Background The optimal management of chronic total carotid artery occlusion (CTO) is still debated. Endovascular treatment is being increasingly used with heterogeneous technical and clinical results.

Methods Patients with CTO treated with modern endovascular approaches during the past several years (January 2018–December 2021) were retrospectively reviewed.

Results Twenty patients, with a mean age of 63.7 years, were treated during the study period. Indications for treatment were recurrent stroke in 12 (60%), hemodynamic impairment in 4 (20%), and progressive stroke in 4 (20%) patients. In 6 (30%) patients, the occlusion was limited to the cervical portion, in 5 (25%) to the petrous segment, and in 9 (45%) to the cavernous segment. Technical treatment success was achieved in 80% of cases. In patients with successful recanalization, median pretreatment hypoperfusion volumes dropped from 126 mL (25–75 IQR, 33–224 mL) to 0 mL (25–75 IQR, 0–31.5 mL). Symptomatic procedure-related complications were 30% and permanent procedure-related morbidity-mortality was 5%. Early stent occlusion occurred in 5 (25%) cases. Two cases were asymptomatic and were not retreated, 3 cases presented transient symptoms of which two were successfully recanalized. Stent occlusion was not associated with permanent symptoms. In successfully recanalized patients no intraprocedural emboli were observed.

Conclusions In the modern endovascular era, revascularization of CTO is a feasible procedure in most cases, and it may be offered in selected patients. However, the high re-occlusion rate is still a limitation of the technique, underlining the need for more research on the technical procedural and periprocedural management.