Endovascular Treatment for Symptomatic Non-acute Carotid Occlusion

Symptomatic non‐acute carotid artery occlusion may lead to recurrent ischemic events,chronic cerebral hypoperfusion, and cognitive decline. Best medical treatment is thestandard foundation of care, but selected patients with persistent hypoperfusion mayremain at risk. Endovascular recanalization may improve cerebral perfusion, butprocedure‐related distal embolization and new ischemic lesions remain important safetyconcerns.Eligible patients will have symptomatic non‐acute carotid artery occlusion, ipsilateralcerebral hypoperfusion, and baseline cognitive impairment defined by aneducation‐adjusted Montreal Cognitive Assessment score of 25 or lower. Participants willbe randomized in a 1:1:1 ratio to best medical treatment alone, endovascularrecanalization without proximal protection plus best medical treatment, or endovascularrecanalization with proximal balloon protection plus best medical treatment.In the proximal protection group, a balloon guide catheter will be used to achieveproximal flow arrest or flow control during key procedural steps. In the unprotectedendovascular group, recanalization will be performed without routine proximal balloonflow control. The primary safety outcome is the number of new ischemic lesions ondiffusion‐weighted magnetic resonance imaging within 24 to 72 hours. The primary efficacyoutcome is the change in Montreal Cognitive Assessment score from baseline to 6 months.