Carotid stenting has been shown to have equivalent efficacy and safety compared to carotid endarterectomy for patients with symptomatic carotid artery stenosis [ ]. Improvements in case selection, technique, and devices have led to improved post-procedural stroke outcomes [ ]. Despite these advances, both revascularization modalities continue to have a clinically relevant stroke risk and evidence of asymptomatic cerebral embolization burden [ ]. Lesion characteristics, procedural and hardware-related factors have been associated with embolization. In addition to the characteristics of the carotid lesion, a complex aortic arch with likely catheter manipulation-related embolization of the contralateral carotid territory has been demonstrated [ ].