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Objective Carotid artery stenting for heavily calcified lesions is challenging for interventionists. A calcium burden is associated with suboptimal dilatation, periprocedural complications, high rates of restenosis, and poor outcomes. We describe the first report of 2 cases of successful carotid artery stenting for heavily calcified lesions using a scoring balloon. Case Presentation The patients were both aged 75 years, 1 male and 1 female, who had experienced ipsilateral stroke prior to the procedures. They had dense calcifications at the lesions, stenosis rates of 95% (near occlusion) and 86% according to the North American Symptomatic Carotid Endarterectomy Trial criteria, and calcification arcs of 270° and 360°, respectively. Considering the heavy calcification, predilation with scoring balloons (NSE PTA balloon; Nipro, Osaka, Japan) at the rated burst pressure was performed in both cases. Sufficient dilatation was achieved, followed by carotid stent deployment (Precise Pro RX; Cordis, Miami Lakes, FL, USA). After postdilatation, the stenosis rates decreased to 21% and 23%, respectively. Although 1 patient experienced prolonged bradycardia and hypotension, they were well managed with anticholinergic and vasoconstrictive agents. Both patients remained asymptomatic. Conclusion Carotid artery stenting using a scoring balloon obtained acceptable improvements in severe stenosis with heavily calcified lesions. This method could be a useful option for the revascularization of heavily calcified lesions.

Introduction In carotid artery stenting (CAS), a guiding catheter (GC) placement to the appropriate position is the first step of the successful procedure. In normal settings, GC is navigated along with stable support of guidewire and inner‐catheter which are sent distally to external carotid artery. In cases of low‐positioned common carotid artery (CCA) lesions, however, safe GC placement without touching lesions is often difficult. Herein, we report the technique of safe GC navigation of “no‐touching” to the low‐position CCA plaque using Newton‐shaped stiff inner‐catheter. Methods We reviewed CAS procedures with low‐positioned CCA lesions using “no‐touching” technique: a balloon guiding catheter (BGC) was coaxially advanced in combination with 4‐French Newton‐shaped stiff inner‐catheter (Newton‐T®, Medikit, Tokyo, Japan). With its advantage of shape and stiffness buffering the kickback force with support of lesser curvature of aortic arch, BGCs were navigated to the appropriate position without touching to the plaques. Results The technique were applied in 5 cases (age: 73‐85 years old, 4 males, 4 left‐sided lesions) among the 37 consequent CAS cases. GC fixation by GooseNeck snare was used concurrently in 2 cases. BGCs were successfully navigated without touching plaques in all cases. CAS procedures were subsequently undergone and no complication was observed. Conclusion GC navigation using “no‐touching” technique with Newton‐T catheter was safe and useful in CAS procedures for low‐positioned CCA lesions.