Endovascular treatment for symptomatic severe stenosis of the petro-cavernous segment of the internal carotid artery: periprocedural complications and clinical outcomes.

objectiveThis study assessed periprocedural complications and high-risk anatomical features in endovascular treatment of symptomatic severe stenosis (> 70%) in the petro-cavernous segment (PC-ICA).

methodsWe conducted a retrospective analysis of 23 patients with acute ischemic stroke and confirmed stenosis of the petrous or cavernous internal carotid artery (PC-ICA) via magnetic resonance angiography. All patients underwent balloon angioplasty and stent placement at a tertiary center between March 2018 and February 2023. Adjunctive mechanical thrombectomy was performed in three cases.

resultsThe lesions were located in the petrous segment in 7 patients (30.4%) and the cavernous segment in 16 patients (69.6%). Perioperative complications occurred in 47.8% (n = 11) of the cohort. Specific complications included in-stent thrombosis (45.5%, n = 5), vasospasm (18.2%, n = 2), plaque prolapse/extrusion (18.2%, n = 2), re-occlusion (9.1%, n = 1), and ocular ischemia (9.1%, n = 1). Although the incidence of new postoperative diffusion-weighted imaging lesions was higher in the complication group (81.8% vs. 41.7%), this difference was not statistically significant (P = 0.123). However, patients who experienced complications had significantly worse 90-day modified Rankin Scale scores ($P < 0.05$).

conclusionWhile endovascular treatment for PC-ICA stenosis is technically feasible, it carries a substantial risk of periprocedural complications, particularly in-stent thrombosis associated with heavy calcification. The fixed bony tortuosity and osseoligamentous encasement limit the vessel's compliance, predisposing it to plaque protrusion. Therefore, strategies focusing on aggressive thrombus management and careful patient selection are essential in this anatomically complex region.