Efficacy and safety analysis of hybrid operation for symptomatic chronic common carotid artery occlusion

doi:10.3969/j.issn.1672-6731.2025.07.004

Abstract

Abstract:

Objective: To explore the technical key points, clinical efficacy and safety of hybrid operation for symptomatic chronic common carotid artery occlusion (CCAO). Methods and Results: A total of 10 patients with symptomatic chronic CCAO who underwent hybrid operation in The First Affiliated Hospital of Harbin Medical University from December 2022 to October 2024 were included. The median preoperative modified Rankin Scale (mRS) score was 2 (1, 2). All patients successfully completed revascularization with a technical success rate of 10/10, including 6 cases treated with carotid endarterectomy (CEA) combined with retrograde transcarotid recanalization (for patients with short CCA residual stumps) and 4 cases treated with CEA combined with antegrade transfemoral recanalization (for patients with long CCA residual stumps). Postoperative complications included one case of cerebral hyperperfusion syndrome (CHS), with no occurrence of neck hematoma, hemorrhagic stroke, ischemic stroke or transient ischemic attack. During a median follow - up of 10 (9, 12) months, there were no cases of restenosis requiring retreatment, ipsilateral ischemic stroke or transient ischemic attack. The median mRS score at last follow - up was 0 (0, 1). The last follow - up mRS score was lower than the preoperative mRS score (Z = - 0.289, P = 0.004). Conclusions: The hybrid operation is safe and effective for treating symptomatic chronic CCAO. In clinical practice, CEA combined with retrograde transcarotid recanalization may demonstrate relatively significant advantages for symptomatic chronic CCAO with shorter residual stumps, potentially facilitating more optimal revascularization outcomes. However, further case validation remains necessary.

Key words: Carotid artery thrombosis, Carotid arterty, common, Endarterectomy, carotid, Saccule and utricle, Stents

摘要：

目的: 探讨复合手术治疗症状性慢性颈总动脉闭塞的技术要点、临床疗效及安全性。方法与结果: 纳入2022年12月至2024年10月在哈尔滨医科大学附属第一医院行复合手术治疗的10例症状性慢性颈总动脉闭塞患者, 术前改良Rankin量表（mRS）中位评分为2（1, 2）分。所有患者均顺利完成血运重建, 技术成功率为10/10, 其中颈动脉内膜切除术联合经颈动脉逆行再通6例（颈总动脉残端较短患者）, 颈动脉内膜切除术联合经股动脉顺行再通4例（颈总动脉残端较长患者）。术后1例发生脑过度灌注综合征, 无颈部血肿、出血性卒中、缺血性卒中或短暂性脑缺血发作等手术相关并发症。中位随访时间10（9, 12）个月, 随访期间无需再次治疗的严重支架内再狭窄、同侧缺血性卒中或短暂性脑缺血发作; 末次随访时mRS中位评分为0（0, 1）分, 较术前降低（Z = - 0.289, P = 0.004）。结论: 复合手术治疗症状性慢性颈总动脉闭塞安全、有效。临床实践中颈动脉内膜切除术联合经颈动脉逆行再通可能对颈总动脉残端较短的症状性慢性颈总动脉闭塞具有相对明显的优势, 可能更易获得理想的血管再通效果, 但尚待更多的病例验证。

关键词: 颈动脉血栓形成, 颈总动脉, 颈动脉内膜切除术, 球囊和椭圆囊, 支架

Hao-yu ZOU, Zhi-yong JI, Chun-lei WANG, Shan-cai XU, Bing-jie ZHENG, Huai-zhang SHI. Efficacy and safety analysis of hybrid operation for symptomatic chronic common carotid artery occlusion[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(7): 586-594.

邹昊宇, 季智勇, 王春雷, 徐善才, 郑秉杰, 史怀璋. 复合手术治疗症状性慢性颈总动脉闭塞疗效分析[J]. 中国现代神经疾病杂志, 2025, 25(7): 586-594.

/ / Recommend / Download Citations

URL: https://journal11.magtechjournal.com/cjcnn/EN/10.3969/j.issn.1672-6731.2025.07.004

https://journal11.magtechjournal.com/cjcnn/EN/Y2025/V25/I7/586

Figures/Tables 6

Table 1. Baseline data of 10 patients with symptomatic chronic CCAO

序号	性别	年龄（岁）	病程（周）	临床症状	既往史及个人史	病变部位	术前mRS（评分）
1	女性	71	24	右下肢无力	糖尿病	左侧	2
2	男性	70	8	头晕伴右上肢无力	高血压、冠心病、吸烟、饮酒	左侧	1
3	女性	69	12	头晕伴左眼视物模糊	无	左侧	2
4	男性	67	4	头晕伴左侧肢体无力	无	右侧	2
5	女性	67	24	左侧肢体麻木、无力	高血压、冠心病、吸烟	右侧	2
6	女性	68	96	头晕伴右侧肢体无力	高血压、吸烟	左侧	2
7	女性	62	20	右侧肢体无力	高血压、糖尿病、吸烟	左侧	2
8	男性	73	48	头晕伴记忆力减退	高血压、糖尿病、冠心病、饮酒	左侧	2
9	男性	49	12	头晕伴左眼视物模糊	糖尿病、吸烟、饮酒	左侧	1
10	男性	73	4	言语障碍伴左眼视物模糊	高血压	左侧	1

Figure 1 Imaging findings before and after operation and intraoperative findings of Case 6 Preoperative anterior DSA showed complete occlusion of the left CCA (arrow indicates, Panel 1a). Preoperative lateral DSA showed collateral blood flow through muscular branches of the left vertebral artery to the occipital artery, with retrograde filling to the left ECA, subsequently reconstituting the origin and intracranial segment of the ICA. The distal left ICA and intracranial segments remained patent (Panel 1b). Preoperative CTP showed preserved cerebral blood volume (CBV, Panel 1c), reduced CBF (Panel 1d), prolonged MTT (Panel 1e), and delayed TTP (Panel 1f) in the left hemisphere, consistent with stage Ⅱ hemodynamic failure (decompensated cerebral perfusion reserve). Intraoperatively, the CCA was exposed via an anterior sternocleidomastoid approach, followed by plaque dissection (Panel 1g). A short guidewire was placed under direct vision, followed by insertion of an 8F vascular sheath with suture fixation (Panel 1h). Attempt to guide a microcatheter ascending through the femoral artery using a short guidewire failed (Panel 1i). Retrograde angiography confirmed true lumen positioning (Panel 1j). Immediately postoperative lateral DSA after balloon angioplasty and stent implantation via the carotid sheath showed no residual stenosis (Panel 1k).

Figure 2 Imaging findings before and after operation and intraoperative findings of Case 9 Preoperative anterior DSA via aortic arch injection showed complete occlusion of the left CCA (arrow indicates, Panel 2a). Preoperative selective anterior DSA of the CCA stump showed a relatively long residual proximal segment (arrow indicates, Panel 2b). Preoperative anterior (Panel 2c) and lateral (Panel 2d) DSA revealed collateral circulation through muscular branches of the left vertebral artery to the occipital artery, with subsequent retrograde flow to the left ECA, reconstituting the proximal ICA and intracranial segments. The distal left ICA and intracranial vasculature were maintained patent. Preoperative CTP showed preserved CBV (Panel 2e), reduced CBF (Panel 2f), prolonged MTT (Panel 2g), and delayed TTP (Panel 2h) in the left hemisphere, consistent with stage Ⅱ hemodynamic failure (decompensated cerebral perfusion reserve). Intraoperatively, the CCA was exposed and plaque was dissected (Panel 2i). Femoral artery angiography confirmed true lumen position and revealed severe stenosis at the CCA origin (Panel 2j). Immediately postoperative anterior DSA after balloon angioplasty and implantation of 2 stents showed successful revascularization (Panel 2k).

Table 2. Surgical and follow-up data of 10 patients with symptomatic chronic CCAO

序号	手术方式	围手术期不良事件	支架类型及规格（mm）	末次随访mRS（评分）	严重支架内再狭窄
1	CEA联合经颈动脉逆行再通	无	Wallstent 9 × 40	0	无
2	CEA联合经颈动脉逆行再通	无	Omnilink Elite 9 × 29	1	无
3	CEA联合经颈动脉逆行再通	无	XACT 8 × 40	1	无
4	CEA联合经颈动脉逆行再通	无	RX Acculink 10 × 40	1	无
5	CEA联合经颈动脉逆行再通	无	Express LD 8 × 27	0	无
6	CEA联合经颈动脉逆行再通	无	Express LD 8 × 37	1	无
7	CEA联合经股动脉顺行再通	无	Wallstent 9 × 40	0	无
8	CEA联合经股动脉顺行再通	无	Express LD 8 × 37	0	无
9	CEA联合经股动脉顺行再通	脑过度灌注综合征	XACT 8 × 40/RX Acculink 9 × 40	0	无
10	CEA联合经股动脉顺行再通	无	Wallstent 9 × 40	0	无

Figure 3 Six-month postoperative follow-up cervical CTA of Case 6 showed favorable vascular remodeling Anterior CTA (Panel 3a). Lateral CTA (Panel 3b).

Figure 4 Twelve - month postoperative follow - up cervical CTA of Case 8 showed excellent vascular remodeling Anterior CTA (Panel 4a). Lateral CTA (Panel 4b).

References 28

1	Chow KVC , O'Leary C , Paxton - Hall F , Lambie D , O'Byrne K . Pembrolizumab - induced toxic epidermal necrolysis: case report. Oxf Med Case Reports, 2022, 3: omac025.
2	Grubb RL Jr , Derdeyn CP , Fritsch SM , Carpenter DA , Yundt KD , Videen TO , Spitznagel EL , Powers WJ . Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA, 1998, 280: 1055- 1060.
3	Furie KL , Kasner SE , Adams RJ , Albers GW , Bush RL , Fagan SC , Halperin JL , Johnston SC , Katzan I , Kernan WN , Mitchell PH , Ovbiagele B , Palesch YY , Sacco RL , Schwamm LH , Wassertheil - Smoller S , Turan TN , Wentworth D , American Heart Association Stroke Council , Council on Cardiovascular Nursing , Council on Clinical Cardiology , Interdisciplinary Council on Quality of Care and Outcomes Research . Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2011, 42: 227- 276.
4	Aboyans V , Ricco JB , Bartelink ML , Björck M , Brodmann M , Cohner T , Collet JP , Czerny M , De Carlo M , Debus S , Espinola - Klein C , Kahan T , Kownator S , Mazzolai L , Naylor R , Roffi M , Röther J , Sprynger M , Tendera M , Tepe G , Venermo M , Vlachopoulos C , Desormais I . 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Kardiol Pol, 2017, 75: 1065- 1160.
5	Fisher M , Martin A , Cosgrove M , Norris JW . The NASCET - ACAS plaque project: North American Symptomatic Carotid Endarterectomy Trial. Asymptomatic carotid atherosclerosis study. Stroke, 1993, 24 (12 Suppl): I24- I25.
6	Bajkó Z , Bălaşa R , Moţăţăianu A , Maier S , Chebuţ OC , Szatmári S . Common carotid artery occlusion: a case series. ISRN Neurol, 2013, ID 198595.
7	Klonaris C , Kouvelos GN , Kafeza M , Koutsoumpelis A , Katsargyris A , Tsigris C . Common carotid artery occlusion treatment: revealing a gap in the current guidelines. Eur J Vasc Endovasc Surg, 2013, 46: 291- 298.
8	Belczak S , Mulatti GC , Abrão SR , da Silva ES , Aun R , Puech - Leão P , de Luccia N . Common carotid artery occlusion: a single- center experience in 40 cases. Int J Angiol, 2016, 25: 39- 43.
9	Choi Y , Byun JS , Choi HS , Choi JK , Kim S . Asymptomatic common carotid artery occlusion and occipital - vertebral artery anastomosis: a case report and literature review. J Korean Soc Radiol, 2023, 84: 1152- 1157.
10	Albuquerque FC , Ahmed A , Mitha A , Stiefel M , McDougall CG . Endovascular recanalization of the chronically occluded brachiocephalic and subclavian arteries: technical considerations and an argument for embolic protection. World Neurosurg, 2013, 80: e327- e336.
11	Duangprasert G , Chotsakulthong P , Durongkaweroj P , Tantongtip D . Carotid -carotid artery crossover bypass using the saphenous vein graft for symptomatic common carotid artery occlusion: how I do it. Acta Neurochir (Wien), 2024, 166: 235.
12	Tsukinowa Y , Isozaki M , Kikuta K . Short jump vein graft for the treatment of symptomatic Riles type 1A occlusion of common carotid artery: case report and review of literature. Acta Neurochir (Wien), 2023, 165: 637- 642.
13	Hecht N , Wessels L , Fekonja L , von Weitzel - Mudersbach P , Vajkoczy P . Bypass strategies for common carotid artery occlusion. Acta Neurochir (Wien), 2019, 161: 1993- 2002.
14	Chen C , Ling C , Luo L , He H , Li M , Bhattarai R , Guo Y , Wang H , Guo Y . Comparison of the effectiveness of ring - stripping retrograde endarterectomy and carotid artery crossover bypass in the treatment of patients with symptomatic Riles type 1A common carotid artery occlusion. J Stroke Cerebrovasc Dis, 2020, 29: 105143.
15	Wang J , Han Q , Zhou P , Hui P , Wang Z , Wang Z , Yu Z , Huang Y . Segmented carotid endarterectomy for treatment of Riles type 1A common carotid artery occlusion. Acta Neurochir (Wien), 2022, 164: 3185- 3196.
16	Liu Y , Jia L , Liu B , Meng X , Yang J , Li J , Zhou Y , Jiao L , Hua Y . Evaluation of endarterectomy recanalization under ultrasound guidance in symptomatic patients with carotid artery occlusion. PLoS One, 2015, 10: e0144381.
17	Ogawa S , Ohgaki F , Mizuta R , Furuta Y , Fujitani S , Fujimoto S , Ota T . Two cases of symptomatic common carotid artery occlusion treated by carotid endarterectomy with L - shaped ministernotomy. Surg Neurol Int, 2020, 11: 1.
18	Miyake S , Nakai Y , Akimoto T , Ishikawa S , Saruta W , Kuroda H , Shimizu S , Yamamoto T . Combined endovascular antegrade and direct retrograde carotid artery stenting for chronic and long segment common carotid artery occlusion: technical note and review of literature. Neurol Med Chir (Tokyo), 2023, 63: 321- 326.
19	Zou C , Li Q , Hong B , Liu JM , Huang QH . Recanalization for chronic occlusion of common carotid artery. Zhonghua Nao Xue Guan Bing Za Zhi (Dian Zi Ban), 2013, 7: 193- 197.
	邹超, 李强, 洪波, 刘建民, 黄清海. 慢性颈总动脉闭塞血管内开通治疗的临床分析. 中华脑血管病杂志(电子版), 2013, 7: 193- 197.
20	Han JT , Wang T , Jia ZC , Li X . Hybrid operation of carotid endarterial plaque stripping combined with transfemoral approach anterograde revascularization for Riles type 1A common carotid artery occlusion. Zhongguo Jie Ru Ying Xiang Yu Zhi Liao Xue, 2023, 20: 143- 147.
	韩金涛, 王涛, 贾子昌, 李选. 颈动脉内膜斑块剥脱联合经股动脉途径顺行开通复合手术治疗Riles 1A型颈总动脉闭塞. 中国介入影像与治疗学, 2023, 20: 143- 147.
21	Hua ZH , Zhang LF , Xu P , Jiao ZY , Cao H , Liu SR , Li Z . Application and evaluation of hybrid operation in the treatment of symptomatic total common carotid artery occlusion. Zhongguo Xue Guan Wai Ke Za Zhi (Dian Zi Ban), 2020, 12: 209- 211.
	化召辉, 张林枫, 徐鹏, 焦周阳, 曹辉, 刘仕睿, 李震. 复合手术在症状性全程颈总动脉闭塞的应用评价. 中国血管外科杂志(电子版), 2020, 12: 209- 211.
22	Jiang SH , Xia Y , Su RQ , Kadeer KHEM , Axier AXMJ , Wang K , Rexiati NZMDJ , Li YT , Maimaitituerxun MMTYS , Tuerxun AZMTJ , Wang ZL , Aisha MMTL , Cheng XJ . A report of composite surgery of 5 cases of common carotid artery occlusion of Riles 1A. Zhongguo Shen Jing Jing Shen Ji Bing Za Zhi, 2023, 49: 456- 461.
	姜世豪, 夏源, 苏日青, 卡合尔曼·卡德尔, 阿西木江·阿西尔, 王凯, 尼扎米丁江·热夏提, 李映婷, 麦麦提亚生·麦麦提吐尔逊, 艾孜买提江·吐尔逊, 王增亮, 买买提力·艾沙, 成晓江. 复合手术治疗5例Riles 1A型颈总动脉闭塞. 中国神经精神疾病杂志, 2023, 49: 456- 461.
23	Pintér L , Cagiannos C , Bakoyiannis CN , Kolvenbach R . Hybrid treatment of common carotid artery occlusion with ring -stripper endarterectomy plus stenting. J Vasc Surg, 2007, 46: 135- 139.
24	Yang Y , Liu X , Wang R , Zhang Y , Zhang D , Zhao J . A treatment option for symptomatic chronic complete internal carotid artery occlusion: hybrid surgery. Front Neurosci, 2020, 14: 392.
25	Jia L , Hua Y , Jiao L , Ma Y , Xing Y , Wang L , Hui P , Pan X , Fang Y , Peng T , Meng X , Zhu H , Wu C , Yan Y , Han B , Yang J , Zhang N , Zhang K , Xu D . Effects of plaque characteristics and artery hemodynamics on the residual stenosis after carotid artery stenting. J Vasc Surg, 2023, 78: 430- 437.
26	Yallampalli S , Zhou W , Lin PH , Bush RL , Lumsden AB . Delayed deformation of self-expanding stents after carotid artery stenting for postendarterectomy restenosis. J Vasc Surg, 2006, 44: 412- 415.
27	Groves AP , Kansagra AP , Cross DT 3rd , Moran CJ , Derdeyn CP . Acute management and outcomes of iatrogenic dissections during cerebral angiography. J Neurointerv Surg, 2017, 9: 499- 501.
28	Zakko J , Ghincea C , Reece TB . Future paradigms of aortic dissection. Cardiol Clin, 2025, 43: 329- 336.

[1]	Dong-hai WANG. The application of hybrid operation in the diagnosis and treatment of cerebrovascular diseases [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(7): 563-568.
[2]	Hai-hong ZHANG, Xue-liang BAI, Kai-ming GAO, Wei LIU, Hong-guang WANG. Clinical efficacy and safety analysis of multimodal image-guided hybrid operation for symptomatic chronic internal carotid artery occlusion [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(7): 569-576.
[3]	Shu-shen LIU, Tao SUN, Long-xin JI, Zhi-wei XUE, Peng ZHAO, Dong-hai WANG. Comparative efficacy of endovascular treatment alone versus hybrid operation for symptomatic chronic internal carotid artery occlusion [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(7): 577-585.
[4]	Shi-min LIU, Xian-min CAO, Ling-feng WU, Zheng-bing XIANG, An WEN, Wen-feng CAO. Endovascular treatment of fulminant idiopathic intracranial hypertension associated with intracranial venous sinus stenosis: one case report [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(6): 538-542.
[5]	He ZHANG, Lin-jie YU, Xi ZHANG, Yun LUO, Yun XU, Jing-wei LI. Efficacy and safety of balloon dilation versus stent implantation in young ischemic stroke patients with symptomatic intracranial artery stenosis [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(5): 411-415.
[6]	Jin-zhao ZHU, Wei-zheng XIE, Jian-gang ZHANG, Guang FENG. Clinical effect analysis of recanalization treatment for acute ischemic stroke with large infarct core caused by intracranial atherosclerotic stenosis and cardiac embolism [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(5): 441-446.
[7]	Qiang ZHANG, Xiang ZHAI, Gang LIU, Xiao-guang TONG, Xing-wei AN, Yue MA. Application of transnasal endoscopy combined with endovascular treatment in the operation of complex skull base tumors [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(9): 751-757.
[8]	Xing-chen ZHOU, Biao ZHAO, Da-wei WANG, Hui ZHANG, Hao WANG, Jing-liang MIN. Analysis of endovascular treatment effects for anterior circulation large vessel occlusion caused by different etiologies [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(9): 758-764.
[9]	Yue-xin MEI, Xin-ran CHEN, Hong-bing CHEN. Endovascular treatment of acute straight sinus thrombosis: one case report [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(8): 684-688.
[10]	Mei-yan SHI, Xian-jun ZHANG, Xian-wei WANG, Yong ZHANG, Nai-dong WANG. Intracranial arterial stenosis stenting via radial artery approach: four cases report [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(5): 382-390.
[11]	Lei ZHOU, Zhong WANG, Guo-jun YANG, Shi-biao DONG, Nan LI, Wei-wei ZHU. Endovascular treatment for blood blister-like aneurysms of internal carotid artery and systematic literature review [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(12): 1056-1062.
[12]	Jie-men CUI, Bin YE, Xin GONG, Hong-yan ZHANG, Xuan SUN. Application of modified SWIM technique in mechanical thrombectomy of acute ischemic stroke [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(11): 883-893.
[13]	Yong-feng HAN, Lei YANG, Hong LI, Dong-liang ZHANG, Chao-song LIU. Hemodynamic investigation of incomplete stent angioplasty with percutaneous transluminal angioplasty and stenting for severe intracranial atherosclerotic stenosis [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(11): 894-905.
[14]	GUO Zhang-bao, XU Xiang-qian, CHEN Min, DUAN Zhen-hui, TANG Kun, LIU Wen-hua. A comparative study of stent thrombectomy and direct aspiration thrombectomy in the treatment of ischemic stroke caused by acute middle cerebral artery M2 segment occlusion [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2022, 22(9): 810-816.
[15]	XU Na, YI Ting-yu, WANG Ze-tuo, WU Yan-min, LIN Ding-lai, CHEN Wen-huo. Efficacy of emergent internal carotid artery stenting after intracranial thrombectomy for acute internal carotid artery stenosis related tandem lesions [J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2022, 22(8): 729-737.

Please choose a citation manager

Content to export