Abstract 437: Total Endovascular Reconstruction of ICA CTO. Technique, Predictors of Success and Complications, An 18‐year Experience
Authors: Chebl A. 
Published: January 2025

Introduction/Purpose
Chronic total ICA occlusion (CTO) can be associated with a high risk of stroke. Surgical bypass is no better than medical therapy. Total endovascular reconstruction (TER) for treatment of carotid CTO is feasible and in this abstract the technique and predictors of outcomes of TER are presented.

Methods
All patients with carotid CTO treated with TER over an 18year period were entered in a prospectively collected database. Patients with angiographically proven symptomatic chronic (>7days) occlusion with impairment of cerebrovascular reserve or recurrent ischemia despite maximal medical therapy were treated under local anesthesia via a femoral approach. Occlusions were crossed with 014inch wires and angioplasty performed. Drug‐eluting coronary and/or self‐expanding stents were deployed in all angioplastied segments. All patients were treated with dual antiplatelet therapy for 6months. Angiographic features (e.g. landing zone in cervical, petrous or cavernous segment) and clinical outcomes and complications (stroke, death, MI, perforation, cranial neuropathy) were recorded. Technical success was defined as restoration of normal antegrade ICA flow. Carotid U/S was performed at discharge, 30days, and at subsequent follow‐up. Angiographic follow‐up was performed between 6‐12months in all willing patients.

Results
Twenty‐six patients with a mean age of 65±7.8years and mean CTO duration of 210.7±456.6days (median 66, range 7‐2190) underwent 29 procedures. Technical success was achieved in 22/26 (85%) on first attempt and in 3/4 on second attempt for total technical success rate of 25/26(96%). The only technical failure was in a patient with no ICA stump at the bulb and all 3 patients requiring a second attempt had a landing zone in the cavernous ICA with failure to cross into the true lumen beyond the lacerum segment. Mean procedural duration was 152±69.8hours (median 136.5hrs) which increased with more distal landing zone: mean 118.5±98, 140.3±46.6, and 169.5±71min for cervical, petrous and cavernous landing zone, respectively. Patients received a median of 2 stents (range 1‐7). Fifty‐five percent were treated via a 6 French transfemoral approach. CTO wires and/or catheters were used in 69% of cases with 34% requiring multiple CTO wires to cross the proximal fibrous cap, to overcome calcified segment or to cross the lacerum segment. Knuckling wire technique was used in 24.1%. Total 30‐day stroke/death/MI was 2/29 (6.9%). There were 2 (6.9%) cases of asymptomatic wire tip retention in the cervical ICA, 1 case of transient contrast extravasation in cervical segment associated with transient vocal cord weakness and 1 case of isolated vocal cord weakness in a patient with a 360‐degree loop in the cervical ICA and a history of ipsilateral neck radiation therapy. There were no cases of acute carotid re‐occlusion but there was 1 asymptomatic re‐occlusion at 7months.

Conclusion
TER has a high technical success rate. The presence of a carotid stump and a more proximal landing zone favored procedural success and shorter over all procedural duration. Although the 30‐day event rate is low there is a risk of transient vocal cord paralysis, wire tip retention and rarely, cervical segment perforation. Acute occlusion is very rare with appropriate technique and dual antiplatelet therapy.