Proximal arrest, distal protection and flow reversal: A triple-combination technique for the endovascular treatment of acute internal carotid artery occlusion

Objective: Patients with acute internal carotid artery occlusion (ICAo) may benefit from endovascular intervention. However, the most effective endovascular strategy remains elusive. In this study, we aimed to assess the feasibility of a modified reperfusion technique integrating proximal arterial occlusion, distal embolization, and flow reversal. Methods: We developed and implemented a combined technique utilizing a balloon guide catheter (BGC). We used the BGC, distal filter, or balloon in combination for treating ICAo. Patients with acute ischemic stroke (AIS) who underwent the combined technique between November 2021 and January 2024 were included. The participants were categorized into the distal filter and the distal balloon groups. The patient demographics and technical performance metrics were recorded. Adverse events related to the procedure were monitored and analyzed. Results: Overall, 91 patients underwent the combined technique. All patients successfully underwent the procedyre, with no patient experiencing procedure-related mortality ormorbidity.The incidences of procedure-related dissection and thrombotic events were 5.49% and 9.89%, respectively. We observed no statistically significant difference in the incidence of adverse events between the distal filter and distal balloon groups. Although the distal filter group demonstrated a higher rate of successful recanalization than the distal balloon group, this difference was not statistically significant. Additionally, we observed no significant differences in the shifts in modified Rankin scalescores at 90 days. Conclusions: The combined technique is feasible, demonstrates an acceptable complication rate, and may potentially reduce the risk of embolus dislodgement. This represents a step toward ensuring more favorable outcomes in patients with ICAo. Research Significance： The significance of this study lies in addressing the critical challenge of optimizing endovascular treatment strategies for patients with acute internal carotid artery occlusion (ICAo). This study introduces a novel reperfusion technique integrating proximal arterial occlusion, distal embolization protection, and flow reversal, potentially improving clinical outcomes for acute ischemic stroke (AIS) patients and advancing the field of neurointervention.