We planned carotid artery stenting (CAS) with “seat belt and air bag” technique for a patient of symptomatic post-radiation pseudo-occlusion of the right cervical internal carotid artery (ICA) in the chronic stage because of an artery-to-artery embolic episode in the sub-acute phase. During the CAS procedure, the right ICA was found to be totally occluded. Neither the left ICAG nor the left vertebral angiogram (VAG) could demonstrate the retrograde opacification of the right ICA below the C2 portion. A 4Fr. catheter was navigated to the cervical C1 vertebral level beyond the occlusion point, where arterial blood was aspirated. However, contrast injection from the catheter seemed risky because a large thrombus may have existed in the ICA above the C1 vertebral level. Left VAG with simultaneous aspiration from the catheter placed in the right ICA under flow reverse condition (named “retrograde injection and suction method”) retrogradely depicted a clean right ICA from its cavernous to cervical portion. This information confirmed us to pass the guidewire across the long occluded lesion safely, leading to a successful CAS of a totally occluded ICA.
