A proposed modern standardized technical approach for symptomatic chronic carotid total occlusion management

Abstract

Chronic carotid total occlusion (CCTO) is a known cause of ischemic stroke and transient ischemic attack. Symptomatic CCTO is associated with up to 30% risk of recurrent ischemic stroke, despite optimal medical treatment. Notably, a randomized controlled trial reported that previous surgical management did not improve the overall prognosis of these patients. Endovascular treatment of CCTO has been proposed as a feasible strategy to re-establish cerebral perfusion in symptomatic patients. However, its use is controversial and not supported by evidence from randomized clinical trials. Recently, a meta-analysis reported a reasonably high procedural success without an excess periprocedural complication rate, but several steps are needed before the procedure is mature enough to be tested in randomized controlled trials. This review highlights the developments in the endovascular recanalization of CCTO and emphasizes key steps towards standardizing the procedure.

Keywords: Chronic carotid total occlusion; carotid atherosclerosis; carotid stent; dissection; hypoperfusion.

Figure 1.

Endovascular recanalization of a short-cervical lesion. (a) Significant perfusion abnormalities on the side of the occlusion; (b) DSA showing the initial stump. (c) Intimal dissection phase, notice the orientation of the vertebral catheter in the direction of the stump and the negative roadmap of the microcatheter, proving early re-entry in the petrous segment, the BGC is inflated. (d) Initial predilation with inflated BGC; (e) final construct with three subsequent Wallstents, no need for further coverage as there was normal, undissected lumen; (f) normalization of perfusion abnormalities immediately after the procedure; (g) 1 month OCT shows good endothelialization of the implant across its entire length. DSA: digital substraction angiography; BGC: balloon guide catheter.

Figure 2.

Long-lesion recanalization with four subsequent Wallstents in a 60-year-old patient. (a) Right ICA injection showing no-stump and retrograde filling of the cavernous segment. (b) Initial dissection with 0.0140″ guidewire and microcatheter through 5-Fr Vertebral. (c) Exchange wire placed in the angular artery. (f) Successful recanalization with four subsequent Wallstents (Boston Scientific), notice significant overlap for the distal proximal two stents with less overlap for the high-cervical and petrous stents. (d,e) OCT follow-up imaging at 1 month shows good endothelialization at the level of proximal stents with small decoaptation of the stents and intraluminal struts at the level of the cervical stents.

Figure 3.

(a) DSA shows a long-term complication of restenosis in a recanalized CCTO; (b) magnified unsubstracted imaging shows stent fracture at the occlusion site; (c) OCT shows intimal hyperplasia due to stents struts malaposition. The patient was successfully treated with the implantation of another stent and angioplasty at this level. CCTO: Chronic carotid total occlusion; DSA: digital substraction angiography.