Staged Endovascular Strategy for Chronic Internal Carotid Artery Occlusion With Contralateral Carotid Stenosis: A Case-Based Technical Review Using Stent Retriever Protection

Background Chronic internal carotid artery occlusion (CICAO) with contralateral stenosis confers high stroke risk, particularly when thrombocytopenia complicates dual antiplatelet therapy (DAPT). We describe a staged revascularization strategy incorporating a stent retriever as a temporary distal protection device during CICAO recanalization after hematologic optimization. Case Presentation A 69-year-old woman with chronic hepatitis B–related thrombocytopenia (20–68 × 10⁹/L) presented with progressive imbalance (NIHSS 3, mRS 2). Imaging revealed bilateral parieto-occipital infarcts, chronic left ICA occlusion, and severe right ICA stenosis (80% North American Symptomatic Carotid Endarterectomy Trial (NASCET)). After eltrombopag therapy increased platelet counts to > 300 × 10⁹/L, DAPT was initiated. Revascularization was performed in two stages: right ICA stenting with distal filter protection, followed 14 days later by left CICAO recanalization using a Catch Mini stent retriever (Balt, Montmorency, France) as temporary embolic protection and dual-stent reconstruction (proximal Wallstent (Boston Scientific, Marlborough, MA, USA) and distal braided Leo+ stent (Balt, Montmorency, France)). Both procedures were completed without periprocedural complications. At 6 months, CTA demonstrated distal re-occlusion of the cavernous (C4) segment; however, the patient remained clinically stable (NIHSS 0) without recurrent ischemic events. Conclusions This report highlights a potential technical solution for embolic protection during chronic carotid occlusion recanalization, addressing a critical limitation of conventional protection devices that require lesion crossing before deployment.