Hybrid Surgery for Symptomatic Chronic Near-Total or Total Occlusion of the Internal Carotid Artery
Stroke remains the second leading cause of death globally, with carotid artery revascularization playing a critical role in reducing stroke incidence. Chronic total occlusion (TO) and near-total occlusion (NO) of the internal carotid artery (ICA) present unique challenges due to their rarity, technical complexity, and associated risks such as periprocedural stroke, intracranial hemorrhage, and carotid-cavernous fistula (CCF). Traditional treatments, including carotid endarterectomy (CEA) and endovascular techniques, have shown limited success rates (40–60% for TO) and notable morbidity (3–9% for NO). This study evaluates a hybrid surgical approach combining CEA with endovascular interventions to improve revascularization outcomes for symptomatic NO and TO patients.
Diagnostic Criteria and Patient Selection
NO was defined by digital subtraction angiography (DSA) findings, requiring two of four criteria: (1) delayed ICA contrast filling, (2) collateral vessel formation, (3) reduced distal ICA diameter compared to the contralateral ICA, or (4) reduced distal ICA diameter relative to the external carotid artery. TO was characterized by complete luminal disappearance beyond the common carotid artery (CCA) bifurcation. Enrolled patients exhibited symptoms attributable to cerebral hypoperfusion or recurrent transient ischemic attacks despite medical therapy for ≥3 months. Preoperative imaging, including computed tomography perfusion (CTP) or emission computed tomography (ECT), confirmed ipsilateral hypoperfusion in 4/7 NO and 7/9 TO patients.
Hybrid Surgical Technique
Procedures were performed in a hybrid suite equipped with C-arm fluoroscopy (GE Innova 4100-Q). For NO cases, CEA was initially performed under general anesthesia to remove bifurcation plaques. The distal intima was anchored to the ICA wall using 7-0 Prolene sutures. If the intima was fragile (e.g., “string sign”), endovascular stenting was employed to complete revascularization. Post-CEA angiography via femoral access guided stent deployment (7-mm WALLSTENT®) for residual stenosis (>30%), intimal dissection, or laceration. Embolic protection devices were unnecessary due to plaque removal.
TO management involved CEA with extended plaque-thrombus removal. If no ICA backflow was observed, a 3-F Fogarty® catheter extracted thrombi. After establishing backflow, a 6-F sheath was advanced into the ICA, with partial closure of the hemostatic valve to maintain antegrade flow and reduce thromboembolic risk. Tandem lesions in the petrous or cavernous segments (C2–C4) were treated with 4.5-mm stents (NEUROFORM EZ®, Enterprise®). Rigid stenoses required 4.0–4.5-mm Wingspan® stents. The C1 segment was reconstructed using a 7×40-mm WALLSTENT®, followed by CCA angiography to confirm patency.
Outcomes and Complications
Sixteen patients (7 NO, 9 TO) with a mean age of 63.85±7.90 (NO) and 67.00±6.28 (TO) years underwent hybrid procedures. Technical success was achieved in 14/16 cases (87.5%), including 6/7 NO (85.7%) and 8/9 TO (88.9%) patients. Stents were required in 2/7 NO and 7/9 TO cases, reflecting greater endovascular dependency for TO (P=0.005).
Intraoperative complications occurred in 1 TO patient (CCF during C4 segment exploration), managed by immediate ICA suture. No perioperative strokes or deaths occurred within 30 days. At median follow-up (19.5±4.0 months), two TO cases developed restenosis: one at the bifurcation (6 months post-op, treated with additional stenting) and one at C2 (23 months post-op, causing stroke and corrected via angioplasty). One NO patient developed asymptomatic ICA occlusion at 4 months, managed conservatively. The 2-year primary patency rate was 70% overall, with no significant difference between NO and TO (P=0.65).
Key Technical Considerations
- Intracranial Outflow Assessment: Successful revascularization depended on adequate distal outflow, particularly for NO cases. Preoperative CTP/ECT identified candidates likely to benefit from flow restoration.
- Endovascular-Stent Synergy: Fragile NO intima or inaccessible plaques were stabilized with stents, avoiding embolization risks. For TO, endovascular techniques addressed tandem lesions unreachable by CEA.
- Sheath Management: Partial sheath closure during TO procedures maintained ICA flow, mitigating thrombosis during prolonged interventions.
- Restenosis Prevention: Bifurcation restenosis in TO cases highlighted the need for stent coverage of hemodynamic stress zones. Future protocols may incorporate routine C1 stenting via femoral access.
Limitations and Future Directions
This retrospective study had a small cohort and lacked a control group comparing hybrid surgery to medical therapy. Non-standardized treatment protocols and the learning curve for hybrid techniques may have influenced outcomes. Larger randomized trials are needed to validate these findings and refine patient selection criteria.
Conclusion
Hybrid surgery combining CEA and endovascular interventions demonstrates high technical success (87.5%) and low perioperative morbidity (6.25%) for symptomatic ICA NO/TO. The approach leverages open surgery for proximal plaque-thrombus clearance and endovascular methods for distal revascularization, addressing limitations of standalone techniques. Preoperative perfusion imaging and tailored stent strategies optimize outcomes, though long-term surveillance remains essential for managing restenosis.
doi.org/10.1097/CM9.0000000000001373
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