Direct endovascular recanalization of chronic carotid occlusion: should we do it? Case report.

Hauck, Erik F; Ogilvy, Christopher S; Siddiqui, Adnan H; Hopkins, L Nelson; Levy, Elad I

BACKGROUND AND IMPORTANCE Patients with chronic carotid artery occlusion face a significant risk of stroke. It is believed that treatment is indicated if medical therapy fails or even as prophylaxis in high-risk patients. Direct surgical repair with carotid endarterectomy has a considerable failure rate and significant associated risks. Indirect repair with an extracranial-to-intracranial bypass has become the mainstay of surgical treatment. In this case study, the authors assess the feasibility of direct endovascular recanalization in the setting of chronic carotid occlusion, and discuss technical nuances and indications in comparison with the world literature and alternative options. CLINICAL PRESENTATION Two patients presented with symptomatic, chronic, complete occlusion of the proximal carotid artery. The duration of documented occlusion exceeded 3 years in one patient and 6 months in the other. METHODS Endovascular recanalization was attempted using extracranial and intracranial stenting with proximal protection (flow arrest/reversal). Both patients had an excellent radiographic result, improving from Thrombolysis in Cerebral Infarction (TICI) grade 0 (no perfusion) to grade 3 (complete perfusion). The first patient's clinical symptoms resolved. The second patient remained unchanged with a mild facial droop. CONCLUSION These preliminary results show potential for the endovascular management of this complicated disease. Long-term results and more data will determine the ultimate place of endovascular recanalization for symptomatic chronic carotid occlusion among other therapies.