Plaque prolapse in carotid artery stenting: mechanisms, imaging and device-based prevention

Carotid artery stenting (CAS) is an established revascularization option for patients with carotid disease at high surgical risk. Periprocedural cerebral embolization remains a clinical concern, and plaque prolapse, the extrusion of atherosclerotic material through the stent struts into the lumen, has emerged as an actionable mechanism directly linked to embolic events and adverse neurological outcomes. This narrative review provides a structured, practice-oriented framework addressing one specific question: how can plaque prolapse be prevented during CAS? Drawing on prospective registries, comparative cohort studies and intravascular imaging analyses based on optical coherence tomography (OCT) and intravascular ultrasound (IVUS), we discuss the main determinants of prolapse risk, plaque morphology, procedural variables and device selection, converging on dual-layer micromesh stent (DLMS) technology as the most advanced device-based solution available. Pooled clinical data indicate a 30-day stroke rate of approximately 1.4% when DLMSs are used in combination with embolic protection, and OCT studies confirm reduced prolapse compared with single-layer stents. Prevention requires an integrated strategy combining lesion-specific characterisation, optimised technique and tailored device selection, while standardised imaging definitions and adequately powered randomised trials with hard clinical endpoints remain research priorities. © 2026 by the authors.