Hybrid Surgical–Endovascular Revascularization for Long‑Segment Common Carotid Artery Occlusion close to the aortic arch: A Case Report

Hybrid Surgical–Endovascular Revascularization for Long‑Segment Common Carotid Artery Occlusion close to the aortic arch: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Hybrid Surgical–Endovascular Revascularization for Long‑Segment Common Carotid Artery Occlusion close to the aortic arch: A Case Report Takeshi Uno, Masaaki Shojima, Yuki Nakamura, Yuta Oyama, Ai Kawaguchi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8459636/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Apr, 2026 Read the published version in Acta Neurochirurgica → Version 1 posted 14 You are reading this latest preprint version Abstract Common carotid artery occlusion (CCAO) is a rare condition without standardized treatment, particularly in cases with long, calcified occlusions. We present a 56-year-old man with symptomatic left CCAO (Riles type 1A) treated with a hybrid surgical–endovascular approach due to limited bypass options. Although a guidewire crossed the lesion, device advancement was prevented by dense plaque. Through cervical exposure, the distal wire was grasped and traction applied, allowing balloon angioplasty and stent placement. Complete revascularization was achieved without complications. This case highlights the effectiveness of hybrid strategies for managing complex CCAO with challenging anatomical features. common carotid artery occlusion hybrid surgery endovascular intervention carotid endarterectomy carotid artery stenting chronic total occlusion Figures Figure 1 Figure 2 Figure 3 Introduction Common carotid artery occlusion (CCAO) is a rare vascular condition, occurring in only 2–4% of patients with symptomatic cerebrovascular disease ( 1 , 2 ), may cause serious damage to the unilateral cerebral hemisphere. Despite the potential impact on patients’ lives, a standardized treatment strategy for symptomatic CCAO has yet to be established ( 3 ). In a previous systematic review involving 146 patients, 137 underwent revascularization procedures, of whom 114 (83.2%) received surgical bypass. This indicates that open-surgical approaches are conventionally the most frequent treatment modality ( 4 ). While it can directly supply the cerebral blood flow into the ischemic lesions, the success of the procedure largely depends on conditions of the donner and recipient arteries in the patients with systemic arteriosclerotic disease. Recently, endovascular treatment is increasingly applied for CCAO as one of least invasive treatment modalities. However, despite its less invasiveness, it still carries certain problems. The occluded segments are often associated with dense fibrotic or heavily calcified plaques, making guidewire passage technically difficult in many cases. Moreover, plaque disruption or dislodgement during the procedure can pose a substantial risk of cerebral embolism ( 5 ). Here, we experienced a patient with intractable CCAO, in whom direct surgical revascularization was not indicated. Simultaneously, carotid artery was occluded close to the aortic arch in long-segment, which was not good candidate for endovascular surgery. To address these challenges, we adopted a hybrid approach that combines surgical cervical exposure with endovascular intervention, aiming to minimize the risk of embolism while achieving reliable revascularization. In this report, we describe the technique and its application in a representative case. Clinical Presentation A 56-year-old man with a history of hypertension and peripheral arterial disease, for which he had previously undergone bilateral superficial femoral artery stenting, presented with a 2-month history of transient right-sided hemiparesis that had been gradually increasing in frequency. Contrast-enhanced computed tomography detected occlusion from the origin of the left CCA, and cerebral blood flow scintigraphy showed hypoperfusion of the left cerebrum. The left subclavian artery (SCA) and left vertebral artery (VA) was also occluded. Cerebral angiography showed that the left external carotid artery (ECA) was perfused distally in a retrograde fashion through the right-to-left scalp and facial cutaneous collaterals, and the left internal carotid artery (ICA) exhibited antegrade flow supplied retrogradely via the ECA (Fig. 1 ). Despite treatment with dual antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg, daily), the patient continued to experience frequent transient ischemic attacks (TIAs) and had a history of asymptomatic cerebral infarctions. Consequently, cerebral revascularization was considered. The occlusive lesion extended from the origin of the left CCA to just before the carotid bifurcation, totaling 112 mm in length. The diameter of the occluded CCA segment was measured at 10 mm on axial computed tomography images. Given the long-segment of occlusion, guidewire traversal in an endovascular approach was anticipated to be difficult. Furthermore, revascularization of such long and large-diameter arteries is expected to generate a significant amount of debris, increasing the risk of distal embolization, which is challenging to remove with endovascular techniques alone. Additionally, the steep bifurcation angle (33.3°) between the aortic arch and the left CCA posed a risk of guiding catheter instability during device delivery, complicating a solo endovascular approach. Solo direct surgical intervention was also deemed inappropriate. Bypass surgery was not feasible because the typical donor vessels, including the left subclavian artery and the vertebral artery, were both occluded, and the right ECA, which served as a collateral source to the left side, was not suitable as a donor's vessel. Moreover, an endarterectomy of the entire occluded segment could necessitate temporary aortic clamping, which was considered excessively invasive. Therefore, a hybrid procedure combining endovascular treatment with a direct surgical approach was chosen. The strategy involved making a cervical incision to expose the carotid artery, performing partial plaque removal under direct vision, and then identifying the true lumen. This would allow for retrograde guidewire advancement through the occluded CCA to reach the aorta, enabling subsequent angioplasty and stenting. Surgical Procedure Surgical Exposure of the Cervical Carotid Artery Under general anesthesia, the patient was placed in a supine position with the head fixed on a ring-shaped headrest, elevated at the mandible, and rotated approximately 20° to the right. A skin incision was made along the anterior border of the sternocleidomastoid muscle (SCM), extending from 3 centimeters above the sternal notch to approximately 3 centimeters below the mastoid process. After dividing the platysma with monopolar electrocautery, the anterior border of the SCM was exposed. Dissection was carried out medial to the internal jugular vein, during which the common facial vein and retromandibular vein were ligated and divided to allow further exposure of the carotid sheath. Although the carotid artery was not palpable due to occlusion, the CCA, ICA, and ECA were identified within the carotid sheath. Vascular loops were applied to the ECA and ICA, and a tourniquet was placed on the CCA. Temporary blood flow occlusion was achieved using a mini-clip on the superior thyroid artery and bulldog clamps on the ECA and ICA. A longitudinal arteriotomy was performed from the ICA to the CCA to expose the plaque. Initial attempts to enter the distal true lumen by probing the fibrous cap using a guidewire were unsuccessful due to its firm consistency. After partial excision of the distal plaque, a 0.025-inch guidewire (Radifocus; Terumo, Tokyo, Japan) was inserted distally into the visually identified true lumen and advanced. Although the wire initially appeared to follow the true lumen, it eventually deviated into a false lumen. Hybrid Revascularization Using Endovascular and Surgical Technique For the endovascular approach, the left common femoral artery was punctured, and an 8-French sheath was inserted. Through this, an 8-French guiding catheter with an enhanced support Vitek-shaped tip (Neuro-EBU, HANACO MEDICAL CO., Ltd., Saitama, Japan) was advanced at the stump of the left CCA. Systemic heparinization was initiated to maintain an activated clotting time (ACT) of over 250 seconds. Initial attempts to traverse the occlusive plaque using a 0.035-inch guidewire (Radifocus; Terumo, Tokyo, Japan) were unsuccessful due to the plaque's hardness. A hydrophilic 0.018-inch guidewire (CHIKAI Black 18; Asahi Intecc, Aichi, Japan) was then carefully advanced, gradually dissecting through the plaque, and ultimately achieved successful passage. This successful traversal was confirmed by direct visualization from the cervical surgical field. Notably, the point of passage through the plaque differed from the presumed true lumen identified during the retrograde approach. To facilitate proximal flow control during the procedure, the guiding catheter was replaced with an 8-F balloon guiding catheter (Optimo; Tokai Med., Aichi, Japan), which was firmly wedged into the proximal segment of the CCA. Although the micro-guidewire successfully crossed the lesion, the plaque was highly resistant, and advancing other devices, such as microcatheters and balloon catheters, proved difficult. When additional force was applied to push the catheter forward, it dislodged from its position. To overcome this, the distal portion of the guidewire was grasped with forceps and pulled upward with force, which enabled the passage of a balloon catheter. Balloon angioplasty was then performed using a 3×40 mm balloon catheter (Rx-Genity; Kaneka, Tokyo, Japan). After angioplasty, the CCA was reperfused, which led to active bleeding. The debris contained in the bleeding was aspirated and flushed out, and the hemorrhage was subsequently controlled by inflating the balloon-guiding catheter. To ensure precise alignment of the proximal end of the stent at the aortic arch, stents were deployed from the surgical field. Overlapping stents (Precise 10×40 mm, 10×40 mm, 9×40 mm; Kaneka, Tokyo, Japan) were used to ensure adequate coverage of the long lesion. Endarterectomy was added to remove residual plaque in the CCA, ECA, and ICA. Then, the arteriotomy was closed. Intraoperative DSA revealed a plaque protrusion with significant stenosis at mid-CCA, which was initially treated with angioplasty using a 7×20 mm balloon (Rx-Genity), followed by placement of a 10×24 mm stent (Wallstent; Stryker, Tokyo, Japan). A filter wire (Filter-wire EZ; Stryker, Tokyo, Japan) was placed at the distal ICA to protect the cerebral circulation for this procedure. Post-stenting angiography showed good antegrade flow without intracranial embolic defects. Diffusion-weighted MRI performed on postoperative days 1 and 10 showed no cerebral infarction. Cerebral angiography performed on postoperative day 14 showed mild in-stent stenosis; however, antegrade blood flow was well preserved, and the patient was discharged with a good outcome. At follow-up 18 months after surgery, carotid ultrasoundconfirmed a well-maintained lumen with preserved antegrade flow. No TIAs were observed thereafter. Discussion This case involved a complete occlusion of the left CCAat its origin, classified as Riles type 1A ( 6 ). Revascularization was successfully achieved using a hybrid approach that combined surgical exposure with endovascular intervention. This technique combines the benefits of carotid endarterectomy (CEA) and carotid artery stenting (CAS), enabling antegrade revascularization without the need for thoracotomy. In this hybrid procedure, several key features contributed to its success. On the surgical side, the guidewire was directly secured using forceps through the exposed carotid artery, allowing for the precise delivery of endovascular devices. This approach also allowed for the external discharge of debris and accurate stent placement without protrusion into the aortic arch. On the endovascular side, the guidewire was passed through the lesion, followed by pre-dilation with a balloon and subsequent stent deployment across the entire lesion. Intraoperative angiography enabled real-time detection of plaque protrusion. To our knowledge, no previous reports have described a similar approach for CCAO, suggesting that this method may offer a minimally invasive and practical treatment option that merits further clinical consideration. CCAO is a relatively rare condition, and no standardized treatment strategy has been established to date. The Society for Vascular Surgery (SVS) guidelines recommend revascularization in patients with occlusive disease of the CCA or brachiocephalic artery who present with symptoms of anterior circulation ischemia ( 4 , 7 ). However, these guidelines do not specifically address CCAO as a distinct clinical entity, and its management currently depends on individualized decision-making based on the severity of symptoms, collateral circulation, and patient comorbidities. Surgical bypass has traditionally been the primary method of revascularization for CCAO. Revascularization using the subclavian artery (SA)-ICA, the vertebral artery (VA)-MCA, and SA-MCA bypasses has been reported in the literature ( 8 ). The present case, classified as Riles type 1A, falls into a category where subclavian–carotid bypass is commonly reported as an only solution. However, this surgical procedure could not be adopted in our patient because of the combined left SA occlusion and VA occlusion. Recently, endovascular techniques have been explored for chronic carotid occlusions ( 9 ), including CCAO ( 5 ). However, these lesions are often long and heavily calcified, rendering wire passage technically difficult. In addition, long occlusions in large-caliber arteries like the CCA may produce substantial debris upon revascularization, increasing the risk of embolic complications when treated with endovascular therapy alone. Furthermore, since CCAO typically begins just distal to its aortic origin, guiding catheters introduced via the femoral artery face a steep branching angle, raising concerns about catheter instability during device delivery. Although various adjunctive techniques have been proposed ( 10 ), the technical success rate for such cases remains limited, with reported success rates of only 60–70% for ICA occlusions ( 11 , 12 , 13 ). Hsu et al. further reported a high incidence of embolic events during endovascular treatment of CCAO ( 5 ). In the present case, the hybrid technique enabled complementary contributions from both surgical and endovascular approaches. Surgically, direct visualization allowed secure grasping of the distal guidewire with forceps, which significantly improved the stability and trackability of endovascular devices. Furthermore, visible plaque can be removed via endarterectomy, reducing the overall plaque burden and enabling the effective external discharge of debris, thereby minimizing the risk of embolism. These advantages are difficult to achieve with endovascular treatment alone. Endovascularly, although initial retrograde attempts under direct vision failed to traverse the lesion, the antegrade passage from the proximal side was eventually successful. This allowed balloon angioplasty and subsequent stent deployment, ensuring luminal patency across the entire treated segment. This synergy between surgical exposure and endovascular treatment was crucial for achieving safe and effective revascularization in the case of CCAO, which presented with long-segment occlusion, firm plaque, and limited collateral options. Conclusion In this case, recurrent TIAs completely resolved following the procedure, and the patient experienced a favorable clinical outcome. As demonstrated, the hybrid approach described here may serve as a safe and effective option for antegrade revascularization in selected patients with CCAO. Further studies involving larger patient cohorts are needed to validate the efficacy and safety of this technique. Abbreviations CCAO common carotid artery occlusion CCA common carotid artery ECA external carotid artery ICA internal carotid artery TIAs transient ischemic attacks SCM sternocleidomastoid muscle SA subclavian artery VA vertebral artery Declarations Compliance with ethical standards The patient provided written informed consent for publication of the data in this report. Conflict of Interest : The authors declare that they have no conflict of interest. Funding: This study was supported by JSPS KAKENHI grant number JP22H03189 (to Masahiro Shin). Author Contribution Takeshi Uno designed the report, drafted the manuscript, and prepared the figures.Masaaki Shojima contributed to the conception of the report and critically revised the manuscript.Yuki Nakamura participated in the patient’s clinical management and collected data.Yuta Oyama assisted in the patient’s perioperative care and contributed to data acquisition.Ai Kawaguchi contributed to the interpretation of data and revised the manuscript.Hirotomo Ten assisted in the surgery and contributed to the discussion section.Masahiro Shin supervised the entire project, provided critical revisions, and approved the final version of the manuscript. References Hass WK, Fields WS, North RR, Kricheff II, Chase NE, Bauer RB (1968) Joint study of extracranial arterial occlusion: II. Arteriography, techniques, sites, and complications. JAMA 203:961–968 Collice M, D'Angelo V, Arena O (1983) Surgical treatment of common carotid artery occlusion. Neurosurgery 12:515–524 Takagi T, Yoshimura S, Yamada K, Enomoto Y, Iwama T (2010) Angioplasty and Stenting of Totally Occluded Common Carotid Artery at the Chronic Stage—Case Report—. Neurol Med Chir (Tokyo) 50:998–1000 Klonaris C, Kouvelos GN, Kafeza M, Koutsoumpelis A, Katsargyris A, Tsigris C (2013) Common carotid artery occlusion treatment: revealing a gap in the current guidelines. Eur J Vasc Endovasc Surg 46:291–298 Hsu JC, Tsai HL (2020) Endovascular recanalization of common carotid artery total occlusion: two case reports and literature review. CVIR Endovasc 3:1–4 Riles TS, Imparato AM, Posner MP, Eikelboom BC (1984) Common carotid occlusion: assessment of the distal vessels. Ann Surg 199:363–366 Brott TG, Halperin JL, Abbara S, ASA/ACCF/AHA/AANN/ et al (2011) AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke. 2011;42:e464-e540 Hecht N, Wessels L, Fekonja L, von Weitzel-Mudersbach P, Vajkoczy P (2019) Bypass strategies for common carotid artery occlusion. Acta Neurochir 161:1993–2002 Shojima M, Nemoto S, Morita A, Miyata T, Namba K, Tanaka Y, Watanabe E (2010) Protected endovascular revascularization of subacute and chronic total occlusion of the internal carotid artery. AJNR Am J Neuroradiol 31:481–486 Uno T, Shojima M, Oyama Y, Yamane F, Matsuno A (2022) Retrograde endovascular revascularization for chronic total occlusion of the internal carotid artery: a case report. Acta Neurochir 164:1015–1019 Myrcha P, Gloviczki P (2021) A systematic review of endovascular treatment for chronic total occlusion of the internal carotid artery. Ann Transl Med 9:1203 Hasan D, Zanaty M, Starke RM, Atallah E, Chalouhi N, Jabbour P et al (2018) Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification: pilot study. J Neurosurg 130:1468–1477 Chao L, Qingbin M, Haowen X, Shanshan X, Qichang F, Zhen C, Sheng G (2021) Imaging predictors for endovascular recanalization of non-acute occlusion of the internal carotid artery based on 3D T1-SPACE MRI and DSA. Front Neurol 12:692128 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Apr, 2026 Read the published version in Acta Neurochirurgica → Version 1 posted Editorial decision: Revision requested 28 Jan, 2026 Reviews received at journal 27 Jan, 2026 Reviews received at journal 25 Jan, 2026 Reviews received at journal 19 Jan, 2026 Reviewers agreed at journal 17 Jan, 2026 Reviewers agreed at journal 17 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviews received at journal 14 Jan, 2026 Reviewers agreed at journal 14 Jan, 2026 Reviewers invited by journal 12 Jan, 2026 Editor assigned by journal 31 Dec, 2025 Submission checks completed at journal 31 Dec, 2025 First submitted to journal 27 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8459636","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":573412745,"identity":"5c075680-e76d-4835-b917-406ceed43273","order_by":0,"name":"Takeshi 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11:57:12","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89085,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFig3.png","url":"https://assets-eu.researchsquare.com/files/rs-8459636/v1/50a7ff90c906d0f37bb3fffa.png"},{"id":100401500,"identity":"5b9ab312-53c8-423f-a6f5-776586b2ba62","added_by":"auto","created_at":"2026-01-16 11:58:56","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":45045,"visible":true,"origin":"","legend":"","description":"","filename":"178311e15bbb4ec59447fd4b38ab72361structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8459636/v1/31b0bd54988ed4e704ff451c.xml"},{"id":100401638,"identity":"cc6b11bf-d972-478b-99a8-08b25b8c161f","added_by":"auto","created_at":"2026-01-16 11:59:08","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52349,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8459636/v1/d20f7171019ef07664ee0b9a.html"},{"id":100400804,"identity":"dfbcb854-eb74-49df-a39f-6e5d960b23fa","added_by":"auto","created_at":"2026-01-16 11:58:27","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":487474,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative imaging\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003eHead and neck computed tomography angiography showed occlusion of the left common carotid artery and left subclavian artery from their origins. \u003cstrong\u003eb-c\u003c/strong\u003e Right external carotid angiography. Image B is a left oblique view, and image C is an inferior view. The right occipital artery (yellow arrow), branching from the right external carotid artery (white arrow), anastomoses with the left occipital artery (yellow-green arrow), showing retrograde flow into the left external carotid artery and antegrade flow into the left internal carotid artery (green arrow). \u003cstrong\u003ed\u003c/strong\u003e Magnetic resonance angiography revealed reduced perfusion in the left internal carotid artery. \u003cstrong\u003ee\u003c/strong\u003e Single-photon emission computed tomography demonstrated the left cerebral hypoperfusion compared to the right.\u003c/p\u003e","description":"","filename":"Fig1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8459636/v1/2abe743054231474cb80d105.jpg"},{"id":100401680,"identity":"c6212400-dd6e-4de5-9d22-b7de96919b43","added_by":"auto","created_at":"2026-01-16 11:59:09","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":494742,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative findings during hybrid surgery\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea-b\u003c/strong\u003eA guidewire inserted via the femoral artery successfully passed through the occluded segment of the left common carotid artery and was grasped with forceps in the surgically exposed field. \u003cstrong\u003ec\u003c/strong\u003eEndovascular devices were inserted through the arteriotomy site. \u003cstrong\u003ed\u003c/strong\u003e A stent was deployed from the proximal to distal direction within the left common carotid artery to avoid protrusion into the aortic arch. \u003cstrong\u003ee-g\u003c/strong\u003ePost-revascularization angiography of the left common carotid artery demonstrated restoration of antegrade cerebral blood flow.\u003c/p\u003e","description":"","filename":"Fig2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8459636/v1/65a9c70144f449b6d15c25b3.jpg"},{"id":100401261,"identity":"22d3a45e-6e21-44ef-af82-33a77012bfe3","added_by":"auto","created_at":"2026-01-16 11:58:49","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":284545,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative imaging assessment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003eCerebral angiography on postoperative day 14 showed the left common carotid artery with minimal in-stent stenosis and preserved antegrade blood flow. \u003cstrong\u003eb\u003c/strong\u003e Single-photon emission computed tomography on postoperative day 10 demonstrated improved perfusion in the left cerebral hemisphere. \u003cstrong\u003ec\u003c/strong\u003e Carotid ultrasound at 18 months postoperatively revealed minimal intimal thickening and sustained antegrade flow.\u003c/p\u003e","description":"","filename":"Fig3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8459636/v1/8456781254da5b0101299e9c.jpg"},{"id":106809161,"identity":"7a578e91-98f1-4ae0-aa43-c094b2d5298a","added_by":"auto","created_at":"2026-04-13 16:07:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1706645,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8459636/v1/ec51aa0c-5acb-4aaf-aae5-125670d9ca16.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hybrid Surgical–Endovascular Revascularization for Long‑Segment Common Carotid Artery Occlusion close to the aortic arch: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCommon carotid artery occlusion (CCAO) is a rare vascular condition, occurring in only 2\u0026ndash;4% of patients with symptomatic cerebrovascular disease (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), may cause serious damage to the unilateral cerebral hemisphere. Despite the potential impact on patients\u0026rsquo; lives, a standardized treatment strategy for symptomatic CCAO has yet to be established (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In a previous systematic review involving 146 patients, 137 underwent revascularization procedures, of whom 114 (83.2%) received surgical bypass. This indicates that open-surgical approaches are conventionally the most frequent treatment modality (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). While it can directly supply the cerebral blood flow into the ischemic lesions, the success of the procedure largely depends on conditions of the donner and recipient arteries in the patients with systemic arteriosclerotic disease. Recently, endovascular treatment is increasingly applied for CCAO as one of least invasive treatment modalities. However, despite its less invasiveness, it still carries certain problems. The occluded segments are often associated with dense fibrotic or heavily calcified plaques, making guidewire passage technically difficult in many cases. Moreover, plaque disruption or dislodgement during the procedure can pose a substantial risk of cerebral embolism (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHere, we experienced a patient with intractable CCAO, in whom direct surgical revascularization was not indicated. Simultaneously, carotid artery was occluded close to the aortic arch in long-segment, which was not good candidate for endovascular surgery. To address these challenges, we adopted a hybrid approach that combines surgical cervical exposure with endovascular intervention, aiming to minimize the risk of embolism while achieving reliable revascularization. In this report, we describe the technique and its application in a representative case.\u003c/p\u003e"},{"header":"Clinical Presentation","content":"\u003cp\u003eA 56-year-old man with a history of hypertension and peripheral arterial disease, for which he had previously undergone bilateral superficial femoral artery stenting, presented with a 2-month history of transient right-sided hemiparesis that had been gradually increasing in frequency. Contrast-enhanced computed tomography detected occlusion from the origin of the left CCA, and cerebral blood flow scintigraphy showed hypoperfusion of the left cerebrum. The left subclavian artery (SCA) and left vertebral artery (VA) was also occluded. Cerebral angiography showed that the left external carotid artery (ECA) was perfused distally in a retrograde fashion through the right-to-left scalp and facial cutaneous collaterals, and the left internal carotid artery (ICA) exhibited antegrade flow supplied retrogradely via the ECA (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite treatment with dual antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg, daily), the patient continued to experience frequent transient ischemic attacks (TIAs) and had a history of asymptomatic cerebral infarctions. Consequently, cerebral revascularization was considered.\u003c/p\u003e \u003cp\u003eThe occlusive lesion extended from the origin of the left CCA to just before the carotid bifurcation, totaling 112 mm in length. The diameter of the occluded CCA segment was measured at 10 mm on axial computed tomography images. Given the long-segment of occlusion, guidewire traversal in an endovascular approach was anticipated to be difficult. Furthermore, revascularization of such long and large-diameter arteries is expected to generate a significant amount of debris, increasing the risk of distal embolization, which is challenging to remove with endovascular techniques alone. Additionally, the steep bifurcation angle (33.3\u0026deg;) between the aortic arch and the left CCA posed a risk of guiding catheter instability during device delivery, complicating a solo endovascular approach.\u003c/p\u003e \u003cp\u003eSolo direct surgical intervention was also deemed inappropriate. Bypass surgery was not feasible because the typical donor vessels, including the left subclavian artery and the vertebral artery, were both occluded, and the right ECA, which served as a collateral source to the left side, was not suitable as a donor's vessel. Moreover, an endarterectomy of the entire occluded segment could necessitate temporary aortic clamping, which was considered excessively invasive.\u003c/p\u003e \u003cp\u003eTherefore, a hybrid procedure combining endovascular treatment with a direct surgical approach was chosen. The strategy involved making a cervical incision to expose the carotid artery, performing partial plaque removal under direct vision, and then identifying the true lumen. This would allow for retrograde guidewire advancement through the occluded CCA to reach the aorta, enabling subsequent angioplasty and stenting.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Procedure\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eSurgical Exposure of the Cervical Carotid Artery\u003c/h2\u003e \u003cp\u003eUnder general anesthesia, the patient was placed in a supine position with the head fixed on a ring-shaped headrest, elevated at the mandible, and rotated approximately 20\u0026deg; to the right. A skin incision was made along the anterior border of the sternocleidomastoid muscle (SCM), extending from 3 centimeters above the sternal notch to approximately 3 centimeters below the mastoid process. After dividing the platysma with monopolar electrocautery, the anterior border of the SCM was exposed. Dissection was carried out medial to the internal jugular vein, during which the common facial vein and retromandibular vein were ligated and divided to allow further exposure of the carotid sheath. Although the carotid artery was not palpable due to occlusion, the CCA, ICA, and ECA were identified within the carotid sheath. Vascular loops were applied to the ECA and ICA, and a tourniquet was placed on the CCA. Temporary blood flow occlusion was achieved using a mini-clip on the superior thyroid artery and bulldog clamps on the ECA and ICA. A longitudinal arteriotomy was performed from the ICA to the CCA to expose the plaque.\u003c/p\u003e \u003cp\u003eInitial attempts to enter the distal true lumen by probing the fibrous cap using a guidewire were unsuccessful due to its firm consistency. After partial excision of the distal plaque, a 0.025-inch guidewire (Radifocus; Terumo, Tokyo, Japan) was inserted distally into the visually identified true lumen and advanced. Although the wire initially appeared to follow the true lumen, it eventually deviated into a false lumen.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eHybrid Revascularization Using Endovascular and Surgical Technique\u003c/h3\u003e\n\u003cp\u003eFor the endovascular approach, the left common femoral artery was punctured, and an 8-French sheath was inserted. Through this, an 8-French guiding catheter with an enhanced support Vitek-shaped tip (Neuro-EBU, HANACO MEDICAL CO., Ltd., Saitama, Japan) was advanced at the stump of the left CCA. Systemic heparinization was initiated to maintain an activated clotting time (ACT) of over 250 seconds.\u003c/p\u003e \u003cp\u003eInitial attempts to traverse the occlusive plaque using a 0.035-inch guidewire (Radifocus; Terumo, Tokyo, Japan) were unsuccessful due to the plaque's hardness. A hydrophilic 0.018-inch guidewire (CHIKAI Black 18; Asahi Intecc, Aichi, Japan) was then carefully advanced, gradually dissecting through the plaque, and ultimately achieved successful passage. This successful traversal was confirmed by direct visualization from the cervical surgical field. Notably, the point of passage through the plaque differed from the presumed true lumen identified during the retrograde approach.\u003c/p\u003e \u003cp\u003eTo facilitate proximal flow control during the procedure, the guiding catheter was replaced with an 8-F balloon guiding catheter (Optimo; Tokai Med., Aichi, Japan), which was firmly wedged into the proximal segment of the CCA. Although the micro-guidewire successfully crossed the lesion, the plaque was highly resistant, and advancing other devices, such as microcatheters and balloon catheters, proved difficult. When additional force was applied to push the catheter forward, it dislodged from its position. To overcome this, the distal portion of the guidewire was grasped with forceps and pulled upward with force, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ewhich enabled the passage of a balloon catheter.\u003c/span\u003e Balloon angioplasty was then performed using a 3\u0026times;40 mm balloon catheter (Rx-Genity; Kaneka, Tokyo, Japan). After angioplasty, the CCA was reperfused, which led to active bleeding. The debris contained in the bleeding was aspirated and flushed out, and the hemorrhage was subsequently controlled by inflating the balloon-guiding catheter.\u003c/p\u003e \u003cp\u003eTo ensure precise alignment of the proximal end of the stent at the aortic arch, stents were deployed from the surgical field. Overlapping stents (Precise 10\u0026times;40 mm, 10\u0026times;40 mm, 9\u0026times;40 mm; Kaneka, Tokyo, Japan) were used to ensure adequate coverage of the long lesion. Endarterectomy was added to remove residual plaque in the CCA, ECA, and ICA. Then, the arteriotomy was closed. Intraoperative DSA revealed a plaque protrusion with significant stenosis at mid-CCA, which was initially treated with angioplasty using a 7\u0026times;20 mm balloon (Rx-Genity), followed by placement of a 10\u0026times;24 mm stent (Wallstent; Stryker, Tokyo, Japan). A filter wire (Filter-wire EZ; Stryker, Tokyo, Japan) was placed at the distal ICA to protect the cerebral circulation for this procedure. Post-stenting angiography showed good antegrade flow without intracranial embolic defects.\u003c/p\u003e \u003cp\u003eDiffusion-weighted MRI performed on postoperative days 1 and 10 showed no cerebral infarction. Cerebral angiography performed on postoperative day 14 showed mild in-stent stenosis; however, antegrade blood flow was well preserved, and the patient was discharged with a good outcome. At follow-up 18 months after surgery, carotid ultrasoundconfirmed a well-maintained lumen with preserved antegrade flow. No TIAs were observed thereafter.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case involved a complete occlusion of the left CCAat its origin, classified as Riles type 1A (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Revascularization was successfully achieved using a hybrid approach that combined surgical exposure with endovascular intervention. This technique combines the benefits of carotid endarterectomy (CEA) and carotid artery stenting (CAS), enabling antegrade revascularization without the need for thoracotomy. In this hybrid procedure, several key features contributed to its success. On the surgical side, the guidewire was directly secured using forceps through the exposed carotid artery, allowing for the precise delivery of endovascular devices. This approach also allowed for the external discharge of debris and accurate stent placement without protrusion into the aortic arch. On the endovascular side, the guidewire was passed through the lesion, followed by pre-dilation with a balloon and subsequent stent deployment across the entire lesion. Intraoperative angiography enabled real-time detection of plaque protrusion. To our knowledge, no previous reports have described a similar approach for CCAO, suggesting that this method may offer a minimally invasive and practical treatment option that merits further clinical consideration.\u003c/p\u003e \u003cp\u003eCCAO is a relatively rare condition, and no standardized treatment strategy has been established to date. The Society for Vascular Surgery (SVS) guidelines recommend revascularization in patients with occlusive disease of the CCA or brachiocephalic artery who present with symptoms of anterior circulation ischemia (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, these guidelines do not specifically address CCAO as a distinct clinical entity, and its management currently depends on individualized decision-making based on the severity of symptoms, collateral circulation, and patient comorbidities. Surgical bypass has traditionally been the primary method of revascularization for CCAO. Revascularization using the subclavian artery (SA)-ICA, the vertebral artery (VA)-MCA, and SA-MCA bypasses has been reported in the literature (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The present case, classified as Riles type 1A, falls into a category where subclavian\u0026ndash;carotid bypass is commonly reported as an only solution. However, this surgical procedure could not be adopted in our patient because of the combined left SA occlusion and VA occlusion.\u003c/p\u003e \u003cp\u003eRecently, endovascular techniques have been explored for chronic carotid occlusions (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), including CCAO (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, these lesions are often long and heavily calcified, rendering wire passage technically difficult. In addition, long occlusions in large-caliber arteries like the CCA may produce substantial debris upon revascularization, increasing the risk of embolic complications when treated with endovascular therapy alone. Furthermore, since CCAO typically begins just distal to its aortic origin, guiding catheters introduced via the femoral artery face a steep branching angle, raising concerns about catheter instability during device delivery. Although various adjunctive techniques have been proposed (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), the technical success rate for such cases remains limited, with reported success rates of only 60\u0026ndash;70% for ICA occlusions (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Hsu et al. further reported a high incidence of embolic events during endovascular treatment of CCAO (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the present case, the hybrid technique enabled complementary contributions from both surgical and endovascular approaches. Surgically, direct visualization allowed secure grasping of the distal guidewire with forceps, which significantly improved the stability and trackability of endovascular devices. Furthermore, visible plaque can be removed via endarterectomy, reducing the overall plaque burden and enabling the effective external discharge of debris, thereby minimizing the risk of embolism. These advantages are difficult to achieve with endovascular treatment alone. Endovascularly, although initial retrograde attempts under direct vision failed to traverse the lesion, the antegrade passage from the proximal side was eventually successful. This allowed balloon angioplasty and subsequent stent deployment, ensuring luminal patency across the entire treated segment. This synergy between surgical exposure and endovascular treatment was crucial for achieving safe and effective revascularization in the case of CCAO, which presented with long-segment occlusion, firm plaque, and limited collateral options.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this case, recurrent TIAs completely resolved following the procedure, and the patient experienced a favorable clinical outcome. As demonstrated, the hybrid approach described here may serve as a safe and effective option for antegrade revascularization in selected patients with CCAO. Further studies involving larger patient cohorts are needed to validate the efficacy and safety of this technique.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCCAO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecommon carotid artery occlusion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCCA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecommon carotid artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eECA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eexternal carotid artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eICA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einternal carotid artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTIAs\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etransient ischemic attacks\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSCM\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esternocleidomastoid muscle\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esubclavian artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eVA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evertebral artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompliance with ethical standards\u003c/h2\u003e \u003cp\u003eThe patient provided written informed consent for publication of the data in this report.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eConflict of Interest\u003c/b\u003e:\u003c/strong\u003e \u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis study was supported by JSPS KAKENHI grant number JP22H03189 (to Masahiro Shin).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTakeshi Uno designed the report, drafted the manuscript, and prepared the figures.Masaaki Shojima contributed to the conception of the report and critically revised the manuscript.Yuki Nakamura participated in the patient\u0026rsquo;s clinical management and collected data.Yuta Oyama assisted in the patient\u0026rsquo;s perioperative care and contributed to data acquisition.Ai Kawaguchi contributed to the interpretation of data and revised the manuscript.Hirotomo Ten assisted in the surgery and contributed to the discussion section.Masahiro Shin supervised the entire project, provided critical revisions, and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHass WK, Fields WS, North RR, Kricheff II, Chase NE, Bauer RB (1968) Joint study of extracranial arterial occlusion: II. Arteriography, techniques, sites, and complications. JAMA 203:961\u0026ndash;968\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollice M, D'Angelo V, Arena O (1983) Surgical treatment of common carotid artery occlusion. Neurosurgery 12:515\u0026ndash;524\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakagi T, Yoshimura S, Yamada K, Enomoto Y, Iwama T (2010) Angioplasty and Stenting of Totally Occluded Common Carotid Artery at the Chronic Stage\u0026mdash;Case Report\u0026mdash;. Neurol Med Chir (Tokyo) 50:998\u0026ndash;1000\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlonaris C, Kouvelos GN, Kafeza M, Koutsoumpelis A, Katsargyris A, Tsigris C (2013) Common carotid artery occlusion treatment: revealing a gap in the current guidelines. Eur J Vasc Endovasc Surg 46:291\u0026ndash;298\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsu JC, Tsai HL (2020) Endovascular recanalization of common carotid artery total occlusion: two case reports and literature review. CVIR Endovasc 3:1\u0026ndash;4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiles TS, Imparato AM, Posner MP, Eikelboom BC (1984) Common carotid occlusion: assessment of the distal vessels. Ann Surg 199:363\u0026ndash;366\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrott TG, Halperin JL, Abbara S, ASA/ACCF/AHA/AANN/ et al (2011) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eAANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS\u003c/span\u003e\u003cspan address=\"http://AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke. 2011;42:e464-e540\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHecht N, Wessels L, Fekonja L, von Weitzel-Mudersbach P, Vajkoczy P (2019) Bypass strategies for common carotid artery occlusion. Acta Neurochir 161:1993\u0026ndash;2002\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShojima M, Nemoto S, Morita A, Miyata T, Namba K, Tanaka Y, Watanabe E (2010) Protected endovascular revascularization of subacute and chronic total occlusion of the internal carotid artery. AJNR Am J Neuroradiol 31:481\u0026ndash;486\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUno T, Shojima M, Oyama Y, Yamane F, Matsuno A (2022) Retrograde endovascular revascularization for chronic total occlusion of the internal carotid artery: a case report. Acta Neurochir 164:1015\u0026ndash;1019\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyrcha P, Gloviczki P (2021) A systematic review of endovascular treatment for chronic total occlusion of the internal carotid artery. Ann Transl Med 9:1203\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasan D, Zanaty M, Starke RM, Atallah E, Chalouhi N, Jabbour P et al (2018) Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification: pilot study. J Neurosurg 130:1468\u0026ndash;1477\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChao L, Qingbin M, Haowen X, Shanshan X, Qichang F, Zhen C, Sheng G (2021) Imaging predictors for endovascular recanalization of non-acute occlusion of the internal carotid artery based on 3D T1-SPACE MRI and DSA. Front Neurol 12:692128\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"common carotid artery occlusion, hybrid surgery, endovascular intervention, carotid endarterectomy, carotid artery stenting, chronic total occlusion","lastPublishedDoi":"10.21203/rs.3.rs-8459636/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8459636/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCommon carotid artery occlusion (CCAO) is a rare condition without standardized treatment, particularly in cases with long, calcified occlusions. We present a 56-year-old man with symptomatic left CCAO (Riles type 1A) treated with a hybrid surgical\u0026ndash;endovascular approach due to limited bypass options. Although a guidewire crossed the lesion, device advancement was prevented by dense plaque. Through cervical exposure, the distal wire was grasped and traction applied, allowing balloon angioplasty and stent placement. Complete revascularization was achieved without complications. This case highlights the effectiveness of hybrid strategies for managing complex CCAO with challenging anatomical features.\u003c/p\u003e","manuscriptTitle":"Hybrid Surgical–Endovascular Revascularization for Long‑Segment Common Carotid Artery Occlusion close to the aortic arch: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 09:06:29","doi":"10.21203/rs.3.rs-8459636/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-28T17:14:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T21:24:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-25T20:23:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T07:41:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308707481989248268810991191561924939932","date":"2026-01-17T19:23:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217997092966232152928393769478196853543","date":"2026-01-17T14:08:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"257030247088736629922259145661785041092","date":"2026-01-15T15:11:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262904802571614083997379197328565605750","date":"2026-01-15T11:01:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-14T16:28:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10481428344239042241877631870571993840","date":"2026-01-14T14:56:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-12T14:40:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-31T09:05:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-31T09:04:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Acta Neurochirurgica","date":"2025-12-27T08:13:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"44fb3ac8-5bb3-4665-94ad-149aa8d8431e","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:04:32+00:00","versionOfRecord":{"articleIdentity":"rs-8459636","link":"https://doi.org/10.1007/s00701-026-06832-4","journal":{"identity":"acta-neurochirurgica","isVorOnly":false,"title":"Acta Neurochirurgica"},"publishedOn":"2026-04-06 15:57:53","publishedOnDateReadable":"April 6th, 2026"},"versionCreatedAt":"2026-01-16 09:06:29","video":"","vorDoi":"10.1007/s00701-026-06832-4","vorDoiUrl":"https://doi.org/10.1007/s00701-026-06832-4","workflowStages":[]},"version":"v1","identity":"rs-8459636","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8459636","identity":"rs-8459636","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}