proposed [transcervical carotid stenting (TCS) þ carotid flow reversal] was associated with a low incidence of new ischemic brain lesions (12.5%) when checked by DW-MRI. The aim of the study was to prove the safety of this hybrid procedure (neck surgery þ CAS) in preventing stroke and silent brain infarctions. We know that the real role of CAS is still the subject of debate and no randomized trial has yet proved the superiority of CAS over CEA. 2 From this point of view the paper lacks a comparison with CEA, which is the gold standard for carotid lesions. As a second point, the device used to protect the brain in this study may also be questionable. For best results, the embolic protection device needs to be matched to each patient and lesion: this means that there is no room for standardization as the same device cannot be suitable for all different patients and lesions. CAS could be considered as an alternative to CEA and I strongly believe that there are precise indications for such a hybrid technique. The critical steps of CAS that are most likely to produce emboli are during engagement of the CCA, advancement of the guiding catheter or sheath into the CCA, crossing of the stenotic lesion with the guide wire, stent deployment and balloon dilatation. The hybrid procedure could reduce the embolic load by removing one of these critical steps. As reported by many other Authors, the crucial aspects of CAS (as for every vascular intervention) are the interventionist’s/surgeon’s learning curve, combined with full knowledge of materials. This hybrid technique needs to be restricted to subgroups of patients with a particularly difficult arch anatomy or shaggy aorta, in order to overcome possible preventable access problems. Moreover, as the operator’s skill and materials improve, the trans-femoral approach may be considered more appropriate due to the mini-invasiveness of access (cutdown vs. percutaneous approach), the duration of the procedure, the LOS and possibly lower expense. The clinical significance of new post-procedural silent ischemic cerebral lesions is still unknown; the only certainty is thattodate,CEAistheprocedurewiththelowestembolicrisk.