• atherosclerosis
• stent
• stroke
• technology

We read with interest the report by Dr Burkhardt and his colleagues of a US multicenter experience with the Walrus balloon guide catheter (BGC) for both elective carotid artery stenting (eCAS) and that performed in conjunction with mechanical thrombectomy (tCAS).1 While eCAS and tCAS have some commonality, eCAS and emergent tCAS in the setting of an acute intracranial occlusion are entirely distinct clinical scenarios. The former—in order to demonstrate clinical benefit or equivalence to options such as medical management or endarterectomy—must be carried out with extreme care to achieve vanishingly low rates of embolic complications. The latter is an all-hands-on-deck, let’s-get-this-vessel-open-NOW scenario where a few additional emboli here or there likely will escape clinical notice. So, for the sake of this discussion, let us focus on the eCAS situation alone. Specifically, what, if any, advantage does a BGC inflated in the common carotid artery (CCA) offer for eCAS?

Carotid stenting is one of the most studied surgeries in the history of medicine. There are numerous large, randomized clinical trials enrolling thousands of patients with independent adjudication of outcomes. The recently published Second Asymptomatic Carotid Surgery Trial (ACST-2 trial), randomizing 3625 patients, is the first large randomized trial to show no difference between CAS and carotid endarterectomy (CEA) in the primary endpoint of stroke.2 Before ACST-2, a consistent criticism of CAS has been the increased incidence of minor stroke when compared with CEA.3 4 While the risk of CAS has been decreasing over time (likely due to more experience, improved devices and especially better patient selection), this criticism has led to a search for better cerebral …