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

Abstract

OBJECTIVE The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%-7% per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization. METHODS The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients, five of whom were female (5/31 [16.13%]). Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Carotid artery occlusion was defined as 100% cross-sectional occlusion of the vessel lumen as documented on CTA or MRA and confirmed by digital subtraction angiography. RESULTS Four types (A-D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2-6 months' follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73). CONCLUSIONS The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.

Endovascular Reperfusion for Acute Isolated Cervical Carotid Occlusions: The Concept of “Hemodynamic Thrombectomy”

“…As demonstrated in this study, a true isolated cervical carotid occlusion, i.e., one that presents with no associated intracranial occlusion, may be infrequent in the setting of acute stroke treatment. Few studies reporting results on the acute treatment of cervical carotid occlusions art to be found in the literature, and they have shown conflicting methods and results [9, 10, 13-18]. Failure to provide a clear definition of carotid occlusions and the imaging method used to characterize the exact carotid segments that are occluded is an important limitation of previous studies.…”

“…The authors included 193 patients in an endovascular group and showed significantly higher rates of favorable outcomes (43.5 vs. 26.3%; p = 0.0001) and of sICH (11.4 vs. 3.9%; p = 0.0011) but not of mortality (26.4 vs. 27.2%; p = 0.85) in the endovascular group compared with an intravenous thrombolysis group [8]. In a recent study, Jadhav et al [17] included 107 acute symptomatic patients presenting with isolated proximal carotid occlusions that were treated by the endovascular approach. The authors showed a recanalization rate of 92% and a rate of good neurologic outcome of 65% (mRS score ≤2), but distal embolization was observed in 22% of the patients, of whom 16% required intra-arterial treatment.…”

“…Therefore, we indicated endovascular treatment of carotid occlusions independent of the type of occlusion. When we compared the data on our 4 patients that did not achieve recanalization with the data from a new study [18] that showed a low recanalization rate of chronic carotid occlusion types C and D, we had 3 patients with carotid occlusion type D (patients 2, 4, and 9) and 1 patient (patient 8) with a dissection. This finding may explain why we could not achieve carotid recanalization in those 3 patients.…”

Assessment of carotid atherosclerotic disease using three-dimensional cardiovascular magnetic resonance vessel wall imaging: comparison with digital subtraction angiography

“…3D CMR VWI images can cover the whole internal carotid artery within 7 min. Assessment of lesions within a large FOV is useful for the selection of stent size and the formulation of surgical procedures [36].…”

Endovascular recanalization of chronically occluded internal carotid artery

“…When reported in the study, the occlusion period was, in general, defined as the time between the radiologically confirmed ICA occlusion date and treatment. In addition, outcomes were analyzed based on the type of ICA occlusion classified as limited to the cervical ICA, and occlusion of the cervical and intracranial ICA (up to the petrocavernous segments) 6 7. Complications were also compared between successfully recanalized ICA versus failed recanalization, and successfully recanalized ICA versus medical management.…”