Surgical and endovascular intervention on internal carotid artery near occlusion

Therapeutic strategy for treating carotid artery near occlusion (CANO) has been controversial. The aim of this study was to review the literature concerning the invasive treatment of atherosclerotic CANO. A review was conducted of the English medical literature from 1980 to 2013 using PubMedand EMBASE database to find studies involving open or endovascular management of CANO. The search identified 20 reports describing invasive treatment of CANO encompassing 770 patients (77.7% men; mean age 66.3±5.2 years). A typical appearance of string sign was noted in nearly 60% of the patients. The vast majority (92.6%) were symptomatic. 479 (62.2%) patients underwent an open procedure, while 291 (38.8%) were treated endovascularly. The technical success rate for the endovascular procedures was 99%, while distal embolic protection devices were applied in most patients (66%). The 30 days procedural stroke rate was 2.1% and 2.4% for open and endovascular repair respectively. During a follow-up period spanning an average of approximately two years the ipsilateral cerebrovascular event rate was 5% and 1.2% for open and endovascular treatmentrespectively. Twenty five (5.2%) restenosis or occlusions were reported for the open procedures, while 13 (5.4%) were also documented for endovascular repair. The current literature concerning the invasive treatment of CANO is weak and cannot support any evidence based recommendation. The necessity to intervene as well as the best therapeutic strategy remains controversial. This review shows that the interventionon symptomatic CANO may consist a relatively safe and effective therapeutic strategy with low perioperative cerebrovascular morbidity for both treatment modalities, although durability and long-term outcomes should be further affirmed. The low incidence of this entity and the dearth of clear evidence support the need for a large multicenter registry to clarify the absolute indications for intervention and define the best therapeutic approach.