stenting Images left: Pre-stenting DSA showing 99% stenosis of left ICA. right: Post-stenting angiogram showing good flow across the stent.

Figure 3: Case 3 – Pre- and Post-Stenting Images left: Pre-stenting DSA showing 90% stenosis of right ICA. right: Post-stenting angiogram showing restoration of flow.

Figure 4: Case 4 – Pre- and Post-Stenting Images left: Pre-stenting DSA showing 70% stenosis of left CCA. right: Post-stenting angiogram showing good luminal patency.

Figure 5: Case 5 – Pre- and Post-Stenting Images left: Pre-stenting DSA showing 70–80% stenosis of right ICA. right: Post-stenting angiogram showing satisfactory flow.

Figure 6: Case 6 – Pre- and Post-Stenting Images left: Pre-stenting DSA showing 80% stenosis of right ICA. right: Post-stenting angiogram showing good distal perfusion.

Figure 7: Case 7 – Pre- and Post-Stenting Images left: Pre-stenting DSA showing 70% stenosis of right ICA. right: Post-stenting angiogram showing adequate revascularisation.

Figure 8: Case 8 – Pre- and Post-Stenting Images left: Pre-stenting DSA showing 70–80% stenosis of right CCA/ICA. right: Post-stenting angiogram showing good flow across the stent.