Using previous imaging data, stent and balloon choices should be made in advance to intraoperative stent placement, and the chosen diameter is additionally evaluated intraoperatively using a variety of Hagar dilators. Endoscopic guidance is extremely helpful in aiding stent delivery (Fig. 40.2). Once the vessel is exposed, the endoscope is advanced until the first side branch is visualized, thereby obtaining a good estimate of the maximum length to avoid jailing of those side branches. In addition, the endoscope can facilitate advancing a wire into the correct vessel, rather than mistakenly entering a smaller side branch distally. Soft wires are preferable and stiff wires as well as long sheaths are not required. Prepping the stent on the balloon should be performed in standard technique, even though elimination of all air or the use of contrast in the balloon is not quite as important as during percutaneous stent delivery. In small patients, if a stent that can be expanded to adult size is too long, it can be shortened during the procedure using standard sterilized wire cutters or strong scissors. Importantly though, this should only be performed for closed-cell design stents, as cutting or shortening open-cell design stents can be associated with a loss of stent integrity and radial strength. Once a wire has been placed in appropriate position, the balloon/stent is advanced over the wire and positioned by visualizing the proximal end of the stenotic lesion. If there are any concerns about wire or balloon positioning, it can be helpful to use a C-arm during stent expansion as this will show if a stent expands unequally or if the balloon/stent may be trapped in a smaller distal vessel. Once the stent is fully expanded, the endoscope is utilized to evaluate the entire stent position and stent lumen (Fig. 40.1). Any struts that expand beyond the proximal end of the vascular lesion can be folded over by the surgeon using some stronger pickups, thereby creating a smooth adherence of the struts to the vessel wall (Fig. 40.3). In addition to visual and endoscopic inspection, it is desirable to perform an exit angiography at the end of the procedure to evaluate the results of stent placement angiographically.