Skip to main content

Advertisement

SpringerLink
Log in

Endovascular recanalization for symptomatic subacute and chronically occluded internal carotid artery: feasibility, safety, a modified radiographic classification system, and clinical outcomes

  • Interventional Neuroradiology
  • Published:
Neuroradiology Aims and scope Submit manuscript

Abstract

Purpose

To evaluate the feasibility and safety of endovascular recanalization for symptomatic subacute and chronic internal carotid artery occlusion (ICAO); to propose a newly modified radiographic classification of ICAO that can rigorously identify suitable candidates for endovascular ICAO treatment.

Methods

We included 42 consecutive patients who had ICAO with ischaemic symptoms refractory to medical therapy. We examined the symptomatology, complications, follow-up results and radiographic images of ICAO receiving attempted endovascular treatment. We attempted to stratify all radiographic images into categories based on morphological occlusion patterns, occlusion segments and distal ICA reconstitution on digital subtraction angiography (DSA).

Results

Four types (A–D) of radiographic ICAO were identified. We redefined type B as having a tapered stump but no distal lumen. The rate of successful recanalization was 83.33% (35/42 ICAOs; type A, 18/20; type B, 7/10; type C, 10/11; type D, 0/1). The perioperative complication rate was 11.90% (5/42), including 3 asymptomatic distal embolisms, 1 symptomatic cerebral infarction and 1 asymptomatic carotid artery dissection. None of these technique-related complications led to severe neurological damage or death. Modified Rankin Scale (mRS) scores after 1–20 months of follow-up were significantly decreased in successfully revascularized patients (P < 0.001). There was no significant change in mRS scores in the 7 patients in whom recanalization failed (P > 0.05).

Conclusions

Endovascular recanalization seems to achieve technical success and clinical improvement for symptomatic subacute and chronic ICAO. Additionally, our newly modified radiographic classification of ICAO may be valuable in assessing the technical feasibility and safety of procedures in symptomatic ICAO patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2.
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Malhotra K, Goyal N, Tsivgoulis G (2017) Internal carotid artery occlusion: pathophysiology, diagnosis, and management. Curr Atheroscler Rep 19(10):41. https://doi.org/10.1007/s11883-017-0677-7

    Article  CAS  PubMed  Google Scholar 

  2. Persoon S, Luitse MJ, de Borst GJ, van der Zwan A, Algra A, Kappelle LJ, Klijn CJ (2011) Symptomatic internal carotid artery occlusion: a long-term follow-up study. J Neurol Neurosurg Psychiatry 82(5):521–526. https://doi.org/10.1136/jnnp.2010.208330

    Article  PubMed  Google Scholar 

  3. Persoon S, Klijn CJ, Algra A, Kappelle LJ (2009) Bilateral carotid artery occlusion with transient or moderately disabling ischaemic stroke: clinical features and long-term outcome. J Neurol 256(10):1728–1735. https://doi.org/10.1007/s00415-009-5194-3

    Article  PubMed  PubMed Central  Google Scholar 

  4. Lin MS, Lin LC, Li HY, Lin CH, Chao CC, Hsu CN, Lin YH, Chen SC, Wu YW, Kao HL (2008) Procedural safety and potential vascular complication of endovascular recanalization for chronic cervical internal carotid artery occlusion. Circ Cardiovasc Interv 1(2):119–125. https://doi.org/10.1161/circinterventions.108.772350

    Article  PubMed  Google Scholar 

  5. Fluri F, Engelter S, Lyrer P (2010) Extracranial-intracranial arterial bypass surgery for occlusive carotid artery disease. Cochrane Database Syst Rev (2):Cd005953. https://doi.org/10.1002/14651858.CD005953.pub2

  6. Grubb RL Jr, Powers WJ, Clarke WR, Videen TO, Adams HP Jr, Derdeyn CP (2013) Surgical results of the carotid occlusion surgery study. J Neurosurg 118(1):25–33. https://doi.org/10.3171/2012.9.jns12551

    Article  PubMed  Google Scholar 

  7. Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP Jr, Derdeyn CP (2011) Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the carotid occlusion surgery study randomized trial. Jama 306(18):1983–1992. https://doi.org/10.1001/jama.2011.1610

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Chen K, Hou X, Zhou Z, Li G, Liu Q, Gui L, Hu J, Shi S (2017) The efficacy and safety of endovascular recanalization of occluded large cerebral arteries during the subacute phase of cerebral infarction: a case series report. Stroke Vasc Neurol 2(3):124–131. https://doi.org/10.1136/svn-2017-000086

    Article  PubMed  PubMed Central  Google Scholar 

  9. Kao HL, Lin MS, Wang CS, Lin YH, Lin LC, Chao CL, Jeng JS, Yip PK, Chen SC (2007) Feasibility of endovascular recanalization for symptomatic cervical internal carotid artery occlusion. J Am Coll Cardiol 49(7):765–771. https://doi.org/10.1016/j.jacc.2006.11.029

    Article  PubMed  Google Scholar 

  10. Thomas AJ, Gupta R, Tayal AH, Kassam AB, Horowitz MB, Jovin TG (2007) Stenting and angioplasty of the symptomatic chronically occluded carotid artery. AJNR Am J Neuroradiol 28(1):168–171. https://doi.org/10.1016/j.jalz.2006.11.002

    Article  CAS  PubMed  Google Scholar 

  11. Fan YL, Wan JQ, Zhou ZW, Chen L, Wang Y, Yao Q, Jiang JY (2014) Neurocognitive improvement after carotid artery stenting in patients with chronic internal carotid artery occlusion: a prospective, controlled, single-center study. Vasc Endovasc Surg 48(4):305–310. https://doi.org/10.1177/1538574414525863

    Article  Google Scholar 

  12. Siddiqui AH, Hopkins LN (2013) Asymptomatic carotid stenosis: the not-so-silent disease. J Am Coll Cardiol 61(25):2510–2513. https://doi.org/10.1016/j.jacc.2013.01.087

    Article  PubMed  Google Scholar 

  13. Huang CC, Chen YH, Lin MS, Lin CH, Li HY, Chiu MJ, Chao CC, Wu YW, Chen YF, Lee JK, Wang MJ, Chen MF, Kao HL (2013) Association of the recovery of objective abnormal cerebral perfusion with neurocognitive improvement after carotid revascularization. J Am Coll Cardiol 61(25):2503–2509. https://doi.org/10.1016/j.jacc.2013.02.059

    Article  PubMed  Google Scholar 

  14. Hasan D, Zanaty M, Starke RM, Atallah E, Chalouhi N, Jabbour P, Singla A, Guerrero WR, Nakagawa D, Samaniego EA, Mbabuike N, Tawk RG, Siddiqui AH, Levy EI, Novakovic RL, White J, Schirmer CM, Brott TG, Shallwani H, Hopkins LN (2018) Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery: pilot study. J Neurosurg 1-10. https://doi.org/10.3171/2018.1.jns172858

  15. Qureshi AI (2002) New grading system for angiographic evaluation of arterial occlusions and recanalization response to intra-arterial thrombolysis in acute ischemic stroke. Neurosurgery 50(6):1405–1414; discussion 1414-1405. https://doi.org/10.1097/00006123-200206000-00049

    Article  PubMed  Google Scholar 

  16. Bamford JM, Sandercock PA, Warlow CP, Slattery J (1989) Interobserver agreement for the assessment of handicap in stroke patients. Stroke 20(6):828. https://doi.org/10.1161/01.str.20.6.828

    Article  CAS  PubMed  Google Scholar 

  17. Flaherty ML, Flemming KD, McClelland R, Jorgensen NW, Brown RD Jr (2004) Population-based study of symptomatic internal carotid artery occlusion: incidence and long-term follow-up. Stroke 35(8):e349–e352. https://doi.org/10.1161/01.STR.0000135024.54608.3f

    Article  PubMed  Google Scholar 

  18. Kim WH, Min PK, Kim DJ, Shim WH (2010) Successful carotid stenting for chronic total occlusion of the internal carotid artery. Korean Circ J 40(6):288–291. https://doi.org/10.4070/kcj.2010.40.6.288

    Article  PubMed  PubMed Central  Google Scholar 

  19. Park S, Park ES, Kwak JH, Lee DG, Suh DC, Sun UK, Lee DH (2015) Endovascular management of long-segmental petrocavernous internal carotid artery (Carotid S) occlusion. 17(3):336-343. https://doi.org/10.5853/jos.2015.17.3.336

  20. Hauck EF, Natarajan SK, Ohta H, Ogilvy CS, Hopkins LN, Siddiqui AH, Levy EI (2011) Emergent endovascular recanalization for cervical internal carotid artery occlusion in patients presenting with acute stroke. Neurosurgery 69(4):899–907; discussion 907. https://doi.org/10.1227/NEU.0b013e31821cfa52

    Article  PubMed  Google Scholar 

  21. Dalyai RT, Chalouhi N, Singhal S, Jabbour P, Gonzalez LF, Dumont AS, Rosenwasser R, Ghobrial G, Tjoumakaris SI (2013) Stent-assisted endovascular recanalization of extracranial internal carotid artery occlusion in acute ischemic stroke. World Neurosurg 79(1):143–148. https://doi.org/10.1016/j.wneu.2012.08.017

    Article  PubMed  Google Scholar 

  22. Issawi A, Klopfenstein J (2015) Can a closed carotid artery be reopened? Curr Cardiol Rep 17(10):85. https://doi.org/10.1007/s11886-015-0638-0

    Article  PubMed  Google Scholar 

  23. Group EIBS (1985) Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med 313(19):1191–1200. https://doi.org/10.1056/nejm198511073131904

    Article  Google Scholar 

  24. Zanaty M, Samaniego EA, Teferi N, Kung DK, Nakagawa D, Hudson J, Ortega-Gutierrez S, Allan L, Jabbour P, Hasan DM (2019) Hybrid surgery for internal carotid artery revascularization. World Neurosurg 121:137–144. https://doi.org/10.1016/jwneu201810091230

    Article  PubMed  Google Scholar 

Download references

Funding

This study was funded by the Key Program of Natural Science Foundation of Guangdong Province, China (No. 2017B030311015), Guangzhou Municipal People’s Livelihood Science and Technology Project (No.201803010085), High-level Hospital Construction Project (No.DFJH201907), Supporting Research Funds for Outstanding Young Medical Talents in Guangdong Province (No.KJ012019442), National Key R&D Program of China (No. 2017YFC1310200) and Science and Technology Plan Foundation of Guangzhou (No.201904010066).

Author information

Authors and Affiliations

  1. Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China

    Mo Liumei, Ma Guixian, Dai Chengbo, Li Changmao, Ma Tengyun, Yang Zhexian, He Chizhong, Xiao Hao, Wang Lijuan, Duan Jinhai & Zhang Yuhu

Authors
  1. Mo Liumei
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ma Guixian
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dai Chengbo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Wang Shuo
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Li Changmao
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ma Tengyun
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yang Zhexian
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. He Chizhong
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Xiao Hao
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Wang Lijuan
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Duan Jinhai
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Zhang Yuhu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Zhang Yuhu.

Ethics declarations

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical approval

The study was approved by the Ethics Committee of Guangdong Provincial People’s Hospital and was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed consent

All participants gave their written informed consent in this study.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mo, L., Ma, G., Dai, C. et al. Endovascular recanalization for symptomatic subacute and chronically occluded internal carotid artery: feasibility, safety, a modified radiographic classification system, and clinical outcomes. Neuroradiology 62, 1323–1334 (2020). https://doi.org/10.1007/s00234-020-02458-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00234-020-02458-0

Keywords

Search

Navigation