This case report describes a novel endovascular method for treating chronic total occlusion (CTO) of the internal carotid artery (ICA).

The patient is a 53 year old male with vascular risk factors who presented to an outside institution with right-sided weakness and dysarthria, was diagnosed as stroke, and discharged with medical management. Patient’s symptoms failed to improve throughout the week prompting him to visit another outside institution, where computed tomography (CT) angiography showed bilateral occlusion of the ICAs at their origins extending intracranially. Patient was then transferred to our hospital, where head CT and CT perfusion revealed bilateral acute infarcts predominantly in left centrum ovale/corona radiata and a large area of hypoperfusion in the entire left hemisphere as well as part of the right hemisphere (mismatch volume of 438-526 ml). Patient had significant neurological deficits despite sustained high perfusion pressure, so the following morning, the patient was taken for angiography showing complete occlusion of the left ICA with support mostly from the left external carotid artery (ECA)/ophthalmic collateralization.

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The microcatheter was able to be advanced to the level of the ophthalmic segment of the left ICA, so the decision was made to proceed with stenting from the left ophthalmic ICA to cervical ICA. Seven consecutive coronary-carotid stents were placed to essentially reconstruct the left ICA. Post-stenting, patient was treated with an Integrilin drip and transitioned to Aspirin and Brilinta the following morning. Patient’s symptoms markedly improved after the procedure. Brain perfusion-diffusion magnetic resonance imaging (MRI) revealed recovery of patient’s penumbra and stability of the existing infarcts despite the delayed nature of revascularization.

This is a rarely reported study in literature describing the successful deployment of multiple stents in recreating the ICA from its extracranial to intracranial portions.