An 83-year-old woman presented with left arm claudication and dizziness with exertion of her left arm. Asymmetric blood pressure measurements were noted in her upper extremities with systolic blood pressure being 30 mm Hg lower in her left arm. (A) Angiography reveals a high grade ostial left subclavian stenosis (arrow) and reversal of flow in the left vertebral artery. (B) There is severe elastic recoil of the left subclavian artery after balloon angioplasty alone and a balloon expandable 9.0 x 28 mm Omnilink (Guidant, Temecula, California) stent is placed. (C) No residual stenosis remains and antegrade flow in the left vertebral artery is immediately restored. Clinical follow-up demonstrated no recurrence of symptoms at 6 months.

Major adverse events were defined as a composite of death, stroke, or myocardial infarction within 30 days, or death or ipsilateral stroke between 31 days and 1 year. In the intention-to-treat analysis (A), the rate of event-free survival at 1 year was 87.8% among patients randomly assigned to carotid stenting, compared with 79.9% among those randomly assigned to endarterectomy (p = 0.053). In the actual-treatment analysis (B), the rate of event-free survival at 1 year was 88.0% among patients who received a stent, compared with 79.9% among those who underwent endarterectomy (p = 0.048). I bars represent 1.5 times the standard error. Reproduced with permission from Yadav et al. (35).

An 82-year-old man with a recent transient ischemic attack affecting the right hemisphere of his body, and accelerating angina, was noted to have a high-grade stenosis in the left internal carotid artery by duplex ultrasonography. (A) Angiography reveals a 90% stenosis of the left internal carotid artery. (B) Owing to proximal vessel tortousity, after the sheath is placed in the common carotid artery, tortousity is displaced distally to the internal carotid artery. (C) After placement of a distal embolic protection device Accunet (Guidant, Temecula, California) and treating the lesion with a self expanding 6 to 8 x 40 mm Acculink (Guidant) nitinol stent, 60% residual stenosis remains. (D) After balloon dilation with a 5.0 x 20 mm ViaTrac balloon (Guidant), <30% residual stenosis remains. CC = common carotid artery; EC = external carotid artery; IC = internal carotid artery.

(A,B) Representative ultrasound images of atherosclerotic carotid plaques with ultrasound analysis. (A) Regular B-mode image of carotid atheroma as shown by arrowheads. Plaque-intima-media thickness (IMT)_max was measured in this mode as shown by an arrow. (B) Integrated backscatter (IBS)-mode image. The red dotted line indicates the region of interest (ROI) in the plaque (intima-media complex), and the blue dotted line indicates the ROI in the adventitia using the manual outline definition mode. Values of cIBS and plaque-IMT_max of this plaque are –19.6 dB and 2.44 mm, respectively. (C,D) Representative IBS images of carotid atheroma from baseline to follow-up. (C) Carotid atheroma at pretreatment. Values of cIBS and plaque-IMT_max of this plaque are –17.8 dB and 2.05 mm, respectively. (D) The same carotid atheroma post-pravastatin therapy (6 months). Values of cIBS and plaque-IMT_max of this plaque are –14.2 dB and 2.10 mm, respectively. CCA = common carotid artery; ICA = internal carotid artery. Adapted with permission from Watanabe et al. (50).

A 78-year-old woman presented with episodic lightheadedness, and a complete work-up including magnetic resonance angiography (MRA) of the brain suggested a high-grade stenosis of the basilar artery (BA). (A) Intracerebral angiography confirms a high-grade proximal BA stenosis (arrow) of 95%. (B) After balloon dilation, <30% residual stenosis remains. She had difficulty with her balance and vision for 1 month after the procedure, but then her symptoms completely resolved. (C) Six months later with symptom recurrence, an MRA demonstrated restenosis of the BA, which is confirmed by intracerebral angiography. Note the hypoplastic left vertebral artery (LVA). (D) After placement of a 2.5 x 12 mm Taxus (Boston Scientific, Natick, Massachusetts) drug-eluting coronary stent (thick arrow), <20% residual stenosis remains, and the patient has had no further neurological events at 24-month follow-up. The hypoplastic LVA and the left inferior cerebellar artery (LICA) (thin arrows) both remain patent after stent placement across these vessels. LPCA = left posterior cerebral artery; RPCA = right posterior cerebral artery; RVA = right vertebral artery.

A 52-year-old man who had undergone a previous renal transplant and coronary artery bypass graft surgery presented with unstable angina. As the graft to the left anterior descending artery (LAD) was occluded, a proximal LAD lesion was stented. Heparin and eptifibatide were used as the antithrombotic and antiplatelet regimen. About 45 min after the procedure, the patient had right hemianopsia, and emergent intracerebral angiography was performed after a computerized tomography scan of the head excluded an intracranial hemorrhage. (A) Anterior circulation angiography: left common carotid angiography with intracranial imaging reveals patent anterior (AC) and middle cerebral (MC) arteries without significant disease of the intracranial internal carotid artery (IC). (B) Posterior circulation angiography: left vertebral angiography with intracranial imaging demonstrates left posterior cerebral artery (PCA) occlusion (arrow). (C) A Tracker catheter (Boston Scientific, Natick, Massachusetts) is placed beyond the occlusion in the left PCA via the vertebral artery approach, and contrast injection through the catheter confirms the patency of the distal vasculature. (D) After local delivery of intra-arterial thrombolytic therapy, flow is restored in the left PCA with the patient leaving the hospital with only a mild residual visual field cut. BA = basilar artery; VA = vertebral artery.

A 39-year-old woman presented with poorly controlled hypertension despite being treated with 2 antihypertensive medications. A renal artery magnetic resonance angiogram suggested right renal artery stenosis. (A) Selective right renal artery angiography demonstrating the classic "beaded" appearance of fibromuscular dysplasia. (B) Selective right renal artery angiography after percutaneous transluminal balloon angioplasty (PTA) continues to demonstrate the classic "beaded" appearance of FMD with a minor angiographic change (arrow) just before the renal artery bifurcation. (C) Results of PressureWire measurement depicting the phasic and mean proximal renal artery pressure (Pa), phasic and mean distal renal artery pressure (Pd), and fractional flow reserve (FFR). This figure demonstrates a distal renal artery to proximal renal artery peak-to-peak systolic gradient of 42 mm Hg, mean pressure gradient of 30 mm Hg, and a mean distal to proximal artery pressure ratio of 0.71. (D) After successful PTA, PressureWire measurement reveals a 0 mm Hg residual gradient and a mean distal to proximal renal artery pressure ratio of 1.0. The patient’s hypertension resolved at follow-up examination, and she did not require any antihypertensive therapy. Adapted with permission from Mahmud et al. (79).

A 69-year-old man with a serum creatinine of 1.7 mg/dl and hypertension (blood pressure 158/97 mm Hg) despite treatment with 4 antihypertensive medications underwent magnetic resonance angiogram, which revealed a left renal artery stenosis. (A) On selective left renal artery angiography, a high-grade left renal artery stenosis of 90% (arrow) in the presence of an accessory left renal artery. (B) After balloon angioplasty, there is evidence of elastic recoil at the ostium and a residual stenosis (arrow) without complete resolution of the pressure gradient across the stenosis. (C) After placement of a 6.0 x 18 mm Herculink stent (Guidant, Temecula, California) in the main renal artery (arrow) and a 3.5 x 13 mm Cypher drug-eluting stent (Cordis, Miami, Florida) in the accessory renal artery, no residual stenosis remains. At 6-month follow-up, the patient had a blood pressure of 130/85 mm Hg and required treatment with 2 antihypertensive medications.

A 68-year-old man presented with severe lifestyle-limiting claudication despite maximum medical therapy including aspirin, cilostazol, atorvastatin, an exercise program, and an aggressive control of all modifiable risk factors including smoking cessation. A noninvasive work-up, including ankle-brachial indices (<0.60 bilaterally) and a magnetic resonance angiogram, suggested severe bilateral aortoiliac and external iliac disease. (A) Abdominal angiography demonstrates bilateral long-segment high-grade disease in the left and right common and external iliac arteries. (B) Kissing balloon angioplasty after placement of 2 self-expanding 9.0 x 100 mm Absolute (Guidant, Temecula, California) stents in the left and right common iliac arteries in the "hugging stent" manner. An additional 8.0 x 56 mm Absolute stent is also placed in an overlapping manner in the left external iliac artery. (C) Final abdominal angiogram reveals no significant residual stenosis and resolution of all resting gradients followed by dramatic symptomatic improvement.

Self-expanding nitinol stent 9 months after implantation showing a severe stent fracture in the distal and a moderate stent fracture (arrows; left panel) in the proximal part of the stent. Angiographically, both lesions were associated with a restenosis >50% diameter reduction (arrows; right panel). Reproduced with permission from Scheinert et al. (127).

A 64-year-old woman with right leg claudication (ankle-brachial index 0.68) despite aggressive medical therapy and an exercise program underwent abdominal angiography with lower extremity runoff. (A) An occluded right superficial femoral artery (SFA) just beyond the ostium is noted with three vessel runoff to the foot via collaterals. (B) The occlusion in the right SFA (arrow) is just beyond the ostium of the vessel. (C) After traversing the stenosis with a 0.035-inch guidewire (Terumo, Japan), the wire is exchanged over an end-hole catheter to a 0.014-inch BMW wire (Guidant, Temecula, California), and atherectomy with a SilverHawk (Foxhollow, California) catheter is performed. (D) Final angiographic result after significant plaque extraction. Duplex ultrasound follow-up at 12 months revealed no evidence of restenosis at the site of atherectomy and the patient remained clinically asymptomatic. CFA = common femoral artery.