Safety of Simultaneous Bilateral Internal Carotid Artery Stenting

Safety of Simultaneous Bilateral Internal Carotid Artery Stenting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Safety of Simultaneous Bilateral Internal Carotid Artery Stenting sherif salah, Hany Aref, Ahmed Elbassiouny, Hosam Afify, Ayman El-Sudany, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5778244/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in The Egyptian Journal of Neurology, Psychiatry and Neurosurgery → Version 1 posted 4 You are reading this latest preprint version Abstract Background : Stroke is a major global cause of death, affecting nearly 13.7 million people annually. Carotid artery stenosis accounts for up to 12% of all ischemic strokes. Bilateral carotid stenosis, which affects between 8% and 39% of patients with symptomatic carotid stenosis, presents a treatment challenge, as it is often a relative contraindication for carotid endarterectomy and is excluded from many clinical trials. With advancements in endovascular technology, simultaneous bilateral carotid angioplasty and stenting (SBCAS) has emerged as a safe and effective option, with complication risks similar to those of unilateral carotid artery stenting. The safety profile of SBCAS has been the subject of various studies, which have reported mixed outcomes. Results : The study included twenty patients; 14 males (70%) and 6 females (30%). The age of the patients ranged from 51 to 75 years with a mean age of 63.95 ± 6.79. Fourteen cases (70%) had ischemic stroke and 6 cases (30%) presented with TIA. Site of stenosis was mainly in the proximal internal carotid artery (70.0% of cases in right side) and (85.0% in left side), while Degree of stenosis showed that 50.0% had more than 70 % stenosis on the right ICA while 70.0% had more than 70 % stenosis in the left side. Timing of intervention was (in minutes) 60.50 ± 7.76; Types of stents in those twenty patients (forty carotid stents, two for each patient) 62.5 % were wall stents, 12.5% were Portege and 25 % were CASPER stent. Forty percent (40%) had hemodynamic depression, 5% had hyper perfusion syndrome. Neither Vascular access complications, Stroke, Cardiac complications or Mortality were reported in our study group. There were no mortality, stroke or Cardiac complications after one month follow up. Conclusion : SBCAS is a safe and effective procedure for properly selected patients with bilateral carotid stenosis and can help reduce the risk of recurrent cerebrovascular events. simultaneous bilateral carotid angioplasty and stenting hemodynamic depression hyper perfusion syndrome Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Stroke is a major global cause of death, affecting nearly 13.7 million people annually [ 1 ]. Carotid artery stenosis accounts for up to 12% of all ischemic strokes. Research supports the use of carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) for patients with symptomatic carotid stenosis, but the optimal treatment remains under study through several large, randomized trials [ 2 ]. Bilateral carotid stenosis, which affects between 8% and 39% of patients with symptomatic carotid stenosis, presents a treatment challenge, as it is often a relative contraindication for CEA and is excluded from many clinical trials [ 3 ]. However, timely revascularization can benefit patients at high risk of stroke. With advancements in endovascular technology, simultaneous bilateral carotid angioplasty and stenting (SBCAS) has emerged as a safe and effective option, with complication risks similar to those of unilateral CAS. Still, the management of bilateral carotid stenosis remains debated, as current treatment options include staged or simultaneous CEA, CAS, or a combination of both [ 4 ]. In the past decade, more evidence has supported SBCAS as aviable and safe procedure for treating bilateral carotid stenosis [ 23 ]. However, SBCAS is associated with an increased risk of peri-procedural complications, such as stroke and myocardial infarction, which are of particular concern due to the cumulative hemodynamic stress involved in treating both arteries simultaneously [ 5 , 6 ]. The safety profile of B-CAS has been the subject of various studies, which have reported mixed outcomes. For instance, meta-analyses have demonstrated that while B-CAS can be performed with an acceptable safety profile when executed by experienced operators, it is associated with a higher incidence of complications compared to unilateral CAS [ 7 ]. This elevated risk arises from the complexity of the procedure and the potential for increased embolic events. Advances in stent technology and embolic protection devices are helping to reduce these risks and improve the overall safety and effectiveness of B-CAS [ 8 ]. Given the ongoing evolution of carotid artery interventions, it is critical to continue evaluating the safety of B-CAS. This paper aims to review current evidence on the risks and benefits of simultaneous bilateral carotid artery stenting and provide insights into its safety profile based on recent research and technological innovations. Methods Aiming to assess the safety of SBCAS, a prospective multicenter study was conducted from March 2021 to August 2023 at the Neuroendovascular Units of Almaadi Military and Ain Shams University Hospitals, with informed consent obtained from all participants. Twenty patients were enrolled and underwent simultaneous bilateral carotid artery stenting (SBCAS). Patients were recruited from both inpatient admissions and outpatient clinics at Almaadi Military and Ain Shams University Hospitals, based on specific inclusion and exclusion criteria. Inclusion criteria included patients with bilateral extra-cranial internal carotid artery stenosis, either symptomatic (> 50%) or asymptomatic (> 70%). The degree of stenosis was initially assessed by duplex ultrasound using the LOGIQ™ P7 system and later confirmed during the procedure using digital subtraction angiography with a Philips Allura Xper FD10 Cath/Angio System. Stenosis measurement followed the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methodology [ 9 ]. The study involved a comprehensive patient history, including family history of stroke, past medical history of risk factors, and present illness symptoms. Clinical assessments were carried out using the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) pre-procedure, post-procedure, and 30 days following the intervention. Laboratory investigations included complete blood count, liver and renal function tests, prothrombin time (PT), partial thromboplastin time (PTT), blood sugar levels, and lipid profile. Cardiac evaluations, including electrocardiograms and transthoracic or transesophageal echocardiography, were performed as clinically indicated. Three types of carotid stents were utilized during the procedures: closed-cell design (Wall stent® - Boston Scientific), open-cell design (Protégé® -EV3), and double-layer design (CASPER Rx stent - Microvention Terumo). Magnetic resonance imaging (MRI) of the brain was performed before the procedure and within 48 hours post-procedure, or as needed during follow-up. All procedures were performed by an experienced interventional neurologist. The procedure began with stenting of the symptomatic side, followed by the contralateral side. Pre-procedure preparation included antiplatelet therapy: aspirin 150 mg/day and clopidogrel (Plavix®) 75 mg/day for one week before the procedure. Alternatively, a loading dose of clopidogrel 300 mg and aspirin 300 mg, or Ticagrelor 90 mg, was administered one day before the procedure. This study was approved by the Ethics Committee of the Faculty of Medicine, Ain Shams University. The clinical endpoints included the incidence of hyper perfusion syndrome, hemodynamic depression, stroke, transient ischemic attacks (TIA), mortality, and cardiac complications within 30 days post-procedure. Symptomatic ischemic complications (stroke or TIA) in perioperative and postoperative period were defined clinically and by MRI-DWI after the procedure in the first week or at any time if was required. Intra- and postoperative HD [ 10 ]. Intra- and postoperative HD, i.e., bradycardia and/or hypotension, were defined as a heart rate of ≤ 60 beats/min and/or a systolic blood pressure level of ≤ 100 mmHg. During the procedure, the patient’s heart rate was measured using electrocardiography, and their blood pressure was evaluated through the sheath in the femoral artery. After the procedure, electrocardiographic monitoring was continued, and non-invasive blood pressure measurements were obtained every 15 min until at least 24 h. After Balloon inflation and angioplasty, 0.5 mg of atropine sulphate was administered if HD occurs. Grading scale of HD is as follows 0 = none, 1 = mild, temporary with hospital stay not prolonged, 2 = prolonged with extended hospital stay, 3 = severe with severe major neurological or cardiac adverse event. The incidence of HPS which was detected clinically as exhibiting symptoms such as an ipsilateral throbbing headache, seizure, or focal neurological symptoms without cerebral infarction. Cardiac complications which were detected clinically by presence of any cardiac symptoms (typical chest pain or dyspnea) investigated by proper investigations (ECG) if happened and mortality within thirty days. The collected data was revised, coded, and introduced to a personal computer using Statistical Package for Social Science (SPSS 25, by IBM: Armonk; New York, USA). A suitable analysis for the data was done according to its type. Quantitative data was summarized by the mean, standard deviation (± SD) while qualitative data was summarized by frequencies and percentages. Results Demographic data and risk factors: - The study included 14 males (70%) and 6 females (30%). The age of the patients ranged from 51 to 75 years with a mean age of 63.95 ± 6.79. As regards the risk factors; 10 cases (50%) were smokers, 11 cases (55%) were diabetic, 18 cases (90%) were hypertensive, 6 cases (30 %) had ischemic heart disease (IHD) and 18 cases (90%) had dyslipidemia. Clinical presentations: -Fourteen cases (70%) had ischemic stroke and 6 cases (30%) presented with TIA. Digital subtraction angiography (DSA) findings (Table 1); Site of stenosis was mainly in the proximal internal carotid artery (70.0% of cases in right side) and (85.0% in left side), while Degree of stenosis showed that 50.0% had more than 70 % stenosis on the right ICA while 70.0% had more than 70 % stenosis in the left side. Table 1: Digital subtraction angiography (DSA) findings Basic angiographic data Total No. = 20 Site of stenosis in the right Side Common - ICA 6 (30.0%) Proximal ICA 14 (70.0%) Site of stenosis in the left Side Common - ICA 3 (15.0%) Proximal ICA 17 (85.0%) Right Carotid stenosis degree Less than 50 0 (0.0%) 50-69% 10 (50.0%) More than 70 10 (50.0%) Left Carotid stenosis degree Less than 50 0 (0.0%) 50-69% 6 (30.0%) More than 70 14 (70.0%) Interventional details; Timing of intervention was (in minutes) 60.50 ± 7.76; Types of stents in those twenty patients (forty carotid stents, two for each patient) 62.5 % were wall stents, 12.5% were portogee and 25 % were CASPER stents as shown in (Table 2) Table 2: Types of carotid stents used in our study Types of stents used Total No. = 40 Wall stent 25 (62.5%) Portogee stent 5 (12.5%) CASPER stent 10 (25%) Post procedural complications (Table 3): - Hemodynamic depression - Forty percent (40%) had hemodynamic depression which required medical treatment intra procedural with no cases for post procedural prolonged HD. Hyper perfusion syndrome - Among those twenty patients, 5% had hyper perfusion syndrome which manifested as headache and confusion which lasted shortly. Neither Vascular access complications, Stroke, Cardiac complications or Mortality were reported in our study group. Table 3: Post procedural complications among the studied patients Periprocedural data Total No. = 20 Vascular access complications Yes 0 (0.0%) No 20 (100.0%) Stroke Yes 0 (0.0%) No 20 (100.0%) Hyper perfusion syndrome Yes 1 (5.0%) No 19 (95.0%) Cardiac complications Yes 0 (0.0%) No 20 (100.0%) Renal dysfunction Yes 0 (0.0%) No 20 (100.0%) Mortality Yes 0 (0.0%) No 20 (100.0%) NIHSS and mRs before and after stenting Before procedure: NIHSS and mRs Scales pre-procedural, the Median (IQR) NIHSS was 1 (0 – 2) and Median (IQR) was 1 (0 – 1) respectively as shown in (Table 4). Table 4: Pre procedural NIHSS and MRS among the studied patients Pre-procedural NIHSS mRs Total No. = 20 NIHSS_pre procedural Median(IQR) 1 (0 – 2) Range 0 – 3 mRs _pre procedural Median(IQR) 1 (0 – 1) Range 0 – 1 After procedure: There was no change in mRs and NIHSS immediately post procedural in comparison with the pre procedural mRs and NIHSS as shown in (Table 5). Table 5: NIHSS and MRS Pre and post procedure among the studied patients Pre Post- procedural Test value P-value Sig. NIHSS Median (IQR) 1 (0 – 2) 1(0 – 2) 0.000≠ 1.000 NS Range 0 – 3 0 – 3 mRs Median (IQR) 1 (0 – 1) 1(0 – 1) 0.000≠ 1.000 NS Range 0 – 1 0 – 1 After one month (30 days follow up): there were no progression in mRs or NIHSS scales as shown in (table 6 & 7) Table 6: NIHSS and mRs after one month among the studied patients Post-procedural (1 month) NIHSS and mRs Total No. = 20 NIHSS Median (IQR) 1 (0 – 2) Range 0 – 3 mRs Median (IQR) 1 (0 – 1) Range 0 – 1 Table 7: NIHSS and mRs after 30 days from BCAS among the studied patients Post- procedural 1 month post Test value P-value Sig. NIHSS Median (IQR) 1(0 – 2) 1 (0 – 2) 0.000≠ 1.000 NS Range 0 – 3 0 – 3 mRs Median (IQR) 1(0 – 1) 1 (0 – 1) 0.000≠ 1.000 NS Range 0 – 1 0 – 1 Follow up brain DW-MRI findings: Ninety five percent of patients (nineteen patients) had no abnormalities while five percent (one patient) had few new restricted spots in DWI without significant neurological deficit as shown in (figure 1). Clinical follow up after one month: there were no mortality, stroke or Cardiac complications after one month follow up as shown in (table 8). Table 8: Clinical follow up after one month among the studied patients Post-procedural (1 month) data Total No. = 20 Stroke No 20 (100.0%) Yes 0 (0.0%) Cardiac complications No 20 (100.0%) Yes 0 (0.0%) Mortality No 20 (100.0%) Yes 0 (0.0%) Discussion The occurrence of severe bilateral carotid artery stenosis (BCS) varies in published studies, ranging from 3.2–39% [ 11 , 12 , 13 ]. Treatment options for BCS include bilateral carotid endarterectomy (CEA), unilateral CEA with contralateral carotid angioplasty and stenting (CAS), and bilateral CAS [ 13 , 14 ]. Simultaneous bilateral CEA is infrequently performed due to the risk of significant injury to the phrenic and vagus nerves, as well as the stellate ganglion, which can lead to higher rates of serious neurological complications during surgery [ 15 ]. The average age of the patients in our study was 63.95 ± 6.79 years. Age and multiple risk factors are believed to influence the development of carotid artery disease [ 16 ]. Our sample had a higher proportion of males (14/20; 70.0%), which aligns with findings from previous studies [ 17 ]. Among the comorbidities in our patients, hypertension and dyslipidaemia were the most common (90%), followed by diabetes mellitus (55%) and ischemic heart disease (30%) consistent with earlier research [ 18 ]. Hypertension increases the risk of ischemic stroke by worsening atherosclerosis and promoting heart disease, with isolated systolic hypertension and elevated pulse pressure posing a greater risk. It is regarded as the most critical modifiable risk factor for both atherosclerosis and stroke [ 19 ]. High total cholesterol and low-density lipoprotein (LDL) levels are linked to atherosclerosis, and diabetes mellitus can double or quadruple the risk of ischemic stroke while also increasing post-stroke morbidity and mortality. Macrovascular disease is the leading cause of death among diabetic patients, with cerebrovascular atherosclerosis being a potential cause of strokes related to diabetes mellitus [ 20 , 21 ]. Regarding the angiographic features of carotid stenosis in our study, stenosis primarily occurred in the internal carotid artery (70.0% of cases in the right ICA and 85.0% in the left ICA). Of the cases, 50.0% exhibited over 70% stenosis on the right ICA, while 70.0% had over 70% stenosis on the left side, which is consistent with most previous studies [ 17 , 22 ]. Over the past decade, increasing evidence has supported the use of simultaneous bilateral carotid artery stenting (SBCAS) as a safe and effective treatment for bilateral carotid stenosis [ 22 ]. The first case of SBCAS was documented in 1997 by Mathur et al. [ 23 ]. Since then, further studies have affirmed the safety and feasibility of this simultaneous approach [ 22 , 24 ]. Some concerns regarding simultaneous procedures include high-risk surgical candidates for CEA, severe concurrent diseases requiring surgical intervention, and the risk of new strokes from severe contralateral carotid stenosis following prolonged hypotension and hemodynamic instability during the procedure [ 25 ]. Conversely, the incidence of bradycardia, hypotension, and hyper perfusion syndrome (HPS) tends to be higher during SBCAS [ 26 ]. In our current study, hyper perfusion syndrome was observed in one case (5%), presenting as headache and confusion, which aligns with findings from previous studies reporting incidences during SBCAS ranging from 2.5–16.7%, compared to 2.1% for unilateral CAS [ 17 , 18 , 22 , 26 ]. Our results can be attributed to appropriate procedural preparation, including blood pressure monitoring and control. As for the incidence of hemodynamic depression, our study found it occurred in 40% of cases, characterized as mild and short-lived during balloon angioplasty, effectively managed with atropine. This is similar to previous studies [ 17 , 22 ], which indicated the incidence of perioperative hemodynamic depression during SBCAS was between 29.16% and 71.8%, compared to 20.0–57.7% for unilateral CAS or staged CAS. Thus, simultaneous BCAS does not appear to significantly increase the risk of hemodynamic depression; if it does occur, vasopressors can be used for treatment, and it should not be a reason to halt the simultaneous procedure. Our findings can be explained by effective blood pressure monitoring and control, alongside careful technical execution during balloon angioplasty. In this study, we did not observe any strokes following SBCAS, which is consistent with previous reports [ 22 , 27 , 28 , 29 , 30 ]. In contrast, stroke rates in other studies ranged from 1.59–5.36% in Lai et al. (2019) [ 18 ], 5.12% in Shchehlov et al. (2021) [ 17 ], 2.4% in Li et al. (2014) [ 12 ], and 4.2% in Jiang et al. (2016) [ 31 ], with unilateral CAS at 3.6% in Dong et al. (2012) [ 32 ] and staged BCAS at 7.7% in Li et al. (2014) [ 12 ].These discrepancies could be attributed to various factors, including meticulous case selection, pre-procedural preparation using dual antiplatelet therapy (DAPT), intraprocedural management, and the relatively small sample size of this study. In our study, all patients underwent follow-up brain diffusion-weighted magnetic resonance imaging (DW-MRI). Nineteen patients (95%) exhibited no abnormalities, while 1 patient (5%) showed a few new restricted spots in diffusion-weighted imaging without significant neurological deficits. This incidence was lower than reported by Oshita et al. (2020) [ 22 ], who noted multiple high-intensity spots in three out of eight procedures (37.5%), two of which were bilateral lesions in group A (SBCAS), and one in group B (staged BCAS), affecting one out of eight procedures (12.5%). All lesions identified in diffusion-weighted imaging were less than 1 mm in diameter, with a median of seven lesions (range 2–7) in group A and four in group B [ 22 ]. Additionally, our findings were lower than those reported by Bijuklic et al. (2013), who found high-intensity lesions in 32.8% of patients following CAS with cerebral embolic protection [ 33 ]. Our results also contrasted with those of Altinbas et al. (2014), who noted that patients undergoing CAS experienced perioperative hemodynamic depression associated with a threefold increase in new high-intensity lesions in diffusion-weighted imaging compared to those without hemodynamic depression, suggesting that avoiding hemodynamic depression could reduce the occurrence of high-intensity lesions during the perioperative period [ 34 ]. Our results can be explained by effective procedural preparation, including blood pressure control before and during the procedure, along with proper technical approaches and manipulation during the crossing of lesions and stent deployment. Post-operative hospital stays for our patients ranged from 2 to 3 days, with most patients discharged the day after the procedure. This duration was shorter than reported in previous studies, such as Oshita et al. (2020), which noted a mean stay of 5.1 ± 1.8 days in the SBCAS group and 5.3 ± 2.3 days in the staged BCAS group [ 22 ]. This difference could be attributed to effective pre- and post-procedural preparation. Clinical follow-up of our patients after one month indicated no mortality, strokes, or cardiac complications, aligning with findings from earlier studies [ 17 , 18 , 22 , 27 ]. This outcome may be due to proper post-procedural care with DAPT and effective risk factor management. In this retrospective study, we observed favourable outcomes in patients who underwent SBCAS and found no significant difference in the 30-day complication rates between simultaneous and staged stenting, as reported in previous studies. This suggests that simultaneous BCAS does not lead to a notable increase in the risk of perioperative complications compared to staged BCAS Conclusion SBCAS is regarded as a relatively safe and effective treatment for selected patients with bilateral carotid stenosis, particularly those facing high stroke risk during open-heart surgery. It is important to thoroughly assess patients to determine the most suitable treatment approach. While the occurrence of hyper perfusion syndrome (HPS) was higher compared to unilateral CAS, the actual number of patients affected was small, and their symptoms were generally mild and resolved spontaneously. Additionally, other procedural complications, such as hemodynamic depression (HD), stroke, and myocardial infarction (MI), were not worse than those seen in staged CAS procedures. Abbreviations CAS : Carotid artery stenting; DW MRI : Diffusion-weighted magnetic resonance imaging; NIHSS : National Institute of Health Stroke Scale; SBCAS : simultaneous bilateral carotid angioplasty and stenting ; mRs : modified ranken scale; ICA : internal carotid artery; CCA : common carotid artery; DSA diagnostic subtraction angiography. Declarations Funding self-funding Conflict of interest the authors declare no conflicts of interest Consent for publication Not applicable Acknowledgements Not applicable. Author contributions SS,HA,AE,HA,AH and FK conceived of the study and participated in its design ,coordination and helped to draft the manuscript. SS, FK and AH participated in the design of the study and performed statistical analysis. All authors have agreed to the conditions noted to authorship agreement form. The authors read and approve the final manuscript Ethics approval and consent to participate the study protocol was approved by Neurology Department Research Ethical Committee in November 2020 (approval number not available). Written informed consent was obtained from the patients participating in the study, or their first-degree relatives if the patient was unable to provide consent, after informing them about the study rationale and their right to withdraw from the study at any time without any consequences. Availability of data and material Dataset is available as master sheet in Excel format and publicly available in neurology Department, Ain shams university, through communicating to the corresponding author. References Feigin, V. L., Nguyen, G., & GBD 2019 Stroke Collaborators. (2021). Global, regional, and national burden of stroke and its risk factors, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurology , 20(9), 795-820. Lamanna, A., Maingard, J., Barras, C. D., Kok, H. K., et al. (2019). Carotid artery stenting: current state of evidence and future directions. Acta Neurologica Scandinavica, 139(4), 318-333. Jiang, X. J., Dong, H., Peng, M., Zou, Y. 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J Clin Imaging Sci 2:72. Jiang, X. J., Dong, H., Peng, M., Zou, Y. B., Song, L., Xu, B., Zhang, H. M., Wu, H. Y., Zhou, X. L., Yang, Y. J., & Gao, R. L. (2016). Simultaneous Bilateral vs Unilateral Carotid Artery Stenting: 30-Day and 1-Year Results. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists , 23 (2), 258–266.https://doi.org/10.1177/1526602815626900. Dong, H., Jiang, X.-j., Peng, M., Ji, W., Wu, H.-y., Hui, R.-t. (2012). Comparison of the safety of simultaneous bilateral carotid artery stenting versus unilateral carotid artery stenting: 30-day and 6-month results. Chinese Medical Journal , 125(6), 1010-1015. Bijuklic, K., Wandler, A., Varnakov, Y., Tuebler, T., & Schofer, J. (2013). Risk factors for cerebral embolization after carotid artery stenting with embolic protection: a diffusion-weighted magnetic resonance imaging study in 837 consecutive patients. Circulation: Cardiovascular Interventions , 6 (3), 311-316. Altinbas, A., Algra, A., Bonati, L. H., Brown, M. M., Kappelle, L. J., de Borst, G. J., ... & van der Worp, H. B. (2014). Periprocedural hemodynamic depression is associated with a higher number of new ischemic brain lesions after stenting in the International Carotid Stenting Study-MRI Substudy. Stroke , 45 (1), 146-151. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in The Egyptian Journal of Neurology, Psychiatry and Neurosurgery → Version 1 posted Editorial decision: Revision requested 08 Jan, 2025 Editor assigned by journal 07 Jan, 2025 Submission checks completed at journal 07 Jan, 2025 First submitted to journal 07 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5778244","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":399483672,"identity":"e505a638-72ed-4400-bdfa-a72a6cddba22","order_by":0,"name":"sherif salah","email":"data:image/png;base64,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","orcid":"","institution":"Military Medical Academy","correspondingAuthor":true,"prefix":"","firstName":"sherif","middleName":"","lastName":"salah","suffix":""},{"id":399483673,"identity":"3852b0b7-2ad5-4954-a680-5fd2d3c68928","order_by":1,"name":"Hany Aref","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Hany","middleName":"","lastName":"Aref","suffix":""},{"id":399483674,"identity":"bf2a78ad-3f48-4d47-9e76-7c54e59dc902","order_by":2,"name":"Ahmed Elbassiouny","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Elbassiouny","suffix":""},{"id":399483675,"identity":"aa23f390-f5a2-4a8a-a6df-2a12eef14e16","order_by":3,"name":"Hosam Afify","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Hosam","middleName":"","lastName":"Afify","suffix":""},{"id":399483676,"identity":"2b83f881-637e-4de0-8743-ca69a63d572b","order_by":4,"name":"Ayman El-Sudany","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Ayman","middleName":"","lastName":"El-Sudany","suffix":""},{"id":399483677,"identity":"cced5af6-d04e-48b3-9514-63c76b297cc6","order_by":5,"name":"Fatma Kenway","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Fatma","middleName":"","lastName":"Kenway","suffix":""}],"badges":[],"createdAt":"2025-01-07 06:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5778244/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5778244/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s41983-025-00979-0","type":"published","date":"2025-07-01T15:57:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73517002,"identity":"f361207f-6927-49b0-a035-fdeef4833b9e","added_by":"auto","created_at":"2025-01-10 17:50:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26989,"visible":true,"origin":"","legend":"\u003cp\u003ePost procedural MIR brain findings among the studied patients\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5778244/v1/6eba587ad0f3a87a7bade7a7.png"},{"id":73517005,"identity":"21649d07-7279-4f8e-bfdc-f67adb76ffe3","added_by":"auto","created_at":"2025-01-10 17:50:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":219837,"visible":true,"origin":"","legend":"\u003cp\u003e77 years old male patient with past history of diabetes and hypertension presented by recurrent transient ischemic attack, MRI brain and MRA showed bilateral internal carotid artery stenosis, DSA showed right and left ICA more than 80 % stenosis\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5778244/v1/27621d37a61bedb2b552e7e3.png"},{"id":73517756,"identity":"aa9a06ef-341c-4bcc-ba8c-e107ac141dcb","added_by":"auto","created_at":"2025-01-10 17:58:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":247666,"visible":true,"origin":"","legend":"\u003cp\u003e(continued); the patient in Figure (2) underwent simultaneous bilateral carotid artery stenting with wall stent 9*40. (note the visible two stents on the right figure)\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5778244/v1/3f4a0dbdc84cd9ebffbfceb9.png"},{"id":73517026,"identity":"67fefdd0-6105-4f49-b5d7-325ef1dabaa8","added_by":"auto","created_at":"2025-01-10 17:50:53","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":570902,"visible":true,"origin":"","legend":"\u003cp\u003e60 years old male patient with past medical history of diabetes, hypertension and Ischemic heart disease presented by dysarthria and right sided weakness, MRI and MRA brain revealed bilateral Internal carotid artery stenosis more than 80 % , DSA of the right common carotid artery revealed tight right internal carotid artery stenosis and after stenting using wall stent 9*40 with pre and post stenting angioplasty.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5778244/v1/a0112ac4bef93e5d28056edd.png"},{"id":73517020,"identity":"74ade701-42b1-43e5-bfbb-c34e22a6a0da","added_by":"auto","created_at":"2025-01-10 17:50:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":492452,"visible":true,"origin":"","legend":"\u003cp\u003e(continued); on the same patient and on DSA of the left common carotid artery, revealed tight left ICA stenosis with stenting using wall stent 9*40.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-5778244/v1/412f78cca933e6b7d78196ae.png"},{"id":73517010,"identity":"d1c24694-e555-4cf8-b69a-bb62916b6845","added_by":"auto","created_at":"2025-01-10 17:50:52","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":635914,"visible":true,"origin":"","legend":"\u003cp\u003e55 years old female patient with past medical history of hypertension presented with recurrent TIA , MRI brain and MRA revealed small vessel disease and bilateral carotid artery stenosis ; more than 80 %, DSA of the left Common carotid artery is shown with stenting using CASPER carotid stent.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-5778244/v1/8ebd9d15f884dda3c6c7e601.png"},{"id":73518999,"identity":"03ab3daf-f64e-4a98-ad6b-6f5ced25ea28","added_by":"auto","created_at":"2025-01-10 18:06:52","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":675919,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(continued) \u003c/strong\u003ethe same patient in figure (6) , DSA of the right Common carotid artery is shown with stenting using CASPER carotid stent; note the two visible stents.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-5778244/v1/e746ffef3327b81366a8a617.png"},{"id":86180215,"identity":"87e9a012-7557-4b05-af50-467458fbea59","added_by":"auto","created_at":"2025-07-07 16:21:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5528765,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5778244/v1/d9417ee7-ad6a-4419-a2f3-32e01fd994b4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety of Simultaneous Bilateral Internal Carotid Artery Stenting","fulltext":[{"header":"Background","content":"\u003cp\u003eStroke is a major global cause of death, affecting nearly 13.7\u0026nbsp;million people annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Carotid artery stenosis accounts for up to 12% of all ischemic strokes. Research supports the use of carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) for patients with symptomatic carotid stenosis, but the optimal treatment remains under study through several large, randomized trials [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Bilateral carotid stenosis, which affects between 8% and 39% of patients with symptomatic carotid stenosis, presents a treatment challenge, as it is often a relative contraindication for CEA and is excluded from many clinical trials [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, timely revascularization can benefit patients at high risk of stroke. With advancements in endovascular technology, simultaneous bilateral carotid angioplasty and stenting (SBCAS) has emerged as a safe and effective option, with complication risks similar to those of unilateral CAS. Still, the management of bilateral carotid stenosis remains debated, as current treatment options include staged or simultaneous CEA, CAS, or a combination of both [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the past decade, more evidence has supported SBCAS as aviable and safe procedure for treating bilateral carotid stenosis [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, SBCAS is associated with an increased risk of peri-procedural complications, such as stroke and myocardial infarction, which are of particular concern due to the cumulative hemodynamic stress involved in treating both arteries simultaneously [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The safety profile of B-CAS has been the subject of various studies, which have reported mixed outcomes. For instance, meta-analyses have demonstrated that while B-CAS can be performed with an acceptable safety profile when executed by experienced operators, it is associated with a higher incidence of complications compared to unilateral CAS [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This elevated risk arises from the complexity of the procedure and the potential for increased embolic events. Advances in stent technology and embolic protection devices are helping to reduce these risks and improve the overall safety and effectiveness of B-CAS [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Given the ongoing evolution of carotid artery interventions, it is critical to continue evaluating the safety of B-CAS. This paper aims to review current evidence on the risks and benefits of simultaneous bilateral carotid artery stenting and provide insights into its safety profile based on recent research and technological innovations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e Aiming to assess the safety of SBCAS, a prospective multicenter study was conducted from March 2021 to August 2023 at the Neuroendovascular Units of Almaadi Military and Ain Shams University Hospitals, with informed consent obtained from all participants. Twenty patients were enrolled and underwent simultaneous bilateral carotid artery stenting (SBCAS). Patients were recruited from both inpatient admissions and outpatient clinics at Almaadi Military and Ain Shams University Hospitals, based on specific inclusion and exclusion criteria. Inclusion criteria included patients with bilateral extra-cranial internal carotid artery stenosis, either symptomatic (\u0026gt;\u0026thinsp;50%) or asymptomatic (\u0026gt;\u0026thinsp;70%). The degree of stenosis was initially assessed by duplex ultrasound using the LOGIQ\u0026trade; P7 system and later confirmed during the procedure using digital subtraction angiography with a Philips Allura Xper FD10 Cath/Angio System. Stenosis measurement followed the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methodology [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The study involved a comprehensive patient history, including family history of stroke, past medical history of risk factors, and present illness symptoms. Clinical assessments were carried out using the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) pre-procedure, post-procedure, and 30 days following the intervention. Laboratory investigations included complete blood count, liver and renal function tests, prothrombin time (PT), partial thromboplastin time (PTT), blood sugar levels, and lipid profile. Cardiac evaluations, including electrocardiograms and transthoracic or transesophageal echocardiography, were performed as clinically indicated. Three types of carotid stents were utilized during the procedures: closed-cell design (Wall stent\u0026reg; - Boston Scientific), open-cell design (Prot\u0026eacute;g\u0026eacute;\u0026reg; -EV3), and double-layer design (CASPER Rx stent - Microvention Terumo). Magnetic resonance imaging (MRI) of the brain was performed before the procedure and within 48 hours post-procedure, or as needed during follow-up. All procedures were performed by an experienced interventional neurologist. The procedure began with stenting of the symptomatic side, followed by the contralateral side. Pre-procedure preparation included antiplatelet therapy: aspirin 150 mg/day and clopidogrel (Plavix\u0026reg;) 75 mg/day for one week before the procedure. Alternatively, a loading dose of clopidogrel 300 mg and aspirin 300 mg, or Ticagrelor 90 mg, was administered one day before the procedure. This study was approved by the Ethics Committee of the Faculty of Medicine, Ain Shams University. The clinical endpoints included the incidence of hyper perfusion syndrome, hemodynamic depression, stroke, transient ischemic attacks (TIA), mortality, and cardiac complications within 30 days post-procedure. Symptomatic ischemic complications (stroke or TIA) in perioperative and postoperative period were defined clinically and by MRI-DWI after the procedure in the first week or at any time if was required. Intra- and postoperative HD [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Intra- and postoperative HD, i.e., bradycardia and/or hypotension, were defined as a heart rate of \u0026le;\u0026thinsp;60 beats/min and/or a systolic blood pressure level of \u0026le;\u0026thinsp;100 mmHg. During the procedure, the patient\u0026rsquo;s heart rate was measured using electrocardiography, and their blood pressure was evaluated through the sheath in the femoral artery. After the procedure, electrocardiographic monitoring was continued, and non-invasive blood pressure measurements were obtained every 15 min until at least 24 h. After Balloon inflation and angioplasty, 0.5 mg of atropine sulphate was administered if HD occurs. Grading scale of HD is as follows 0\u0026thinsp;=\u0026thinsp;none, 1\u0026thinsp;=\u0026thinsp;mild, temporary with hospital stay not prolonged, 2\u0026thinsp;=\u0026thinsp;prolonged with extended hospital stay, 3\u0026thinsp;=\u0026thinsp;severe with severe major neurological or cardiac adverse event. The incidence of HPS which was detected clinically as exhibiting symptoms such as an ipsilateral throbbing headache, seizure, or focal neurological symptoms without cerebral infarction. Cardiac complications which were detected clinically by presence of any cardiac symptoms (typical chest pain or dyspnea) investigated by proper investigations (ECG) if happened and mortality within thirty days. The collected data was revised, coded, and introduced to a personal computer using Statistical Package for Social Science (SPSS 25, by IBM: Armonk; New York, USA). A suitable analysis for the data was done according to its type. Quantitative data was summarized by the mean, standard deviation (\u0026plusmn;\u0026thinsp;SD) while qualitative data was summarized by frequencies and percentages.\u003c/p\u003e"},{"header":"Results","content":"\u003col class=\"decimal_type\"\u003e\n \u003cli\u003eDemographic data and risk factors: - The study included 14 males (70%) and 6 females (30%). The age of the patients ranged from 51 to 75 years with a mean age of 63.95 \u0026plusmn; 6.79. As regards the risk factors; 10 cases (50%) were smokers, 11 cases (55%) were diabetic, 18 cases (90%) were hypertensive, 6 cases (30 %) had ischemic heart disease (IHD) and 18 cases (90%) had dyslipidemia.\u003c/li\u003e\n \u003cli\u003eClinical presentations: -Fourteen cases (70%) had ischemic stroke and 6 cases (30%) presented with TIA.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDigital subtraction angiography (DSA) findings (Table 1); Site of stenosis was mainly in the proximal internal carotid artery (70.0% of cases in right side) and (85.0% in left side), while Degree of stenosis showed that 50.0% had more than 70 % stenosis on the right ICA while 70.0% had more than 70 % stenosis in the left side.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTable 1: Digital subtraction angiography (DSA) findings\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"90%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eBasic angiographic data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal No. = 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSite of stenosis in the right Side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCommon - ICA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProximal ICA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSite of stenosis in the left Side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCommon - ICA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProximal ICA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (85.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eRight Carotid stenosis\u0026nbsp;\u003cbr\u003e\u0026nbsp;degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLess than 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50-69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMore than 70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eLeft Carotid stenosis\u0026nbsp;\u003cbr\u003e\u0026nbsp;degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLess than 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50-69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMore than 70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003eInterventional details; Timing of intervention was (in minutes) 60.50 \u0026plusmn; 7.76; Types of stents in those twenty patients (forty carotid stents, two for each patient) 62.5 % were wall stents, 12.5% were portogee and 25 % were CASPER stents as shown in (Table 2)\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTable 2: Types of carotid stents used in our study\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"74%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eTypes of stents used\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003eTotal No. = 40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eWall stent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e25 (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003ePortogee stent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e5 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eCASPER stent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e10 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003ePost procedural complications (Table 3): - Hemodynamic depression - Forty percent (40%) had hemodynamic depression which required medical treatment intra procedural with no cases for post procedural prolonged HD. Hyper perfusion syndrome - Among those twenty patients, 5% had hyper perfusion syndrome which manifested as headache and confusion which lasted shortly. Neither Vascular access complications, Stroke, Cardiac complications or Mortality were reported in our study group.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTable 3: Post procedural complications among the studied patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"89%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003ePeriprocedural data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eTotal No. = 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eVascular access\u0026nbsp;\u003cbr\u003e\u0026nbsp;complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eStroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eHyper perfusion syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e19 (95.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eCardiac complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eRenal dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eMortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003col start=\"6\"\u003e\n \u003cli\u003eNIHSS and mRs before and after stenting\u003c/li\u003e\n\u003c/ol\u003e\n\u003col style=\"list-style-type: upper-roman;\"\u003e\n \u003cli\u003eBefore procedure: NIHSS and mRs Scales pre-procedural, the Median (IQR) NIHSS was 1 (0 \u0026ndash; 2) and Median (IQR) was 1 (0 \u0026ndash; 1) respectively as shown in (Table 4).\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTable 4: Pre procedural NIHSS and MRS among the studied patients\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"90%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003ePre-procedural NIHSS mRs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eTotal No. = 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003eNIHSS_pre procedural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eMedian(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e1 (0 \u0026ndash; 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003emRs _pre procedural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eMedian(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e1 (0 \u0026ndash; 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003col start=\"2\" style=\"list-style-type: upper-roman;\"\u003e\n \u003cli\u003eAfter procedure: There was no change in mRs and NIHSS immediately post procedural in comparison with the pre procedural mRs and NIHSS as shown in (Table 5).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTable 5: NIHSS and MRS Pre and post procedure among the studied patients\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"87%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003ePre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003ePost-\u003cbr\u003e\u0026nbsp;procedural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eTest value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003eSig.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003eNIHSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (0 \u0026ndash; 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1(0 \u0026ndash; 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.000\u0026ne;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 3px;\"\u003e\n \u003cp\u003emRs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (0 \u0026ndash; 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1(0 \u0026ndash; 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.000\u0026ne;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003col start=\"3\" style=\"list-style-type: upper-roman;\"\u003e\n \u003cli\u003eAfter one month (30 days follow up): there were no progression in mRs or NIHSS scales as shown in (table 6 \u0026amp; 7)\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTable 6: NIHSS and mRs after one month among the studied patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"87%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003ePost-procedural (1 month) NIHSS and mRs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eTotal No. = 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003eNIHSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1 (0 \u0026ndash; 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003emRs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1 (0 \u0026ndash; 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 7: NIHSS and mRs after 30 days from BCAS among the studied patients\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"87%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003ePost-\u003cbr\u003e\u0026nbsp;procedural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e1 month post\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003eTest value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eSig.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eNIHSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1(0 \u0026ndash; 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e1 (0 \u0026ndash; 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.000\u0026ne;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003emRs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1(0 \u0026ndash; 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e1 (0 \u0026ndash; 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.000\u0026ne;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0 \u0026ndash; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003col start=\"7\"\u003e\n \u003cli\u003eFollow up brain DW-MRI findings: Ninety five percent of patients (nineteen patients) had no abnormalities while five percent (one patient) had few new restricted spots in DWI without significant neurological deficit as shown in (figure 1).\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"8\"\u003e\n \u003cli\u003eClinical follow up after one month: there were no mortality, stroke or Cardiac complications after one month follow up as shown in (table 8).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTable 8: Clinical follow up after one month among the studied patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"81%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePost-procedural (1 month) data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eTotal No. = 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eStroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eCardiac complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eMortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe occurrence of severe bilateral carotid artery stenosis (BCS) varies in published studies, ranging from 3.2\u0026ndash;39% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Treatment options for BCS include bilateral carotid endarterectomy (CEA), unilateral CEA with contralateral carotid angioplasty and stenting (CAS), and bilateral CAS [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Simultaneous bilateral CEA is infrequently performed due to the risk of significant injury to the phrenic and vagus nerves, as well as the stellate ganglion, which can lead to higher rates of serious neurological complications during surgery [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The average age of the patients in our study was 63.95\u0026thinsp;\u0026plusmn;\u0026thinsp;6.79 years. Age and multiple risk factors are believed to influence the development of carotid artery disease [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our sample had a higher proportion of males (14/20; 70.0%), which aligns with findings from previous studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Among the comorbidities in our patients, hypertension and dyslipidaemia were the most common (90%), followed by diabetes mellitus (55%) and ischemic heart disease (30%) consistent with earlier research [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Hypertension increases the risk of ischemic stroke by worsening atherosclerosis and promoting heart disease, with isolated systolic hypertension and elevated pulse pressure posing a greater risk. It is regarded as the most critical modifiable risk factor for both atherosclerosis and stroke [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. High total cholesterol and low-density lipoprotein (LDL) levels are linked to atherosclerosis, and diabetes mellitus can double or quadruple the risk of ischemic stroke while also increasing post-stroke morbidity and mortality. Macrovascular disease is the leading cause of death among diabetic patients, with cerebrovascular atherosclerosis being a potential cause of strokes related to diabetes mellitus [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Regarding the angiographic features of carotid stenosis in our study, stenosis primarily occurred in the internal carotid artery (70.0% of cases in the right ICA and 85.0% in the left ICA). Of the cases, 50.0% exhibited over 70% stenosis on the right ICA, while 70.0% had over 70% stenosis on the left side, which is consistent with most previous studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Over the past decade, increasing evidence has supported the use of simultaneous bilateral carotid artery stenting (SBCAS) as a safe and effective treatment for bilateral carotid stenosis [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The first case of SBCAS was documented in 1997 by Mathur et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Since then, further studies have affirmed the safety and feasibility of this simultaneous approach [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Some concerns regarding simultaneous procedures include high-risk surgical candidates for CEA, severe concurrent diseases requiring surgical intervention, and the risk of new strokes from severe contralateral carotid stenosis following prolonged hypotension and hemodynamic instability during the procedure [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Conversely, the incidence of bradycardia, hypotension, and hyper perfusion syndrome (HPS) tends to be higher during SBCAS [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In our current study, hyper perfusion syndrome was observed in one case (5%), presenting as headache and confusion, which aligns with findings from previous studies reporting incidences during SBCAS ranging from 2.5\u0026ndash;16.7%, compared to 2.1% for unilateral CAS [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Our results can be attributed to appropriate procedural preparation, including blood pressure monitoring and control. As for the incidence of hemodynamic depression, our study found it occurred in 40% of cases, characterized as mild and short-lived during balloon angioplasty, effectively managed with atropine. This is similar to previous studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which indicated the incidence of perioperative hemodynamic depression during SBCAS was between 29.16% and 71.8%, compared to 20.0\u0026ndash;57.7% for unilateral CAS or staged CAS. Thus, simultaneous BCAS does not appear to significantly increase the risk of hemodynamic depression; if it does occur, vasopressors can be used for treatment, and it should not be a reason to halt the simultaneous procedure. Our findings can be explained by effective blood pressure monitoring and control, alongside careful technical execution during balloon angioplasty. In this study, we did not observe any strokes following SBCAS, which is consistent with previous reports [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In contrast, stroke rates in other studies ranged from 1.59\u0026ndash;5.36% in Lai et al. (2019) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], 5.12% in Shchehlov et al. (2021) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], 2.4% in Li et al. (2014) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and 4.2% in Jiang et al. (2016) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], with unilateral CAS at 3.6% in Dong et al. (2012) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and staged BCAS at 7.7% in Li et al. (2014) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].These discrepancies could be attributed to various factors, including meticulous case selection, pre-procedural preparation using dual antiplatelet therapy (DAPT), intraprocedural management, and the relatively small sample size of this study. In our study, all patients underwent follow-up brain diffusion-weighted magnetic resonance imaging (DW-MRI). Nineteen patients (95%) exhibited no abnormalities, while 1 patient (5%) showed a few new restricted spots in diffusion-weighted imaging without significant neurological deficits. This incidence was lower than reported by Oshita et al. (2020) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], who noted multiple high-intensity spots in three out of eight procedures (37.5%), two of which were bilateral lesions in group A (SBCAS), and one in group B (staged BCAS), affecting one out of eight procedures (12.5%). All lesions identified in diffusion-weighted imaging were less than 1 mm in diameter, with a median of seven lesions (range 2\u0026ndash;7) in group A and four in group B [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Additionally, our findings were lower than those reported by Bijuklic et al. (2013), who found high-intensity lesions in 32.8% of patients following CAS with cerebral embolic protection [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Our results also contrasted with those of Altinbas et al. (2014), who noted that patients undergoing CAS experienced perioperative hemodynamic depression associated with a threefold increase in new high-intensity lesions in diffusion-weighted imaging compared to those without hemodynamic depression, suggesting that avoiding hemodynamic depression could reduce the occurrence of high-intensity lesions during the perioperative period [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Our results can be explained by effective procedural preparation, including blood pressure control before and during the procedure, along with proper technical approaches and manipulation during the crossing of lesions and stent deployment. Post-operative hospital stays for our patients ranged from 2 to 3 days, with most patients discharged the day after the procedure. This duration was shorter than reported in previous studies, such as Oshita et al. (2020), which noted a mean stay of 5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 days in the SBCAS group and 5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 days in the staged BCAS group [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This difference could be attributed to effective pre- and post-procedural preparation. Clinical follow-up of our patients after one month indicated no mortality, strokes, or cardiac complications, aligning with findings from earlier studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This outcome may be due to proper post-procedural care with DAPT and effective risk factor management. In this retrospective study, we observed favourable outcomes in patients who underwent SBCAS and found no significant difference in the 30-day complication rates between simultaneous and staged stenting, as reported in previous studies. This suggests that simultaneous BCAS does not lead to a notable increase in the risk of perioperative complications compared to staged BCAS\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSBCAS is regarded as a relatively safe and effective treatment for selected patients with bilateral carotid stenosis, particularly those facing high stroke risk during open-heart surgery. It is important to thoroughly assess patients to determine the most suitable treatment approach. While the occurrence of hyper perfusion syndrome (HPS) was higher compared to unilateral CAS, the actual number of patients affected was small, and their symptoms were generally mild and resolved spontaneously. Additionally, other procedural complications, such as hemodynamic depression (HD), stroke, and myocardial infarction (MI), were not worse than those seen in staged CAS procedures.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCAS\u003c/strong\u003e: Carotid artery stenting; \u003cstrong\u003eDW MRI\u003c/strong\u003e: Diffusion-weighted magnetic resonance imaging; \u003cstrong\u003eNIHSS\u003c/strong\u003e: National Institute of Health Stroke Scale; \u003cstrong\u003eSBCAS\u003c/strong\u003e : simultaneous bilateral carotid angioplasty and stenting ; \u003cstrong\u003emRs :\u0026nbsp;\u003c/strong\u003emodified ranken scale; \u003cstrong\u003eICA\u003c/strong\u003e : internal carotid artery; \u003cstrong\u003eCCA\u003c/strong\u003e: common carotid artery; \u003cstrong\u003eDSA\u003c/strong\u003e diagnostic subtraction angiography.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003eself-funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003ethe authors declare no conflicts of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSS,HA,AE,HA,AH and FK conceived of the study and participated in its design ,coordination and helped to draft the manuscript. SS, FK and AH participated in the design of the study and performed statistical analysis. All authors have agreed to the conditions noted to authorship agreement form. The authors read and approve the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e Ethics approval and consent to participate\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003ethe study protocol was approved by Neurology Department Research Ethical Committee in November 2020 (approval number not available). Written informed consent was obtained from the patients participating in the study, or their first-degree relatives if the patient was unable to provide consent, after informing them about the study rationale and their right to withdraw from the study at any time without any consequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e Availability of data and material \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDataset is available as master sheet in Excel format and publicly available in neurology Department, Ain shams university, through communicating to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003e\u003cstrong\u003eFeigin, V. L., Nguyen, G., \u0026amp; GBD 2019 Stroke Collaborators. 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(2012). \u003c/strong\u003eComparison of the safety of simultaneous bilateral carotid artery stenting versus unilateral carotid artery stenting: 30-day and 6-month results. \u003cem\u003eChinese Medical Journal\u003c/em\u003e, 125(6), 1010-1015.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eBijuklic, K., Wandler, A., Varnakov, Y., Tuebler, T., \u0026amp; Schofer, J. (2013). \u003c/strong\u003eRisk factors for cerebral embolization after carotid artery stenting with embolic protection: a diffusion-weighted magnetic resonance imaging study in 837 consecutive patients. \u003cem\u003eCirculation: Cardiovascular Interventions\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e(3), 311-316.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAltinbas, A., Algra, A., Bonati, L. H., Brown, M. M., Kappelle, L. J., de Borst, G. J., ... \u0026amp; van der Worp, H. B. (2014). \u003c/strong\u003ePeriprocedural hemodynamic depression is associated with a higher number of new ischemic brain lesions after stenting in the International Carotid Stenting Study-MRI Substudy. \u003cem\u003eStroke\u003c/em\u003e, \u003cem\u003e45\u003c/em\u003e(1), 146-151.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-neurology-psychiatry-and-neurosurgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejnp","sideBox":"Learn more about [The Egyptian Journal of Neurology, Psychiatry and Neurosurgery](http://ejnpn.springeropen.com)","snPcode":"41983","submissionUrl":"https://submission.springernature.com/new-submission/41983/3","title":"The Egyptian Journal of Neurology, Psychiatry and Neurosurgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"simultaneous bilateral carotid angioplasty and stenting, hemodynamic depression, hyper perfusion syndrome","lastPublishedDoi":"10.21203/rs.3.rs-5778244/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5778244/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Stroke is a major global cause of death, affecting nearly 13.7 million people annually. Carotid artery stenosis accounts for up to 12% of all ischemic strokes. Bilateral carotid stenosis, which affects between 8% and 39% of patients with symptomatic carotid stenosis, presents a treatment challenge, as it is often a relative contraindication for carotid endarterectomy and is excluded from many clinical trials. With advancements in endovascular technology, simultaneous bilateral carotid angioplasty and stenting (SBCAS) has emerged as a safe and effective option, with complication risks similar to those of unilateral carotid artery stenting. The safety profile of SBCAS has been the subject of various studies, which have reported mixed outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The study included twenty patients; 14 males (70%) and 6 females (30%). The age of the patients ranged from 51 to 75 years with a mean age of 63.95 ± 6.79. Fourteen cases (70%) had ischemic stroke and 6 cases (30%) presented with TIA. Site of stenosis was mainly in the proximal internal carotid artery (70.0% of cases in right side) and (85.0% in left side), while Degree of stenosis showed that 50.0% had more than 70 % stenosis on the right ICA while 70.0% had more than 70 % stenosis in the left side. Timing of intervention was (in minutes) 60.50 ± 7.76; Types of stents in those twenty patients (forty carotid stents, two for each patient) 62.5 % were wall stents, 12.5% were Portege and 25 % were CASPER stent. Forty percent (40%) had hemodynamic depression, 5% had hyper perfusion syndrome. Neither Vascular access complications, Stroke, Cardiac complications or Mortality were reported in our study group. There were no mortality, stroke or Cardiac complications after one month follow up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: SBCAS is a safe and effective procedure for properly selected patients with bilateral carotid stenosis and can help reduce the risk of recurrent cerebrovascular events.\u003c/p\u003e","manuscriptTitle":"Safety of Simultaneous Bilateral Internal Carotid Artery Stenting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-10 17:50:47","doi":"10.21203/rs.3.rs-5778244/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-08T14:32:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-07T10:33:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-07T10:31:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Neurology, Psychiatry and Neurosurgery","date":"2025-01-07T05:56:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-neurology-psychiatry-and-neurosurgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejnp","sideBox":"Learn more about [The Egyptian Journal of Neurology, Psychiatry and Neurosurgery](http://ejnpn.springeropen.com)","snPcode":"41983","submissionUrl":"https://submission.springernature.com/new-submission/41983/3","title":"The Egyptian Journal of Neurology, Psychiatry and Neurosurgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6858978e-775d-4cb9-b5fa-29f9fdb84db0","owner":[],"postedDate":"January 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:15:25+00:00","versionOfRecord":{"articleIdentity":"rs-5778244","link":"https://doi.org/10.1186/s41983-025-00979-0","journal":{"identity":"the-egyptian-journal-of-neurology-psychiatry-and-neurosurgery","isVorOnly":false,"title":"The Egyptian Journal of Neurology, Psychiatry and Neurosurgery"},"publishedOn":"2025-07-01 15:57:54","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-01-10 17:50:47","video":"","vorDoi":"10.1186/s41983-025-00979-0","vorDoiUrl":"https://doi.org/10.1186/s41983-025-00979-0","workflowStages":[]},"version":"v1","identity":"rs-5778244","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5778244","identity":"rs-5778244","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}