Indications for cerebral revascularization for patients with atherosclerotic carotid occlusion

Patients with complete carotid occlusion and recent ischemic symptoms are at high risk for subsequent stroke, particularly those with evidence of severe hemodynamic impairment due to poor collateral flow. Treatment options for these patients include direct extracranial to intracranial arterial bypass, or interventions aimed at improving collateral sources of flow such as endarterectomy or angioplasty and stenting of the ipsilateral external carotid artery, the contralateral carotid artery, or the vertebral arteries. The evidence supporting the use of these procedures for patients with complete occlusion of the carotid artery will be the focus of this article. The use of physiologic imaging to select subgroups of patients at high risk due to hemodynamic factors will also be discussed.