BackgroundRevascularization with carotid stent (CAS) is considered the therapeutic alternative to endarterectomy (CEA). However, its role compared to CEA remains questioned, mainly due of the heterogeneity of long-term results. The objective of this study was to report the efficacy and durability of CAS in terms of stroke prevention in a “real world experience”.MethodThis was a single-center retrospective analysis of 344 patients treated with CAS between January 2001 and December 2015.The primary outcome of the trial was stroke, myocardial infarction, or death during a periprocedural period or any stroke event over a 15-year follow-up. The secondary aim was to identify risk factors for 30-day complications, long-term neurological complications, and intra-stent restenosis.ResultsThe primary composite end point (any stroke, myocardial infarction, or death during the periprocedural period) was 2.3%. The use of an EPD was protective against major complications.Long-term follow-up was achieved in 294 patients (85,5%) with a median of 50 months (range 0-155 months). Fifty-six (16,3%) died within this period, most commonly of nonvascular causes (4 patients had stroke-related deaths). During the follow-up period, 8 strokes and 3 TIAs were diagnosed (3.2%).ISR determined by sequential ultrasound was assessed in 4.4% of the patients and remained asymptomatic in all but 2 patients (0.6%). All patients with restenosis underwent revascularization with balloon angioplasty.ConclusionThe long-term follow-up results of our study validate CAS as a safe and durable procedure with which to prevent ipsilateral stroke, with an acceptable rate of restenosis, recurrence and mortality.

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A 46-year-old woman was sent for cardiac catheterization due to symptomatic severe aortic regurgitation (AR) with preserved systolic left ventricular function on transthoracic echocardiogram. Aortography showed an atypical aortic valve morphology, and a remarkable absence of cusps coaptation (Fig. 1A, white arrow). Transesophageal echocardiogram showed a severe AR due to a dysfunctional aortic valve with 4 cusps (Fig. 1B). Retrospective electrocardiography-gated multidetector cardiac computed tomography (MDCCT) confirmed a quadricuspid aortic valve morphology (Fig. 1C), with a smaller anomalous fourth cusp in the anterior position between right and left aortic cusps (type B according to Hurwitz and Robert's classification), without further aortic root or ascending aortic abnormalities: aortic valve ring area diameters were 18 × 26.6 mm (area 415 mm 2 ), 36.7 × 32.4 mm for aortic root, 31.5 mm for sinotubular junction, and 34 mm for ascending aorta. No other structural cardiac defect was found.Quadricuspid aortic valve is a rare congenital cardiac defect with an estimated frequency of 0.05%. Approximately 75% present with significant AR due to the absence of central cusps coaptation, typically without other aortic root abnormalities but coexisting congenital cardiac defect in up to 30% of cases. Ascending aortic dilatation has been recently reported also in 30% of cases. Most patients develop symptoms at middle-age (40-60 years old). Surgical aortic valve replacement is the preferred treatment, although in selected cases valve repair (surgical excision of the small fourth cusp and resuspension of the other cusps achieving tricuspid functionality) can be considered. MDCCT provides clear images and definite anatomical information for classification or surgical considerations. Conflict of interest: None declared

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