Background Chronic total occlusion (CTO) of the cervical internal carotid artery (cICA) is an important cause of recurrent ischemic events. While revascularization can occur by both open and endovascular means, medical management has largely remained the mainstay of treatment. Methods This is a single center cohort of patients with symptomatic cICA CTO diagnosed on digital subtraction angiography between Jan 2021 and June 2025. Patients were grouped based on medical management or endovascular revascularization. Demographics, clinical and procedural characteristics and outcomes metrics were collected via a locally maintained endovascular registry and via chart review. The primary outcome of interest was recurrent ischemic events, either transient ischemic attack (TIA) or acute ischemic stroke (AIS), over the observational period. Other outcomes of interest included periprocedural serious adverse events (SAEs). Results A total of 88 cICA CTO patients (median 69y, 35% F, 80% Hispanic) were included. Hypertension was more common in medially managed patients (94% vs 81%, p=0.013) as well as atrial fibrillation (17.9% vs 0%, p=0.034). Demographics and clinical characteristics were otherwise well‐matched between groups. Recurrent ischemic events occurred more commonly in medically managed patients (95.5% vs 0%, p<0.001). Patients who underwent treatment of CTO experienced no major peri‐procedural SAEs. One patient did develop hematemesis in the days following revascularization and his anti‐platelet regimen was switched to aspirin and cilostazol with no further events. There was a trend toward higher mortality in medically managed patients that did not reach statistical significance (19.4% vs 9.5%, p=0.282). Conclusion In this single center retrospective study, patients with symptomatic cICA CTO experienced a high rate of recurrent ischemic events. Recanalization carried low peri‐procedural risk and was associated with fewer recurrent ischemic events. The findings of this study are subject to limitations inherent to its retrospective design. The single center nature of this study limits external validity. Prospective, multi‐center, randomized studies are needed. image
Miller et al. (Sat,) studied this question.