A systematic review of endovascular treatment for chronic total occlusion of the internal carotid artery

Abstract

The management of patients with symptomatic chronic total occlusion (CTO) of the internal carotid artery (ICA) is controversial. The aim of this systematic review was to investigate patient selection, technical success, early and late outcome of endovascular treatment for CTO of the ICA. PubMed/Medline and EMBASE databases were searched until January 2, 2020 for studies on endovascular treatment for CTO of the ICA. A descriptive analysis of demographic, clinical and anatomic data, endovascular technique, perioperative and late outcomes was performed. A total of 1,222 articles were screened, 8 retrospective or prospective cohort studies were reviewed; 276 patients, 18.9% females, mean age: 64.3 years, underwent attempt at endovascular treatment of 278 lesions. 213 patients (77.2%) had neurological symptoms; the others had evidence of ipsilateral cerebral hypoperfusion. 238 lesions (91.2%) were treated >30 days after diagnosis of occlusion. Technical success was 66.9 %. Perioperative mortality was 1.64% (4/243), early stroke rate was 3.3%. Follow-up averaged 23.4 months (range: 0.25-84), late mortality was 1.89% (5/265), stroke rate was 3.4% (9/265). Stroke rate was similar after successful stenting (3.57%, 4/112) vs. failed stenting (3.61%, 2/61; P=1.00), stroke/death rates were also similar after successful stenting (5.36%, 6/112) than after failed stenting (3.28%, 2/61; P=0.71). Endovascular treatment of CTO of the ICA in eight cohort studies was safe and feasible with a technical success of 67% and a low rate of early and late neurological complications.Pooled data in this review failed to confirm the benefit of successful stenting on stroke and mortality, but some of the included studies suggest benefit and some also supported improvement in neurocognitive function after successful stenting. Prospective randomized trials to investigate the benefit of endovascular treatment in addition to best medical therapy for symptomatic CTO of the ICA are urgently needed.

Hybrid surgery versus endovascular intervention for patients with chronic internal carotid artery occlusion: A single-center retrospective study

“…Both hybrid surgery and EI can recanalize an occluded carotid artery with a low rate of neurological complications. The technical success rate of EI was 55%-70%, while that of hybrid surgery was significantly increased to 66.0%-98% (1,5). Despite these data, the assessment and treatment of patients with ICAO remain controversial.…”

“…A multicenter, prospective, randomized controlled study indicated that symptomatic patients with CICAO did not benefit from extracranial-intracranial (EC-IC) artery bypass (4) Thus, carotid endarterectomy (CEA) and endovascular interventions (EI) are potential but challenging choices. Due to technical difficulty and unfavorable outcomes in early clinical trials, society guidelines failed to recommend carotid revascularization surgery for patients with CICAO (5,6).…”

“…In recent years, some studies have reported considerable progress in carotid recanalization with advancements in technology. On the one hand, EI with distal and proximal protective devices has been proven to be feasible and safe in recanalizing the occluded ICA (5,7,8). On the other hand, hybrid surgery seems to be a more promising and advantageous approach in the treatment of CICAO (9, 10).…”

Case of effective suction to secure the true lumen for acute occlusion after carotid endarterectomy

“…Although it is difficult to judge the length of the lesion preoperatively, the possibility of distal extension should be considered. Some authors have suggested that the rate of success of recanalization can decrease with longer lesions [10] , [11] , [12] . Anzuini et al.…”

“…Prolonged attempts to pass through the lesion may also lead to complications. Myrcha and Gloviczki noted that if the lesion cannot be traversed within 30 minutes, the procedure must be halted [11] . Surgeons should be prepared for other methods, such as bypass surgery, in case recanalization fails.…”