Volume 257, October 2025, 109049Author links open overlay panel, , , , , , , Highlights•

This study identified the key predictors of restenosis.

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Developed a prediction model for recanalization of CICAO.

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Only patients who underwent endovascular recanalization treatment were included.

AbstractBackground

Current evidence regarding restenosis after successful endovascular recanalization for chronic internal carotid artery occlusion (CICAO) remains limited. This study aimed to investigate the incidence and risk factors of restenosis following technically successful revascularization for CICAO, and to develop a novel risk score for risk stratification.

Methods

This retrospective cohort study included 204 patients with CICAO who underwent successful endovascular recanalization. The incidence of restenosis was assessed, risk factors were identified through multivariable regression analysis, and a predictive model for restenosis was developed using multivariable regression analysis.

Results

During a mean imaging follow-up duration of 16.1 ± 8.5 months, 47 patients (23.5 %) developed internal carotid artery restenosis or reocclusion. A multivariable logistic regression model constructed using backward stepwise regression demonstrated an area under the curve values of 0.758 in the training set and 0.757 in the test set. The model identified three independent risk factors: internal carotid artery tortuosity, non-tapered stump morphology, and residual stenosis > 30 %.

Conclusion

This study demonstrated a restenosis rate of 23.5 % following successful endovascular recanalization for CICAO. Internal carotid artery tortuosity, non-tapered stump morphology, and residual stenosis > 30 % were identified as independent predictors of restenosis.

Introduction

Chronic internal carotid artery occlusion (CICAO) is a major cause of ischemic stroke, accounting for 6–20 % of annual cases [1], [2]. Endovascular therapy has emerged as an effective treatment strategy for CICAO [3], [4], demonstrating efficacy in reducing recurrent ischemic events [5], [6]. Recent advancements in endovascular techniques have led to the increasing adoption of this approach for cerebrovascular reconstruction in CICAO.

Emerging evidence from small-scale studies suggests concerning restenosis and reocclusion rates of 14–15 % following endovascular recanalization for CICAO [6], [7], significantly higher than the 3–5 % restenosis rates observed after carotid artery stenting (CAS) for atherosclerotic stenosis [8]. Such high rates of postprocedural restenosis substantially compromise the long-term therapeutic benefits of endovascular revascularization for CICAO. Despite its clinical significance, current evidence remains insufficient to characterize restenosis patterns and predictors in this specific population.

This study aimed to investigate the incidence and risk factors of restenosis following successful endovascular recanalization for CICAO, and to develop a predictive model for restenosis occurrence.

Section snippetsPatient selection

This retrospective study included 204 patients who underwent successful endovascular recanalization for CICAO at X Hospital between March 2019 and June 2023. The inclusion criteria were as follows: digital subtraction angiography (DSA) confirming complete occlusion in any segment from the origin to the terminal portion of the internal carotid artery (ICA); a history of ipsilateral ischemic events, including amaurosis fugax, transient ischemic attack, or ischemic stroke; evidence of ipsilateral

Baseline characteristics

The study enrolled 204 consecutive patients with CICAO who met the criteria for endovascular recanalization. Demographic, clinical, and lesion characteristics are provided in Table 1, Table 2. During a mean imaging follow-up of 16.1 ± 8.5 months, restenosis occurred in 47 patients (23.5 %), with incidence rates of 21.7 % in the training and 26.2 % in the testing cohorts. Over a mean clinical follow-up duration of 44.4 ± 14.0 months, 17 patients (8.3 %) developed ipsilateral ischemic stroke. No

Discussion

This study reports the midterm restenosis rate following successful standalone endovascular recanalization in 204 patients with CICAO. Key predictors of restenosis were identified, and a clinical predictive model was developed, offering important insights for guiding therapeutic decision-making and follow-up management in this patient population. To our knowledge, this is the first comprehensive investigation to address restenosis risk stratification and predictive model development

Limitations

Our study has a few limitations. First, although it represents the largest cohort to date evaluating restenosis following endovascular recanalization for CICAO, the moderate sample size may still limit the generalizability of our findings. Second, the retrospective design of this study may introduce potential selection bias. Additionally, since the analysis relied solely on single-center data without multicenter validation, the findings require further verification through prospective

Conclusion

This study demonstrated a 23.5 % restenosis rate following successful endovascular recanalization for CICAO. Patients with restenosis had a significantly higher risk of recurrent ischemic stroke compared with those without restenosis. A validated predictive model was developed, identifying three independent risk factors for restenosis: ICA tortuosity, residual stenosis ≥ 30 %, and non-tapered stump morphology. These findings offer insights important for risk stratification and personalized

Ethical approval

The local ethics committee approved the study protocol, and the requirement for written informed consent was waived, given the retrospective study design and use of anonymized data.

Funding

This work was supported by the Natural Science Foundation of Beijing Municipality (grant number 7212007).

CRediT authorship contribution statement

Xiguang Fu: Writing – original draft, Project administration, Formal analysis, Data curation, Conceptualization. Haoyu Zhu: Writing – original draft, Data curation. Yuqi Song: Data curation. Jiarui Zhang: Formal analysis. Mengyuan Yuan: Data curation. Shengjun Sun: Data curation. Yong Zhang: Writing – review & editing, Formal analysis, Data curation, Conceptualization. Chuhan Jiang: Writing – review & editing, Formal analysis.

AcknowledgmentsThe authors acknowledge the assistance of the Endovascular Neurosurgery Research Group members (Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China.). We thank Editage (www.editage.cn) for English language editing.Consent to participate

The authors affirm that human research participants provided informed consent for publication of the images in Figure(s) 1a, 1b and 1 c.The participant has consented to the submission of the case report to the journal. Patients signed informed

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