Endovascular management of chronic internal carotid occlusion with Penumbra system

Carotid occlusion is a common disease and its incidence is about 6 in 100000. Annual risk of stroke is between 3% and 10% in older than 60 years with carotid occlusion and recurrent ischemic event have been reported in 25% of symptomatic carotid occlusion.1 Since many years ago it has been advocated in complete arterial occlusion, there was no chance for emboli to pass into the distal circulation. Therefore, a complete occlusion of the internal carotid artery (ICA) has been regarded as no need to follow-up and the natural history and optimal management of this condition remain undetermined up to now.2 Nowadays, chronic occluded vessels could be revascularized by endovascular techniques. It has been successfully used in peripheral and coronary arteries.3 The recent development of endovascular therapy has enabled the recanalization of carotid occlusion technically although it needs more study to evaluate its efficacy. In this case presentation, we describe new technique in opening symptomatic chronic carotid occlusion with the aim of reducing risk of distal embolization using the Penumbra thromboaspiration system (Alameda, California, USA). A 56-year-old man was refereed with history of repeated stroke in the territory of left anterior circulation since 1 month ago. He was treated medically and evaluated for risk factors of stroke. He was heavy smoker. Carotid duplex study showed bilateral carotid occlusion. Digital subtraction angiography confirmed bilateral ICA occlusion from the origin. ICAs were filled in cavernous part by retrograde flow from ophthalmic arteries of external carotid arteries (ECAs). The patient had repeated transient ischemic attack in spite of best medical treatment. Due to the deterioration of the patient, it was decided to treat the patient by endovascular revascularization. The risks and benefits of the procedure were explained to the patient and his relatives. An informed consent was obtained from the patient. The patient underwent endovascular revascularization, he was under aspirin and plavix for 2 weeks. The procedure was performed under general anesthesia and via the percutaneous transfemoral route. Heparin was injected intravenously to maintain activated clotting time between 200 and 250 seconds. Guiding catheter 8 Fr was placed in the left common carotid artery (CCA). With contrast injection it was shown that there was left ICA Iranian Journal of Neurology