Objectives Spontaneous recanalization of a chronic total occlusion of the extra-cranial internal carotid artery is an under-reported clinical entity. This paper reviews the different etiologies of internal carotid artery occlusion, its natural course, as well as the significance and our recommendations for the management of spontaneous internal carotid artery recanalization. Methods A review of literature on etiology, diagnosis, and treatment of internal carotid artery occlusion and recanalization was conducted. PubMed database was searched using the terms “internal carotid occlusion” and “recanalization”. Articles were reviewed and studies involving the management of internal carotid artery occlusion and spontaneous recanalization were included. We subsequently developed a management algorithm for chronic total occlusion of the internal carotid artery and spontaneous recanalization of such lesions based on the available evidence. Results Common etiologies of chronic total occlusion of the internal carotid artery include carotid atherosclerotic disease, cardioembolic, and carotid dissection. Progression of an asymptomatic to symptomatic occlusion is estimated at 2–8% annually. Well-compensated patients can be asymptomatic. In others, clinical symptoms range from ipsilateral or global hypoperfusion to embolic stroke in some cases of spontaneous recanalization. Spontaneous recanalization occurs in 2.3–10.3% of patients but rarely results in a cerebrovascular event. Conclusions Progression of an asymptomatic chronic total occlusion of the internal carotid artery to symptomatic is infrequent. The management algorithm of chronic total occlusion of the internal carotid artery and spontaneous recanalization of the internal carotid artery must be tailored to the patient based on symptoms, etiology of the lesion, imaging findings, surgical risk, and reliability for follow-up.

Objectives To report our experience and compare the results of percutaneous endovascular aortic aneurysm repair (PEVAR) performed under monitored anesthesia care (MAC) to PEVAR under general anesthesia (GA). Methods A retrospective review of patients who underwent non-emergency endovascular abdominal aortic aneurysm repair (EVAR) was completed. Patients were excluded if they had a complex repair, including fenestrated, branched, or parallel endografting. Demographics, operative data, 30-day mortality/morbidity and postoperative outcomes were analyzed. Results A total of 159 patients were identified with a median age of 69. 115 patients had PEVAR, 45 (39.1%) PEVAR MAC and 70 (60.9%) PEVAR GA. PEVAR MAC compared to PEVAR GA had decreased operative time (106 vs. 134 min, P < 0.001), time in the operating room (163 vs. 245 min, P = 0.016), and estimated blood loss (EBL) (115 vs. 176 mL P = 0.012). There was no statistically significant difference in the hospital length of stay (LOS) (1.9 vs. 2.7 days, P = 0.133), and post-operative complications including pulmonary (2.2 vs. 2.9%, P = 0.835). Forty-four patients had EVAR with a femoral cutdown (FC), including 14 PEVAR conversions. PEVAR conversion was associated with higher EBL (543 vs. 323 mL, P = 0.03), operative time (230 vs. 178 min, P = 0.01), and operating room time (307 vs. 275 min, P = 0.01) compared to planned EVAR with FC. Conclusions PEVAR under MAC is associated with shorter time in the operating room compared to PEVAR under GA. PEVAR under MAC does however not decrease overall morbidities, including postoperative pulmonary complications.

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