Chronic carotid occlusion revascularization via vasa vasorum

Cathether angiogram shows chronic internal carotid artery (ICA) occlusion with "braided apprearance" reconstitution due to enlarged vasa vasorum of the vessel wall.

Cone beam CT during common carotid artery injection shows vasa vasorum associated with the vessel wall and helps planning the navigation.

Treatment by antegrade navigation of the ICA vasa vasorum with a microwire all the way up to the intracranial unaffected ICA terminal segment, followed by retrograde balloon angioplasty and retrograde stent angioplasty of the entire affected segment.

Chronically occluded left internal carotid artery with signs of reconstitution via vasa varosum of the vessel wall, giving a typical "braided" appearance. This patient was repeatedly symptomatic due tohypoperfusion and evidence of a thrombogenic event.

It was possible to navigate the subintimal dilated vasa vasorum inside the internal carotid artery vessel wall all the way to the intracranial circulation. In reverse order Balloon PTA all the way down to the carotid bifurcation and angioplasty with multiple stents led to complete revascularisation of the original internal carotid artery lumen.

While technically possible, the indications, clinical benefit and procedural risk of this endovascular revascularisation treatment lacksof chronic carotid artery occlusions is highly controversial. In subacute carotid occlusions the rate of iatrogenic thrombembolism is reportedly very high. While there is a lack of proper scientific evidence to date and remains unclear at the time of writing. However, case based reports suggest the rate of iatrogenic thrombembolism appearsdue to endovascular revascularisation might be significantly lower than in revascularisationchronic braided type carotid reconstitution via vasa vasorum. One of those endovascular procedures of acute/subacute carotid occlusionsis documented here for educational purposes.