Revascularization of bilateral chronic ICA occlusion

Presented at LINNC Paris 2026 by Pr. Jan Gralla and team, this live case demonstrates the complex endovascular revascularization of a bilateral chronic internal carotid artery (ICA) occlusion.

Clinical Presentation & Strategic Decision-Making

The session features a 57-year-old male with a 10-year history of neurovascular decline, progressing from a left ICA chronic occlusion and high-grade petrous right ICA stenosis in 2016 to a complete bilateral ICA occlusion in 2026. Presenting with psychomotor slowing and severe, bilateral ACA/MCA territory hypoperfusion, the patient requires a targeted recanalization strategy to restore cerebral blood flow.

Key technical highlights and expert panel debates

Lesion crossing & material: Navigating the CCA using an 8 Fr sheath and a Balloon Guide Catheter (BGC), then advancing a microcatheter via a subintimal passage with a specialized CTO wire setup (Emboguard, Chikai Black, Gaia).
Critical re-entry strategy: Mastering true-lumen re-entry within the short extradural, cavernous ICA segment to secure a clear entrance into the intradural compartment and prevent subarachnoid hemorrhage (SAH) near the dural border.
Reconstruction & complications: Performing PTA and stenting, with a panel debate on stent choice, TCAR/Shockwave utility, early vs. late chronic occlusion, and how to prevent reperfusion syndrome.

Bilateral chronic ICA occlusion

Clinical Presentation & Strategic Decision-Making

Key technical highlights and expert panel debates

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