Chronic carotid occlusion revascularization via vasa vasorum

Case contributed by Yves Leonard Voss

Presentation

Chronic right sided carotid occlusion of unknown duration. Today presenting with fluctuating global aphasia.

Patient Data

Age: 80
Gender: Male

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. 

Case Discussion

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 hypoperfusion 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 revascularization of the original internal carotid artery lumen.

While technically possible, the indications, clinical benefit and procedural risk of endovascular revascularization of 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 at the time of writing, case based reports suggest the rate of iatrogenic thrombembolism due to endovascular revascularization might be significantly lower in chronic braided type carotid reconstitution via vasa vasorum. One of those endovascular procedures is documented here for educational purposes. 

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