Angioplasty and stenting for symptomatic extracranial non-tandem internal carotid artery occlusion

Introduction: Symptomatic internal carotid artery occlusion (ICAO) can lead to neurologic decline, recurrent stroke, and mortality.

Objective: We sought to evaluate the safety and feasibility of endovascular revascularization for ICAO without tandem intracranial large vessel occlusion (LVO).

Design, setting, and participants: This is a retrospective cohort analysis of all patients presenting to a single academic center with ischemic stroke and ipsilateral cervical ICAO from November 2003 through April 2016. Patients were excluded if pre-procedural angiography demonstrated tandem LVO or if patients were known to have chronic ICAO.

Main outcomes and measures: Study endpoints included discharge neurologic examination, post-procedural infarct burden, 3-month functional outcomes, and treatment durability.

Results: A total of 107 patients with symptomatic angiographically-confirmed cervical ICAO without tandem LVO were identified. Median admission NIH Stroke Scale (NIHSS) score was 8 (IQR 11). Baseline radiographic stroke severity was assessed by ASPECT score (median 9; IQR 2), perfusion mismatch (present in 93%), and clinical imaging mismatch (42%). Median time from symptom onset to treatment was 25 hours (IQR 61). Successful revascularization was achieved in 92% of patients. At discharge, 83% had stable/improved NIHSS score, while at 3 months 65% achieved independence (modified Rankin Scale score ≤2). The most common complication was distal embolization (22%) of which 16% required intra-arterial treatment. Rate of significant restenosis (≥70%) was 15% at 1 year.

Conclusions: Stenting in selected patients at risk of neurologic deterioration due to symptomatic ICAO can be performed with high rates of technical success and good clinical outcomes. Because of significant peri-procedural risks and high rates of restenosis, randomized studies are necessary to understand the benefit of this approach.