Exploring New Frontiers: Endovascular Treatment of the Occluded ICA

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21 Exploring New Frontiers

Endovascular Treatment of the Occluded ICA

Tiziano Tallarita, Harry J. Cloft, Alejandro A. Rabinstein, Giuseppe Lanzino

Introduction

Surgical revascularization of the occluded extracranial carotid artery has been established as a potential therapy in selected patients.1 However, this procedure has not been widely applied because its intrinsic risks and the questionable benefits. Endovascular revascularization of acutely and chronically occluded femoral and coronary arteries has been performed for some time with good degree of clinical and radiological success. Application of these techniques to the extracranial carotid and vertebral arteries has lagged behind for fear of dislodging emboli. With advances in endovascular techniques, increasing experience with angioplasty and stenting of large extracranial cervical vessels, and the availability of a variety of distal protection devices, several operators have reported their results following endovascular revascularization of the acutely or even chronically occluded internal carotid artery (ICA).2–20 In this chapter, we provide an overview of the rationale, techniques, results, and complications of endovascular revascularization of acute and chronic occlusion of the extracranial ICA.

Acute carotid occlusion

Management of patients with stroke caused by acute ICA occlusion is challenging. Medical therapy alone is associated with a high rate of permanent severe neurological disability and mortality.1 In patients with acute stroke and ICA occlusion, early restoration of flow in the occluded ICA may prevent further worsening, improve symptoms, and reduce the risk of recurrent stroke.2 Currently, the invasive treatment of patients with acute ICA occlusion is not standardized. Acute ICA occlusion responds poorly to intravenous thrombolysis alone or in combination with intra-arterial pharmacological thrombolysis with recanalization rates ranging from 10%21 to 50%,22–24 and resultant mortality of 50%.21–24 Slightly better clinical results have been reported following mechanical thrombectomy, but only a few reports are available.25,26

Over the past decade, several authors2,3–11,27 have reported the feasibility of endovascular revascularization of the acutely occluded internal carotid artery with angioplasty and stenting with higher rates of recanalization and clinical improvement than reported with other methods (Table 21–1).

Table 21–1 Results of Endovascular Revascularization for Acute/Subacute ICA Occlusion.

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Technique

Symptomatic acute thrombosis of the proximal ICA often occurs in concomitance with ICA bifurcation (T-lesion) or MCA occlusion. The natural history of associated proximal ICA and central distal occlusions is poor.2,3–10,12 Acute revascularization of the proximal ICA in such cases allows catheterization and thrombolysis of the distal segment and, by increasing distal flow, improves the chances of maintaining vessel patency after successful distal thrombolysis. In addition, stenting of the occluded ICA may “trap” thrombus against the carotid wall, potentially decreasing the risk of delayed distal emboli.

In these patients we perform a rapid diagnostic angiography with a 5F catheter and assess the status of the carotid bifurcation as well as the status of external carotid collaterals by studying the angiograms in the delayed phases. Angiography of the contralateral side is helpful to assess the presence or absence of collateral vessels. In the presence of a short ICA occlusion that does not extend to the ICA bifurcation terminus, the contralateral angiogram allows for a depiction of the anatomy of the ipsilateral MCA distribution. However, symptoms are usually related to distal MCA occlusion or the occlusion extends to the carotid bifurcation terminus and this distal occlusion also demands treatment.

After a diagnosis of the ICA occlusion and assessment of the collateral circulation, the 5F catheter is exchanged for a larger guide-catheter, which is placed in the distal common carotid artery. We prefer to perform the procedure under full heparinization. However, this is often not feasible because these patients had received variable doses of intravenous thrombolytics or intra-arterial pharmacological thrombolysis for coexistent distal occlusion. In such cases, a limited bolus of 2000 to 3000 units of heparin is administered before catheterization.

We usually try to cross the occluded segment with a filter-type distal protection. Often this is not possible and a stiffer and more steerable microguidewire is required to cross the occluded segment. The occlusion is then negotiated with a 0.014-inch or 0.018-inch steerable microguidewire. In some cases, a larger guidewire (0.035 inch) may be necessary. A microcatheter is then navigated over the microguidewire across the occluded segment and an angiogram through the microcatheter distal to the occluded segment is performed to assess the status of the carotid distal to the occlusion and the intracranial circulation.

With the microguidewire as a “buddy-wire,” we try to cross the occlusion with a filter wire for distal protection. When this is possible, the protection device is landed in the distal cervical segment. A self-expandable stent is deployed in the proximal cervical carotid and poststent angiograms are obtained to confirm revascularization. Immediately after stent placement, patients are administered oral clopidrogel (300 mg) and aspirin (325 mg). Based on the findings of the post-stent angiogram further intervention is usually required. This may include thrombolysis (pharmacological or mechanical) or even further stenting of the ICA distally to the occluded segment or the proximal MCA. If a central occlusion distal to the proximal ICA occlusion exists, revascularization of the distal occlusion is critical to maximize the chance of a good functional outcome.

At the completion of the procedure, strict blood pressure control is maintained in those patients with successful recanalization (systolic pressure below 160 mm Hg in patients with acute occlusions or below 140 mm Hg when the occlusion is subacute or chronic). Clopidogrel is continued for 30 days and aspirin indefinitely. A head CT scan is routinely performed the following morning to rule out hemorrhage and to assess the extent of the infarcted area (Figure 21–1).

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Figure 21–1 A 69-year-old man presented with acute right hemiparesis and aphasia. Cerebral angiography, left common carotid artery injection (A) lateral projection shows acute occlusion of the origin of the left ICA immediately distal to the bifurcation. Contralateral carotid angiography (B) shows hypoplastic A1 segment (arrow) on the right with some filling of the left distal anterior cerebral artery territory through the anterior communicating artery. A guide-catheter was placed into the distal common carotid artery. We attempted to cross the occlusion with a filter wire but this proved impossible. A 0.014 microguidewire was then advanced through the occlusion. With the microguidewire in place as a “buddy wire,” we were then able to cross the occlusion with a filter wire. C, Shows the filter protection device deployed into the distal cervical ICA (arrow) and a “buddy wire” (double arrows) in place across the occlusion as well. A self-expandable stent was then advanced across the occlusion (D). Left common carotid artery injection following stent deployment, lateral projection shows flow through the stent but evidence of distal occlusion. Microcatheter injection after stent deployment shows thrombus into the cavernous ICA and occlusion of the intracranial ICA bifurcation (E). F, After mechanical and intra-arterial thrombolysis there was partial recanalization of the ipsilateral middle cerebral artery with persistent diffuse intraluminal thrombus. Telescoping enterprise (Cordis Neurovascular, Johnson and Johnson, Camden, NJ) stents placed into the M1 segment and across the intracranial ICA bifurcation: there is re-establishment of distal flow into both the anterior cerebral and middle cerebral arteries (G and H). Final lateral projection (I) shows re-establishment of flow through the previously occluded proximal ICA.

Results and Complications

Over the past 10 years, several authors have detailed their results with revascularization of the acutely occluded ICA. Nedeltchev and coworkers11 studied 56 consecutive patients who suffered an MCA stroke following ICA occlusion between 1997 and 2003. Twenty-five of these patients underwent attempted endovascular revascularization (endovascular group), while 31 patients received medical treatment consisting of antiplatelet medications and, in some cases, heparin therapy (medical group). Recanalization of the ICA was achieved in 84% of patients in the endovascular group with a combination of thrombo-aspiration through an 8-French guide-catheter and stent deployment in the occluded ICA. Recanalization of the coexistent MCA occlusion (TIMI grade 2 and 3) was obtained in 52% of these patients. In the endovascular group, outcome at 3 months was favorable (modified Rankin score of 0–2) in 56% of patients and unfavorable in 24%. Twenty percent of patients died. In the medically treated group, a favorable outcome was observed in only 26% of patients. This series stresses the importance of recanalization of the coexistent distal occlusion since MCA recanalization was the only predictor of good outcome. Symptomatic hemorrhage occurred in 8%. Although concerns exist regarding the risk of dissection and vessel perforation during blind “probing” of the occluded segment, these complications were not observed in this series.

Jovin and collaborators2 reported a series of 23 patients who underwent successful ICA revascularization (in two additional patients crossing of the occlusion was not possible and no stent could be deployed). Of these 23 patients, 15 were revascularized within the time window for acute stroke therapy while the remaining eight had suffered subacute ICA occlusion and demonstrated ongoing symptoms related to hemodynamic compromise. A good outcome at 30 days was reported in five patients (33%) with acute ICA occlusion. Four of the five patients experiencing a good outcome did not have a coexistent intracranial occlusion and the fifth one had a coexistent MCA occlusion that was revascularized with pharmacological intra-arterial thrombolysis. No patient who had a tandem occlusion that did not revascularize achieved a good outcome. Complications related to the endovascular procedure included one asymptomatic hemorrhage and one dissection of the ICA without flow compromise. No serious complications were observed in the eight patients who had received IV tPA in conjunction with endovascular revascularization indicating the feasibility and safety of this approach. Table 21–1 provides a comprehensive summary of results and complications after revascularization of acute ICA occlusion.

Chronic carotid occlusion

Endovascular revascularization of chronically occluded femoral, subclavian, and coronary arteries is an established practice in selected patients. In 2005, Terada et al.28 reported the first patient with chronic carotid occlusion who underwent successful endovascular revascularization with flow reversal. Two years later, Kao and coworkers,13 using a technique utilized to reopen occluded coronary arteries, reported the first series of 30 patients with chronic carotid occlusion who underwent attempted endovascular revascularization. Following these early reports, several other authors have reported successful recanalization of the chronically occluded ICA (Table 21–2).

Table 21–2 Results of Endovascular Revascularization for Chronic ICA Occlusion.

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Potential candidates for revascularization of chronic ICA occlusion must fulfill the following criteria:13–15 (1) hemodynamic symptoms ascribed to the occluded territory, (2) hemodynamic failure demonstrated by perfusion studies, and (3) angiographic demonstration of a relatively short occluded segment.14 This last angiographic requirement can be difficult to evaluate. Careful analysis of the angiograms with assessment of late retrograde filling of the ICA segment distal to the occlusion through collateral circulation is of critical importance to select patients who may benefit from endovascular recanalization. Assessment of the extent of occlusion can be difficult with other noninvasive angiographic techniques such as CTA and MRA, although dynamic CTA can offer valuable information.

Techniques

Technical pitfalls of chronic ICA occlusion recanalization are related primarily to crossing the occlusion while avoiding dislodgment of distal emboli.29–31 Various techniques have been described to circumvent these problems and minimize the risk of distal emboli.

Patients are premedicated with clopidrogel 75 mg/day and aspirin 325 mg/day starting 5 days before the procedure. After obtaining femoral access, intravenous heparin is administered with the goal of maintaining the activated clotting time around 300 seconds. The procedure can be done under local anesthesia and this permits careful clinical assessment during each step. However, general anesthesia is preferred in uncooperative patients or in case of difficult and tortuous proximal anatomy, which makes catheterization challenging.

The availability of “protection devices” has increased the safety of recanalization of the occluded ICA. Four types of “protection devices” are available for use in the extracranial carotid: distal occlusion balloon, distal filter, proximal occlusion catheter, and the Parodi’s device.32,33 The main disadvantage of the first two is the need to cross the lesions before device deployment with the consequent risk of cerebral microembolization before distal protection is established.34–36

Proximal occlusion can be achieved with one of two methods. One of these methods involves obtaining proximal occlusion with a double lumen balloon catheter positioned and inflated in the common carotid artery proximal to the occlusion. The inner lumen of the balloon allows passage of devices while the balloon is inflated though the other lumen. The goal of proximal occlusion is to prevent anterograde flow to dislodge emboli during and immediately after revascularization. Proximal common carotid occlusion alone is insufficient to prevent particles from embolizing to the brain37 because of collateral vessels from the external carotid artery. In cases where the external carotid artery is patent, a separate small (5F) guide-catheter can be placed in the common carotid artery to allow passage of a small compliant balloon that can be separately inflated into the external carotid artery.

The other method by which proximal occlusion can be achieved is the Parodi Anti-Embolization Catheter (PAEC). This is an ingenious device originally designed to allow flow reversal during angioplasty and stenting of carotid stenosis. It consists of a triple lumen-guiding catheter with an occlusion balloon at the distal end. This balloon has a teardrop shape to prevent any dead space between the orifice of the catheter and the occlusion balloon. Occlusion of the common carotid artery is achieved by inflating this balloon while access to the lesion is possible through the main inner lumen. The main lumen has an inner diameter of 7F that allows for navigation of balloons and stents. The main lumen is connected to a three-way Y-adapter at its proximal end so that one has access to the lesion through the main lumen while suction is applied or reversal of flow is created through the other ports. In addition, the extra side port can be used for the insertion of an external carotid artery occlusion balloon, if one is needed.33 The Parodi device also allows for activation of an arteriovenous fistula through connection with the femoral vein and this allows true flow reversal.33

If distal protection is used instead of proximal flow arrest, then a guide-catheter of sufficient internal diameter to allow for passage of multiple devices if needed is placed into the common carotid proximally to the occlusion (Figure 21–2).

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Figure 21–2 A 64-year-old female with multiple risk factors for atherosclerotic disease and prior history of left carotid endarterectomy and extracranial ICA-ICA saphenous graft elsewhere for ICA occlusion, presented with orthostatic symptoms of left hemispheric ischemia. Left common carotid artery injection shows occlusion of the ICA and external carotid artery and tandem severe stenosis of the graft (A) with patent ICA distal to the graft (B). She underwent angioplasty of the distal graft stenosis with resolution of her symptoms. She was readmitted 3 months later with recurrent symptoms of 1 month duration and catheter angiography showed occlusion of the graft (C). A 0.035 guidewire was negotiated through the occluded graft followed by a coronary angioplasty balloon and sequential angioplasty of the graft was performed with excellent restoration of flow through the occluded graft and the intracranial circulation (D to F).

Crossing the lesion

A microcatheter and microguidewire (0.016 inch or 0.014 inch) are typically used to cross the occluded ICA. The microcatheter is parked immediately proximal to the occlusion to provide backup support to the microguidewire as it is passed through the occluded segment. A tapered-tip stiff 0.014-inch guidewire specifically designed to cross coronary occlusions can be particularly helpful in this phase.13 Care must be paid to avoid too much torquing or “drilling” of the microcatheter during this phase to avoid entering a false lumen with the risk of dissection or perforation. It is often difficult or even impossible to cross the occluded segment with the microguidewire. Resistance to passage of the microguidewire can be used as a criterion to judge the length and location of the occlusion.14 Often, if the microguidewire does not cross the occluded segment, it is necessary to use a 0.035 guidewire to penetrate the occluded portion. In such cases, a 4F catheter can be passed through the occlusion over the 0.035 guidewire to gently “dilate” the channel. The guidewire is gently advanced while making sure that the microguidewire is within the true lumen of the vessel on orthogonal projections. At this point the microcatheter can be advanced distal to the occlusion and a gentle injection can be performed to confirm position into the true lumen and confirm patency of the ICA segment distal to the occlusion.

Distal Protection Technique

The microcatheter is exchanged for a small-diameter (1.5 or 2.0 mm) coronary angioplasty balloon, which is inflated to 6 to 8 atm. Percutaneous transluminal angioplasty is then performed from the distal occluded segment of the ICA to the proximal portion to predilatate the occlusion. A filter-type embolic protection device is then advanced parallel to the microguidewire and deployed distally if an adequate distal landing zone with diameter >3 mm can be identified. A self-expanding stent is then placed across the occlusion, followed by postdilation using a 4- to 6-mm–diameter balloon. A final ipsilateral intracranial angiogram is obtained to confirm re-established antegrade perfusion.

Proximal Occlusion Technique

An angioplasty balloon 20 to 40 mm in length is navigated over the microguidewire. Angioplasty of the ICA from distal to proximal is then performed. Following angioplasty, 50 to 60 ml of blood are aspirated from the double lumen balloon catheter placed in the common carotid artery to remove any debris mobilized during angioplasty. An angiogram is done by gentle injection to assess for anterograde flow. The point of occlusion can usually be identified on this angiogram as the segment (usually in proximity of the bifurcation) with the most significant residual stenosis. A self-expandable stent can then be deployed to cover this segment.

Results and complications

Recently, Lin et al.16 updated their original experience and reported their results in 54 patients who underwent revascularization for chronic ICA occlusion. Revascularization was achieved in 63% of patients. Distal protection devices were used in 73% of cases. In 10 patients, the use of distal embolic protection devices was not possible because of small distal vessel diameter. In the patients in whom technical success was achieved, the residual stenosis was 9%. The combined morbidity and mortality at 3 months was 4%. Vascular complications included an iatrogenic carotid-cavernous fistula, a delayed cervical ICA pseudoaneurysm, and extravasation of contrast in the neck during attempted crossing of ICA occlusion.

In 2009, Terada and coworkers14 reported a series of 14 patients with a total of 15 occluded ICAs who underwent endovascular revascularization using the proximal occlusion technique and flow reversal. All of the patients were suffering from hemodynamic symptoms refractory to medical therapy. They reported a technical success rate of 93% (14 out of 15 occlusions). Revascularized occlusions involved the cervical ICA in 10 cases and the petrous or cavernous portions of the artery in the remaining four. Complications included one case of distal MCA branch occlusion without clinical sequelae and one SAH due to microwire perforation of an MCA branch. No patient suffered recurrent symptoms at a mean follow up of 26.1 months. No cases of clinical hyperperfusion were observed.

Restenosis of the revascularized segment is a potential concern. However, experience in other vascular territories suggests that the risk of restenosis after revascularization of an occluded artery is higher in the coronary circulation38 than in the iliac and subclavian arteries.39,40 This observation would suggest that restenosis may be lower if the vessel diameter is greater than 3 mm. In this respect, the restenosis rate should be lower in the ICA and the largest series reported so far confirm this supposition as no restenosis >50% was observed by Terada and coworkers in their 14 cases,14 while Kao and coworkers reported a restenosis rate of 13.6%.13

Cerebrovascular autoregulation in regions with chronic ischemia may be defective, and a sudden increase of perfusion after revascularization of chronic ICA occlusion raises concerns for hyperperfusion syndrome. Strict control of blood pressure after endovascular recanalization is critical to prevent or minimize the effects of this complication. Surprisingly, according to the literature, no cases of hyperperfusion syndrome were detected after revascularization of chronic ICA occlusion.14–17,20 A summary of results and complications in published series of ICA occlusion is shown in Table 21–2.

Conclusion

Endovascular revascularization of ICA occlusion is feasible in cases of both acute and chronic occlusion. In patients with acute occlusion, outcome is closely dependent on revascularization of coexistent distal intracranial ICA or MCA occlusions. In patients with chronic occlusion, endovascular revascularization can be achieved in patients with short segment occlusion and retrograde partial filling of the supraclinoid ICA through collaterals. With further refinements of endovascular technique and better imaging techniques, a large proportion of patients affected by symptomatic ICA occlusion may be candidates for this procedure.

References

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