Rethinking Surgery Of The Occluded Carotid
Mario Zanaty, Edgar Samaniego, David Hasan
Introduction: Medically refractory chronically occluded internal carotid artery (COICA) results in T.I.As/stroke, dementia and refractory hypertension. There is no standard treatment.
Objective: Classifying COICA to different subgroups can lead to successful recanalization and disease control.
Methods: A retrospective analysis of the database was performed to assess risks/benefits after recanalization via endovascular techniques (ET) or hybrid surgery (HS: ET plus carotid endarterectomy).
Results: We derived a classification from 100 COICA to assess the risk/benefit of recanalization in 38 symptomatic COICAs (37 patients). Successful recanalization occurred in 100% of type A and B (ET), 66.67% of type C (ET+HS) and 25% of type D (ET). Complications occurred in 5.00% of type A and B, 44.44% in type C and 12.5% in type D. Successful recanalization improved the symptoms, controlled the T.I.As, and reversed hypertension in 85.71% (23/27). Failure to recanalize lead to recurrent T.I.As/strokes in 40% of the patients. Bradycardia was associated with the type of COICA (90% of type A, 80% of type B, 44% of type C and 44% of type D). It was transient and asymptomatic except in 8.10%. Large penumbras were associated with worse preop MoCA scores. Successful revascularization leads to the resolution of penumbra and improvement in cognition in all patients.
Conclusions: Type A and B medically refractory COICA can be treated by ET, while type C by hybrid surgery. We do not advise any intervention for type D. This provides the patient with disease control and improved cognition.