Protected endovascular revascularization of subacute and chronic total occlusion of the internal carotid artery

Abstract

Background and purpose: The natural course of symptomatic carotid artery occlusion with hemodynamic impairment is poor. Surgical revascularization may improve the outcome; however, its efficacy has not been established yet. The goal of this study was to characterize the technical and clinical outcomes following endovascular recanalization of the ICA under cerebral circulatory protection.

Materials and methods: Endovascular recanalization was attempted in 8 patients with symptomatic ICA occlusions. The duration of the occlusion ranged from 7 days to 7 months (mean, 2.5 months), and the mean length of the occlusion was 95 mm. Cerebral hemodynamics ipsilateral to the side of the occlusion were severely impaired in all patients. The endovascular procedure was performed under total cerebral circulatory protection, beginning with proximal protection with a subsequent switch to distal protection after successful guidewire passage.

Results: The occlusion was recanalized successfully in 7 of 8 patients (88%), resulting in improvement of ipsilateral cerebral hemodynamics without symptomatic stroke. Small asymptomatic ischemic lesions were detected in 6 of 8 patients (75%) on DWI, and 1 patient developed a mild groin hematoma. Ischemic episodes did not recur during the mean follow-up period of 19 months. However, 1 patient experienced asymptomatic reocclusion, which was re-treated successfully without complications, while another patient developed mild retinal hemorrhage at 3 months after the procedure due to the combination of antiplatelet and anticoagulant therapy.

Conclusions: Endovascular revascularization of an ICA occlusion is feasible and well-tolerated in patients with subacute or chronic total occlusion of the ICA.

Fig 1.

Recanalization procedure schematic. A, The procedure is initiated with proximal protection with the occlusion balloon at the CCA and the ECA. B, The aspiration catheter is navigated along the guidewire, which is passed successfully across the occluded segment under proximal protection. C, The distal protection balloon is navigated beyond the occluded segment through the extraction port of the aspiration catheter. D, The occluded segment is dilated with the balloon under distal protection. E, The ICA is recanalized after the stents are deployed and the thrombi are aspirated.

Fig 2.

Successful recanalization of a left chronic ICA occlusion (case 4). A 78-year-old man with recurrent episodes of transient right hemiparesis underwent recanalization at 6 months after the initial diagnosis of left ICA occlusion. A–C, Lateral projections of the left carotid angiogram. A, Before treatment, the occlusive lesion extends from the cervical segment to the petrous segment of the ICA. B, Just after the recanalization. C, One-year follow-up. D, DWI obtained 1 day after the procedure. Asymptomatic small ischemic lesions ≤9 mm are detected in the ipsilateral side of the recanalized ICA and in the contralateral side. E and F, SPECT images with acetazolamide vasodilatory challenge before and 13 months after the procedure, respectively. Severe impairment of the left cerebral hemispheric vascular reserve improved after successful recanalization of the ipsilateral ICA.

Fig 3.

Successful recanalization of right chronic ICA occlusion (case 5). A 69-year-old man with a minor completed stroke in the right parietal lobe underwent recanalization at 7 months after the initial diagnosis of right ICA occlusion. A–C, Lateral projections of the right carotid angiogram. A, Before treatment, the occlusive lesion extends from the cervical segment to the cavernous segment of the ICA. B, Just after the recanalization. C, Sagittal reconstruction of 3D-CTA obtained 4 months after the procedure shows no restenosis along the recanalized ICA. D, DWI obtained 1 day after the procedure. Small asymptomatic ischemic lesions are detected in the ipsilateral cerebral hemisphere. E and F, SPECT images with acetazolamide vasodilatory challenge before and 6 months after the procedure, respectively. Severe impairment of the vascular reserve of the right cerebral hemisphere improved after successful recanalization of the right ICA.