Patient description: A 46-year-old man presents with dizziness and frequent headaches. He has a family history of CAD, but no other cardiovascular risk factors such as smoking, high blood pressure, and diabetes mellitus and is physically active. The patient's LDL-C and HDL-C levels were 545 and 53 mg/dL, respectively. His fasting glucose and triglyceride levels (85 and 158 mg/dL, resp.) were within normal limits. The patient reported no use of lipid-lowering medications. Neck auscultation revealed a systolic murmur 3+/6+ in the neck, radiating to the skull. Ultrasonography of the carotid arteries, revealed severe stenosis in the left internal carotid artery (LICA), as well as moderate stenosis in the right internal carotid artery (RICA) estimated between 40% and 50%. For the LICA, the peak-systolic (PSV) and end-diastolic velocity (EDV) cutoff values were 208.5 cm/s and 54.5 cm/s, respectively; RICA PSV was 91.72 cm/s and RICA EDV was 37.37 cm/s. Plaque was observed in the anterior and posterior walls of the internal carotid artery and common carotid artery, which were characterized as bulky plates extending to the middle third of the internal coronary arteries (ICAs) and as predominantly echogenic and hyperechoic, with less than 50% of the area being echolucent with uneven surfaces.

Clinical trial eligibility criteria: eligible ages (years): 18.0-999.0,  Carotid Artery Disease Stroke Patient is at least 18 years old; 2. Patient is willing and capable of complying with the study protocol requirements, including the specified follow-up period; 3. Patient is willing to provide written informed consent prior to enrollment in the study; 4. Male, infertile female, or non-lactating female of child bearing potential practicing an acceptable method of birth control with a negative pregnancy test within 7-days prior to study procedure; 5. Patient is either symptomatic, i.e. with a history of TIAs or non-disabling stroke within 6 months of the procedure, with carotid stenosis ≥ 50%, or asymptomatic with carotid stenosis ≥ 80%, as diagnosed by angiography using methodology;4 6. The target lesion is located in the internal carotid artery (ICA) and the reference vessel diameter, i.e. the common carotid artery (CCA) is < 10 mm based on angiographic assessment  Acute evolving or recent stroke within 7 days of study evaluation; 2. Cardiac embolism; 3. Acute myocardial infarction less than 72 hours prior to the procedure; 4. Major surgical procedure within 30 days preceding CAS; 5. Major surgical procedure within 30 days after the index procedure; 6. Prior major ipsilateral stroke with residual deficit or other neurologic conditions that may affect neurological assessments; 7. Pregnancy or breastfeeding; 8. Severe chronic renal insufficiency (serum creatinine is ≥ 2.5 mg/dL); 9. Contraindication to study medications, including antiplatelet therapy; 10. Prior sensitivity to contrast media that cannot adequately be controlled with pre-medication; 11. Untreatable bleeding diathesis or hypercoagulable state or refusal to blood transfusions; 12. History of uncontrolled pulmonary hypertension; 13. Intracranial pathology; 14. Patient unable or unwilling to undergo DW-MRI of the brain 15. Patient without adequate transtemporal window for transcranial Doppler examination 16. Other anatomic or co-morbid conditions that, in the investigator's opinion, could limit the patient's ability to participate in the study or to comply with follow-up requirements, or impact the scientific soundness of the study results. 17. Isolated ipsilateral hemisphere leading to subject intolerance to flow reversal; 18. Anatomic conditions that preclude performance of carotid artery stenting