Stenting and angioplasty of the symptomatic chronically occluded carotid artery

Abstract

Patients with hemodynamic impairment ipsilateral to a carotid occlusion are at a high risk of subsequent stroke, and currently 2 surgical options have been studied: extracranial-to-intracranial bypass and direct thromboendarterectomy. We report the successful revascularization of 2 symptomatic chronically occluded carotid arteries with stenting and angioplasty.

Fig 1.

A, Diffusion-weighted MR imaging of patient 1 shows a linear pattern of increased signal intensity in the internal border zone region of the right hemisphere (white solid arrow). B, Fluid-attenuated inversion recovery image sequence shows an old right parietal infarct with encephalomalacia that was clinically silent before the procedure. C, Conventional angiography from the right common carotid artery confirms the presence of a total occlusion of the right internal carotid artery at the bifurcation (solid black arrow). D, Poststent placement and angioplasty of the occlusion show normal antegrade flow distal to the previously occluded segment (dashed black arrow). E, A xenon CT postacetazolamide performed before stent placement shows lack of cerebral vasoreactivity in the right hemisphere in contrast to the left side. F, Poststenting and angioplasty xenon CT reveal augmentation of flow to the right hemisphere except for the known area of infarct in the right parietal lobe. G, Color maps demonstrating the differences in flows before (from Fig E) and after (from Fig F) the procedure show the improved augmented blood flow to the right hemisphere as demarcated by the red color.

Fig 2.

A, Diffusion-weighted MR imaging of patient 2 shows a linear pattern of increased signal intensity in the internal borderzone region of the right hemisphere (white arrow). B, Conventional angiography confirms the presence of a heavily calcified bulb with total occlusion of the internal carotid artery at the bifurcation (solid black arrow). C, Poststent placement and angioplasty show the antegrade flow across the occluded segment distally (dashed black arrow). D, The patient also had an atherosclerotic stenosis evident at the C1 level of the extracranial internal carotid artery that was not revascularized (black arrowhead). There is normal filling of the intracranial vessels. E, A xenon CT after preprocedure acetazolamide administration demonstrates poor cerebral vasoreactivity to the right hemisphere. F, A xenon CT after postprocedure acetazolamide administration demonstrates robust augmentation of blood flow to the right hemisphere. G, The color map demonstrates the difference in blood flows between Figures E and F, with red demarcating an increase in flow postprocedure. H, Diffusion-weighted MR imaging after stent placement revealed no additional acute infarcts as a result of the procedure.