AIM: The aim of this study was to use the maximum of all the protective measures to make carotid angioplasty and stenting (CAS) a safe procedure.METHODS: Twenty patients with severe carotid disease have been treated. These patients were considered as high risk for carotid endarterectomy and not suitable for transfemoral CAS for anatomic reasons. Transcervical approach to the common carotid (CCA) and the internal jungular vein (IJV) has been used. The vessels were cannulated with introducing sheaths and the flow in the internal carotid (ICA) was reversed by occluding the proximal CCA and creating a fistula with the IJV by connecting the two sheaths. The carotid lesion was crossed under retrograde flow and a filter was positioned and opened in the distal ICA. Antegrade flow was then resumed and CAS was performed.RESULTS: All procedures were successful and uneventful with the exception of transient hypotension in 3 patients. The mean time of flow reversal was less than 1.5 min. Seventeen patients were discharged the following morning and 3 on the subsequent day, because of hypotension.CONCLUSION: The results of this preliminary study indicate that the combination of several protective measures for CAS is effective. Further series are required to confirm our findings.