Revascularization technique for a long occlusive lesion in a case of symptomatic chronic occlusion of the internal carotid artery

The risk of stroke in patients presenting with chronic occlusion of the internal carotid artery (COICA), despite the best medical treatment, is reported at the level of 10–20% per year [1]. Hypoperfusion of the brain either resulting from insufficient collateral circulation through the arterial cerebral circle or from occlusion of the cerebral arteries is the most common cause of such strokes. Although endovascular repair (ER) of the occluded artery remains a therapeutic option, success of such revascularization primarily depends on the location and length of the occlusion [2, 3]. ER of a long COICA is technically challenging, and the repair is associated with a risk of complications comprising distal embolization, perforation or dissection of the ICA, arteriovenous fistula to the cavernous sinus and hyperperfusion syndrome [3]. In patients presenting with a very tortuous course of the ICA in the carotid canal, navigating through the lesion and stent deployment are especially difficult. Fortunately, new guidewires, low-profile stents and balloons facilitate successful repair of symptomatic occlusions of the ICA, even in technically demanding cases. Here we present the treatment of a 73-year-old woman presenting with stroke resulting from occlusion of the left internal carotid artery. After conservative management (hypotension and double antiplatelet therapy, statin) her clinical status improved and the signs of cerebral ischemia receded. Still, during the following 3 weeks she had many recurrent 3–5-minute episodes of aphasia and hemiplegia, with several falls. Her National Institutes of Health Stroke Scale (NIHSS) score was 6–7 points. Angiography (Figure 1 B) revealed occlusion of the left ICA from its cervical (C1) to the lacerum/cavernous (C3/4) segment, and also occlusion of the horizontal (M1) segment of the middle cerebral artery, with collateral circulation to the distal segments of the middle cerebral artery coming from the anterior cerebral artery, which in turn received inflow from the posterior communicating artery. Computed tomography perfusion study (Figure 1 A) demonstrated hypoperfusion of the left cerebral hemisphere, with the mismatch volume of 112 ml. Considering the neurological status of this patient, we decided to attempt ER of the occluded ICA. After introduction of the 9F Mo.Ma proximal protection system (Medtronic, Mineapolis, MA, USA), over the V-14 ControlWire (Boston Scientific, Natick, MA, USA) guidewire, the 3MAX (Penumbra,...


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