To the Editor Re: Evaluation of the self-expanding effect of carotid stents in the early postoperative period. Ergun O et al. Vascular 2024;32: 589-595

We read with interest the above-named article. We congratulate the authors on their efforts to make carotid stenting and angioplasty (CAS) a less invasive procedure. We do, however, have some concerns with the publication.

The authors have failed to cite the extensive literature on the use of self-expanding carotid stents (SES) alone, or with only pre-stent angioplasty for less aggressive CAS and reduction of carotid sinus reactions (CSRs).^1–5 It has been established that SES alone can expand a carotid stenosis, both in the early postoperative period ² and long-term. ⁶ The anatomic success of this genuinely less aggressive technique depends on plaque morphology, particularly the degree of calcification as determined using CT angiography (CTA). ⁶

The authors used balloon angioplasty and they inflated the balloons to their nominal pressures, or full diameters. The balloon diameters correspond to the actual diameters of normal internal carotid arteries. How does this actually represent a “less aggressive” or “minimal balloon dilatation” technique? They do not state whether post-stent angioplasty was performed, which is the most likely stage of CAS to generate distal emboli. How often did they need to use larger balloons or overinflation to achieve their desired 30% residual stenosis? There is no documentation of whether their approach resulted in less CSR, and there is no indication of the long-term anatomic and clinical outcomes.

We believe that the publication would have been greatly improved by a more complete documentation of the clinical and imaging information in their patient cohort and a better review of the existing literature.