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A 66-year-old man with a dilated cardiomyopathy (ejection fraction 12%), type 2 diabetes mellitus and left carotid endarterectomy 2 years ago now presents with deteriorating cardiac function. During the evaluation for cardiac transplantation, a carotid duplex scan revealed an estimated left internal carotid stenosis of 80-99%. Although asymptomatic, his severe carotid stenosis would have excluded him from consideration for cardiac transplantation, so, he was referred for carotid revascularization. As a result of the re-stenotic nature of the lesion and his severe cardiomyopathy, the risk for carotid endarterectomy (CEA) was increased. He was entered in the multicenter FDA-sponsored SAPPHIRE (stenting and angioplasty with protection in patients at high risk for endarterectomy) study and was randomized to carotid stenting.