Neuroradiology (2006) 48:847–851
DOI 10.1007/s00234-006-0126-8

INTERVENTIONAL NEURORADIOLOGY

Carotid angioplasty with stenting for chronic internal
carotid artery occlusion: technical note
Nozomu Kobayashi & Shigeru Miyachi &
Kenichi Hattori & Toshihiko Tanasawa & Takeshi Okada &
Otone Endo & Naohito Yamamoto

Received: 28 March 2006 / Accepted: 19 June 2006 / Published online: 10 August 2006
# Springer-Verlag 2006

Abstract
Introduction Carotid angioplasty with stenting (CAS) is
becoming accepted as an effective and reliable treatment
option for severe carotid artery stenosis. However, it is
rarely applied for carotid occlusion, especially in its chronic
stage. We report our experience of CAS for chronic internal
carotid artery occlusion representing compromised cerebral
blood flow using various protection methods.
Methods A 77-year-old woman, who was already diagnosed with severe left internal carotid artery stenosis,
suddenly had right hemiparesis and aphasia. At that time,
she was treated conservatively because her neurological
status was quite good, in spite of left carotid artery
occlusion. Her symptoms improved in the short term,
except slight aphasia, but deteriorated again 18 days from
the onset, and magnetic resonance imaging (MRI) showed
new ischemic lesions. CAS was then performed for the
occluded carotid artery on the 23rd day from the first onset.
Results Using the proximal protection technique, the
occluded lesion was crossed carefully with a microguidewire. Stents were also placed successfully with the distal
protection technique. The occluded carotid artery was
completely recanalized without any unfavorable events or
neurological deterioration.

N. Kobayashi (*) : T. Tanasawa : T. Okada : O. Endo :
N. Yamamoto
Department of Neurosurgery, Kainan Hospital Aichi Prefectural
Welfare Federation of Agricultural Cooperatives, Aichi, Japan
e-mail: cbk71850@pop06.odn.ne.jp
S. Miyachi : K. Hattori
Department of Neurosurgery,
Nagoya University Graduate School of Medicine,
Nagoya, Japan

Conclusion In this patient, CAS was successfully to treat
chronic carotid artery occlusion. These procedures and
techniques are reviewed and discussed.
Keywords Carotid angioplasty with stenting (CAS) .
Carotid artery occlusion . Protection method

Introduction
Carotid angioplasty with stenting (CAS) is nowadays
recognized as a useful modality for severe carotid artery
stenosis as well as carotid endarterectomy [1, 2]. Although
it is indeed a useful method, it is rarely performed for
carotid artery occlusion except for neurological rescue in
the hyperacute phase just after the occlusion [3]. We report
the case of a patient with progressive stroke due to chronic
carotid artery occlusion who was treated with CAS,
resulting in successful recanalization and an excellent
outcome. In this paper we report our experience from the
technical point of view.

Case presentation
A 77-year-old female, who had suffered left amaurosis
fugax, was diagnosed with severe left internal cervical
carotid artery (ICA) stenosis and external carotid artery
(ECA) occlusion (Fig. 1). Single photon emission tomography (SPECT) showed severely compromised cerebral
blood flow (CBF). Although cerebral angiography and
further treatments were recommended at this point, she
refused further examination.
Three days later, she was brought to our emergency
room suffering from mild right hemiparesis and dysphasia.

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Neuroradiology (2006) 48:847–851

At this stage, we did not consider early recanalization
because of the irreversible broad ischemic area revealed on
DWI, and opted for medical therapy including hemodilution and antiplatelet drugs. Her symptoms gradually
resolved and improved to fully independent activity of
daily living. However, 18 days after the onset, she suddenly
suffered aphasia again, and a DWI study showed new
ischemic lesions in the left watershed area (Fig. 3a). As the
progressive ischemic symptoms were considered to be due
to hemodynamic compromise, we decided on carotid
recanalization using endovascular intervention.

Techniques

Fig. 1 Three-dimensional MR angiography shows left ICA stenosis
(arrow) and ECA occlusion

Her National Institute of Health Stroke Scale (NIHSS) [4]
score was 6. An emergency CT scan showed no apparent
early ischemic signs, but MR imaging showed am area of
high signal in the left middle cerebral artery region on
diffusion-weighted images (DWI), and her left ICA was not
seen on MR angiography (Fig. 2a,b). The angiogram
acquired soon after onset revealed complete occlusion of
the common carotid artery (CCA) at the level of the second
thoracic vertebra (Fig. 2c).

We already had information about the location of the stenotic
lesion, which was at the level of fourth cervical vertebra in the
initial angiogram. Further, three-dimensional CT angiography
after the onset showed that the distal ICA was patent at least at
the level of the second cervical vertebra (Fig. 3b). Therefore,
we considered that angioplasty would be possible within the
cervical area, but not intracranially.
A 9F balloon catheter (Patrieve, Clinical Supply, Gifu,
Japan) as the guiding catheter was navigated into the CCA, and
the balloon was inflated sufficiently for proximal protection. In
this condition, the lesion was crossed with a guidwire (GT wire
0.016-45; Terumo Corporation, Tokyo, Japan) and microcatheter (Transit II, Cordis Neurovascular), and the patency of
the distal part of the ICA was confirmed (Fig. 4a).
Under inflation of the proximal balloon, angioplasty was
performed with a balloon catheter (Amiia, Cordis Neurovascular) and the stent (Protage, EV3) was placed. The
stent seemed to be open widely enough. Then, the distal
protection balloon (Percusurge Guardwire, Medtronic) was
navigated distal to the stent and inflated. Under distal
protection, the proximal balloon was deflated and the
aspiration catheter (Thrombaster, Kaneka Medics, Osaka,
Japan) was navigated just beneath the distal balloon. A

Fig. 2 High-intensity area in the middle cerebral artery region is revealed on DWI obtained on admission (a). The left ICA is not seen on MR
angiography (b). Occlusion of the CCA is seen on the angiogram (c)

Neuroradiology (2006) 48:847–851

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Fig. 3 DWI obtained soon after
the second ischemic attack
shows new high-intensity
lesions in the watershed area of
the left hemisphere (a). The
distal end of occluded lesion is
seen on 3D-CT angiography (b).
The distal part of the ICA is
opacified and visualized (arrow)
in this study

retrograde angiogram with a small amount of contrast
material injected through the aspiration catheter showed a
large contrast defect in the CCA proximal to the stent
Fig. 4 Patency of the distal part
of the ICA above and around C2
is shown on superselective angiography (a). The severe stenotic lesion remains (b) in the
region just proximal to the
deployed stent (arrow), which
was treated with another stent.
Vasospasm is seen on the side
distal from the stent as well
(open arrow). Although mild
vasospasm remains (c), the occlusion or stenosis is well-resolved (d), and intracranial
blood flow is shown to be
dramatically improved on angiography (e)

(Fig. 4b). This finding was considered to represent a
remaining mural thrombus, plaque shift or intimal dissection caused by stenting. Therefore, another stent (Protage,

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EV3) was deployed just proximal to the former stent in a
telescoped fashion. Improvement of the stenosis and no instent thrombus were confirmed on the repeated angiogram
under the distal protection. Then 40 ml of blood was
aspirated, and the distal protection was released. The total
balloon occlusion time was 26 min.
The final angiogram showed successful recanalization
without stenosis and remarkable improvement of cerebral
blood flow in spite of mild vasospasm (Fig. 4c–e). MR
imaging showed no apparent new ischemic lesion on DWI
after the procedure. The postoperative course was uneventful. She was managed in the intensive care unit for 2 days,
then discharged 45 days later in a stable neurological state
with a NIHSS score of 2 after rehabilitation.
Three-dimensional CT angiography and curved multiplanar reconstruction images taken 6 months later showed
no in-stent restenosis and the recovery of vasospasm
(Fig. 5). She fully recovered neurologically.

Discussion
Although angiographic recanalization for complete ICA
occlusion is sometimes indicated for neurological or survival
rescue in the acute stage [5, 6], in some instances, asymptomatic or neurologically stable patients with extracranial ICA
occlusion basically have no indication for endovascular
Fig. 5 Three-dimensional CT
angiography performed about
10 months after the procedure
shows that vasospasm just distal
to the stents has clearly dissolved (a). Patency is very well
established and restenosis is not
observed (b)

Neuroradiology (2006) 48:847–851

recanalization because the location and length of the stenotic
lesion is unclear and there is a high risk of distal migration of
thrombus on catheterization through the thrombus and
stenting. Recently however, Terada et al. have reported its
feasibility and efficacy [3]. Recanalization for symptomatic
subclavian artery occlusion is generally justified even in the
chronic stage, and some reports have indicated its efficacy [7,
8]. We treated our patient conservatively at first because her
symptoms were not so severe at a NIHSS score of 6.
However, the second stroke due to the ICA occlusion was
considered progressive ischemia due to hemodynamic compromise and a high-risk state requiring revascularization. Only
revascularization by direct recanalization was available because an extracranial–intracranial arterial bypass could not be
adopted due to ECA occlusion. Therefore, we decided on
direct angioplasty and stenting even though it was performed
18 days after occlusion.
In this patient, there were some specific and favorable
factors. First, we had already acquired information on the
stenotic lesion by three-dimensional CT angiography before
its occlusion. Second, there was no collateral pathway via the
ECA, which had been occluded in advance. Third, we were
able to evaluate the patency of the distal ICA by threedimensional CT angiography. From the technical point of
view, the utmost care should be taken to avoid embolic
complications due to the distal migration of thrombi. The
movement of an unstable or fresh thrombus is likely to occur

Neuroradiology (2006) 48:847–851

in the lesion being crossing with the microguidewire [9]. To
avoid this accident, a proximal protection method is essential
[3]. Fortunately, there was no need for ECA protection in
this patient. Thus, we were able to successfully place the
microcatheter distal to the thrombus under the simple
proximal protection. However, if the ECA opens unexpectedly due to the angioplasty maneuver, there is the risk of
distal migration of the embolus due to the reversed flow
from the ECA. Therefore, we placed the distal protection
balloon system at a patent portion of the ICA, and achieved
complete interruption of the carotid artery blood flow during
the angioplasty and stenting. This is a variation of the triple
protection method, the so-called “seatbelt and airbag
technique” [10], which is the combination of proximal [11]
and distal protection [12] techniques.
It is very useful to evacuate the blood including the
thrombus and debris after the endovascular procedure,
because we know the distal end of the thrombi which
should be located at least below the distal protection
balloon and can confirm shift of the remaining thrombus
or plaque with a small injection of contrast agent after the
proximal balloon is released without fear of embolic
complications. Although complete protection with enough
inflation of the distal balloon is the key to success,
overinflation may cause vasospasm or dissection such as
in our patient. As for treatment for any remaining thrombus,
there are two alternatives; one is the use of thrombolytic
agents to shrink it, and the other is direct angioplasty with
the balloon or stents to press it against the carotid wall. In
this instance, the mural thrombus was relatively large, and
seemed to have a high risk of detaching and distal
migration during fibrinolysis. We therefore selected another
stent deployment, resulting in successful immobilization
and compression of the thrombus.
The development of a protection system can serve to
reduce the risk of embolic migration [10, 13]. Since
crossing of the lesion under proximal protection is essential,
the combination with distal balloon protection should be
very useful and enhance safety. This case suggests the
feasibility of recanalizing successfully even in chronic
carotid occlusion. However, all maneuvers should be
performed meticulously to avoid mechanical vascular
trauma due to the blind approach and catheterization.

Conclusion
Since the efficacy of extracranial–intracranial arterial
bypass is now under reevaluation [14–16], the treatment
strategy for the chronic compromised CBF state resulting
from carotid occlusion remains unclear. In this special case
of a patient with no indication for bypass surgery,
endovascular recanalization is the treatment choice and is

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a very effective and safe procedure when undertaken with
the proper protective methods.

Conflict of interest statement
of interest.

We declare that we have no conflict

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