![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-48.png)
Talk about controvercial. When a carotid goes down, either there is a stroke or there is not. If not, then you keep it closed. Right? Usually yes. But not every time. Medicine is art and science — beware of doctors (and people in general) that will never do anything different as much as of those that never play by the rules.
History is a multi-year CTO presenting with a recent deterioration.
MRI two years ago
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-01.png)
CT now
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-02.png)
Perfusion
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-03.png)
Angio — small ACOM, bad left A1. Delay of left ACA compared with right, and left MCA compared with PCA. Seems legit…
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-05.png)
The problem is a stenosis of the main COW collateral at the P1 segment.
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-06.png)
Usual ophthalmic reconstitution. But wait, is there more?
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-07.png)
See something?
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-08.png)
What is the tortuous artery following ICA from the stump?
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-09.png)
Vasa Vasorum — see CTA above. Channel in wall of the ex-ICA. Good thing is that it joins the ICA proper at the cavernous segment which is extradural. Safer to get there.
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-10.png)
How did we get into the vasa vasorum. With help of the Gaia wire — specifically designed for CTOs, used in cardiology and peripheral work. This is Gaia 2
More Gaia work below…
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-11.png)
Great — now we lost the vasorum… Its not so simple
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-12.png)
Some more looking — this is patient work. And unfruitful as it turned out with the headway duo
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-13.png)
However, the Offset (a much underused tool in stroke) does the trick — Goia finds starting points, offset tip then goes up — its supportive enough to keep going but atraumatic enough to stay in the right place hopefully.
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-15.png)
Keeps going
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-16.png)
Until horizontal petrous segment where we stopped pushing and checked where we were. Probably should have kept pushing
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-17.png)
Here is a movie of how this went
OK. no surprize here. we still arent in the cavernous segment…
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-19.png)
Despite advancing the Offset into the cavernous segment, see how it is not exactly in the right-looking place?
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-20.png)
Still subintimal
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-21.png)
Takes patience to find the right road — Gaia gain found another channel and offset followed
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-22.png)
Movie
Right place all right
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-24.png)
Another nice thing about the offset — it kind of angioplastied a path already
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-25.png)
Too early to selebrate way too early… An exachange 014 300 cm wire is needed here. A lot more work to do here. Starting with angioplasty.
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-26.png)
Proximal to distal is the way to build it. Starting with a few wallstents.
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-27.png)
Notice something… Despite full dose integrilin the neo-ICA is closed again. See, there has not been an RBC in that lumen for years, and we are not even in the true lumen… its a bit thrombogenic…
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-28.png)
How about what happens when aspiration is applied to the BMX… to heck for new thrombus
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-29.png)
Now for the rest of the construct. Thats a job for Onyx Resolute. Or maybe 10 other untested things. So we like the Onyx…
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-30.png)
A few telescoping ones. Long ones cant make all the turns
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-31.png)
Total of 3
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-32.png)
Victory…
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-33.png)
See why you need that 300 wire… Its not an easy thing to do. And its not done yet.
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-34.png)
A Pipeline to top it off. Another option is to use the Pipes for the whole intracranial segment instead of the Onyxes. But we like it our way
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-35.png)
Well, all it took is GAIA 2/AVIGO/OFFSET/MAVERICK/WALLSTENT/ONYX RESOLUTE/PED/SHIELD — not to mention BMX, and Transcend 300, and the Celt that is still to come when this all ends well…
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-36.png)
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-37.png)
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-38.png)
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-39.png)
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-40.png)
Now for some beautiful images
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-43.png)
Before
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-47.png)
Final — See how the vasa vasorum is not the same path as the revascularized carotid
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-46.png)
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-44.png)
Patency can be followed by ultrasound
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-49.png)
Angio 3 days later
![](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-50.png)
MRI post
![Post MRI](http://www.neuroangio.org/wp-content/uploads/Archives/Stroke/ICA-Chronic-Total-Occlusion-Revascularization/Internal-carotid-artery-chronic-total-occlusion-revascularization-51.png)
No less controvertial now…