Endovascular Recanalization of Bilateral Chronic Internal Carotid Artery Occlusion: Exemplary Case of the Laborious and Difficult but Worthwhile Endeavor

Chronic occlusion of the internal carotid artery (COICA) is a disease whose scope of risk may be substantially underestimated. Patients with medically refractory COICA, beyond being at permanent risk of direct damage to the brain through acute and chronic hemodynamic and embolic infarction, are at elevated risk of adverse cardiac events; organ damage through chronic, reactive hypertension as a result of cerebral high-volume collateralization and chronic cognitive impairment, which may be the least monitored adverse event. The recanalization of symptomatic COICA has been increasingly advocated in recent literature. However, no society recommendations or international guidelines are in favour of recanalizing medically refractory COICA yet. The risks of periprocedural complications should not be underestimated, and because of the nature of COICA, the endeavor is often complex and lengthy. Consequently, many medical professionals still consider COICA an “untouchable” disease and do not address its association with elevated risk of adverse events. A 44-year-old female patient with type II diabetes, arterial hypertension, lupus erythematosus, and a smoking history presented with paralysis of her left leg. Chronic occlusions of both internal carotid arteries (ICAs) were diagnosed, and she was referred for endovascular treatment. Both ICAs were reconstructed through balloon dilatation and stenting. During the following 2 years, stenosis at the origin of the left vertebral artery, distal stenoses of the left ICA, and an incidental aneurysm of the right middle cerebral artery were also managed through endovascular means. The long-term outcome of the patient was excellent. This chapter focuses on treatment strategies, expected issues, and outcomes of endovascular COICA recanalization.