Is it possible to place a stent in a 100% occluded carotid artery in an older adult patient with a history of atherosclerosis, hypertension, and other cardiovascular risk factors?

Stenting a 100% Occluded Carotid Artery

Carotid revascularization is not recommended for patients with chronic total occlusion of the carotid artery. 1

Guideline-Based Contraindication

The major cardiovascular guidelines explicitly classify chronic total carotid occlusion as a Class III (No Benefit) indication, meaning revascularization should not be performed. 1 This recommendation applies to both carotid endarterectomy (CEA) and carotid artery stenting (CAS). 1

Technical and Clinical Rationale

Why Complete Occlusions Are Not Stented

• Technical impossibility: A 100% occluded vessel has no patent lumen through which to pass guidewires, catheters, or stenting equipment necessary for endovascular intervention. 2

• Established collateral circulation: By the time a carotid artery reaches complete chronic occlusion, the brain has typically developed collateral blood flow pathways through the Circle of Willis and other anastomotic channels. 3

• Risk-benefit profile: The procedural risks of attempting to recanalize a chronically occluded vessel would far exceed any potential benefit, as the territory is already being supplied by alternative routes. 1

Important Distinction: Chronic vs. Acute Occlusion

The guidelines specifically refer to chronic total occlusion. 1 This is fundamentally different from:

• Acute occlusion: May be amenable to emergency thrombectomy or thrombolysis in the hyperacute stroke setting (different clinical scenario entirely)
• Near-occlusion: Defined as 95-99% stenosis with "trickle flow" or distal vessel collapse, which represents a distinct pathophysiologic entity where revascularization outcomes are less favorable but the vessel remains patent. 1

Alternative Management Strategies

For Patients with Complete Carotid Occlusion and Symptoms

When patients have symptomatic ischemia despite complete carotid occlusion, the focus shifts to:

• Optimal medical therapy: Aggressive antiplatelet therapy, statin therapy, blood pressure control, and risk factor modification. 4

• Contralateral carotid evaluation: If the patient has symptoms and contralateral stenosis, revascularization of the patent contralateral vessel may be appropriate using standard criteria (≥50% symptomatic or ≥70% asymptomatic stenosis). 1

• Extracranial-intracranial bypass: In highly selected patients with documented severe hemodynamic impairment and recurrent symptoms despite medical therapy, direct EC-IC bypass may be considered, though this remains controversial and is performed only at specialized centers. 2

• External carotid artery interventions: In rare cases, revascularization of the ipsilateral external carotid artery or optimization of vertebral artery flow may improve collateral circulation. 2

Common Clinical Pitfall

Do not confuse high-grade stenosis with complete occlusion. Imaging interpretation is critical:

• Duplex ultrasound may suggest occlusion when severe stenosis with minimal flow is present
• CTA or MRA should be used for confirmation, as these modalities better distinguish between near-occlusion (99% with string sign) and true 100% occlusion. 1
• If any residual lumen exists, the vessel is not completely occluded and standard revascularization criteria may apply. 1

Evidence Quality Note

The Class III recommendation against revascularization of chronic total carotid occlusion carries Level of Evidence C, 1 reflecting expert consensus rather than randomized trial data—which would be unethical to pursue given the technical impossibility and clear lack of benefit.