Surreal illustration of a blocked carotid artery transforming into a flowing river.

Unlocking the Mysteries of Chronic Carotid Artery Occlusion: A New Hope for Hybrid Surgical Approaches

Jordan Keane in Health & Wellness June 2025 • 5 min read.

"Discover how a novel classification system and hybrid surgical techniques are revolutionizing the treatment of chronic internal carotid artery occlusion (COICA), offering renewed hope for patients with this challenging condition."

Chronic Internal Carotid Artery Occlusion (COICA) represents a significant challenge in vascular surgery. This condition, characterized by the long-term blockage of the internal carotid artery, can lead to severe neurological consequences, including stroke. The original article by Liu et al.¹ highlights the innovative use of hybrid surgery, combining carotid endarterectomy and endovascular angioplasty, to address this complex problem. Their work underscores the ongoing efforts to find effective treatments for COICA and improve patient outcomes.

The article, however, prompted a critical discussion regarding the classification and treatment strategies for COICA. A letter to the editor raised important points about the duration of occlusion, the techniques used for recanalization, and the significance of classifying COICA based on supraclinoid filling and the presence of an internal carotid artery (ICA) stump. This ongoing dialogue is crucial for refining our understanding and approach to managing COICA.

This article delves into the complexities surrounding COICA, examining the proposed classification system and the potential of hybrid surgical interventions. We aim to provide a comprehensive overview of the current understanding of COICA, the challenges in its treatment, and the promising avenues for future research and clinical practice. By bridging the gap between complex medical research and accessible information, we hope to empower individuals to better understand this condition and the innovative approaches being developed to combat it.

Understanding the COICA Classification System

Surreal illustration of a blocked carotid artery transforming into a flowing river.

One of the key points of discussion revolves around the classification of COICA. The original classification of COICA depends on supraclinoid filling. However, it did not consider the presence or absence of an internal carotid artery (ICA) stump. The suggested classification system takes into account both supraclinoid filling and the presence of an ICA stump, offering a more detailed and potentially more useful framework for guiding treatment decisions. The classification system categorizes COICA into four main types:

The presence or absence of an ICA stump, along with the pattern of supraclinoid filling, significantly impacts the feasibility and success of endovascular interventions. Types A and B COICA, characterized by the presence of an ICA stump and supraclinoid filling, are often more amenable to endovascular techniques. In contrast, Types C and D COICA, which lack an ICA stump, pose greater challenges and may require alternative approaches such as hybrid surgery.

Type A: Tapered occlusion of the ICA stump with patent lumen distally from collateral filling.
Type B: Nontapered ICA stump with patent lumen distally from collateral filling.
Type C: No ICA stump and patent lumen distally from collateral filling.
Type D: No ICA stump and occluded lumen distally until ICA bifurcation.

The value of a detailed classification system lies in its ability to predict the success and safety of endovascular interventions. For instance, studies have shown that Types A and B COICA are more likely to be successfully opened using endovascular techniques, whereas Types C and D COICA may require more complex strategies. Understanding these nuances is crucial for tailoring treatment plans to individual patient needs and maximizing the likelihood of positive outcomes.

The Future of COICA Treatment

Ongoing research and clinical experience will continue to refine our understanding of COICA and optimize treatment strategies. As technology advances and new techniques emerge, the potential for successful revascularization and improved patient outcomes will only continue to grow. The hybrid approach, combining the strengths of both open surgery and endovascular techniques, holds particular promise for addressing the challenges posed by complex COICA cases.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.wneu.2018.09.033, Alternate LINK

Title: Letter To The Editor Regarding “Estimation And Recanalization Of Chronic Occluded Internal Carotid Artery: Hybrid Operation By Carotid Endarterectomy And Endovascular Angioplasty”

Subject: Neurology (clinical)

Journal: World Neurosurgery

Publisher: Elsevier BV

Authors: Mario Zanaty, Edgar A. Samaniego, David M. Hasan

Published: 2019-01-01

Everything You Need To Know

What is Chronic Internal Carotid Artery Occlusion (COICA) and why is it a significant concern?

Chronic Internal Carotid Artery Occlusion (COICA) is a condition where the internal carotid artery experiences long-term blockage. This blockage can lead to severe neurological issues, such as stroke. Effective treatments are needed to improve outcomes for those affected by COICA. Hybrid surgery, like the combination of carotid endarterectomy and endovascular angioplasty, represents a step forward. Further refinement in classification and treatment strategies are crucial for managing COICA effectively.

How does the new classification system for Chronic Internal Carotid Artery Occlusion (COICA) work, and what are the different types?

The classification system categorizes COICA into four types based on two main factors: the presence or absence of an internal carotid artery (ICA) stump, and the pattern of supraclinoid filling. These types are: Type A (Tapered occlusion of the ICA stump with patent lumen distally from collateral filling), Type B (Nontapered ICA stump with patent lumen distally from collateral filling), Type C (No ICA stump and patent lumen distally from collateral filling), and Type D (No ICA stump and occluded lumen distally until ICA bifurcation). The classification aids in predicting the success and safety of endovascular interventions.

How does the presence or absence of an internal carotid artery (ICA) stump affect the treatment strategy for Chronic Internal Carotid Artery Occlusion (COICA)?

The presence of an internal carotid artery (ICA) stump and the pattern of supraclinoid filling are key factors in determining the feasibility and success of endovascular interventions for Chronic Internal Carotid Artery Occlusion (COICA). Types A and B COICA, which have an ICA stump and supraclinoid filling, are generally more suitable for endovascular techniques. Types C and D COICA, lacking an ICA stump, present greater challenges and may require alternative approaches such as hybrid surgery. Therefore, treatment strategies are tailored to these specific classifications to maximize positive outcomes.

What are hybrid surgical approaches for Chronic Internal Carotid Artery Occlusion (COICA), and how do they improve treatment outcomes?

Hybrid surgical approaches combine open surgical techniques, such as carotid endarterectomy, with endovascular methods like angioplasty. This approach allows surgeons to address complex cases of Chronic Internal Carotid Artery Occlusion (COICA) that might not be effectively treated with a single method. While not explicitly detailed, the goal is to leverage the strengths of both techniques to improve revascularization and outcomes, especially in challenging cases like Types C and D COICA where an internal carotid artery (ICA) stump is absent.

What does the future hold for the treatment of Chronic Internal Carotid Artery Occlusion (COICA), and what advancements are on the horizon?

Ongoing research and advancements in technology are expected to refine our understanding and treatment of Chronic Internal Carotid Artery Occlusion (COICA). The development of new endovascular techniques and improvements in hybrid surgical approaches promise to enhance revascularization and improve patient outcomes. The future likely involves more personalized treatment plans based on detailed classifications and the integration of innovative technologies to tackle the complexities of COICA.