The management of chronic or subacute internal carotid artery (ICA) occlusions has been challenging clinically. Carotid endarterectomy and superficial temporal artery to middle cerebral artery bypass have been studied in high risk stroke patients with results showing no benefits in symptomatic COICA patients. Consequently, some centers have employed angioplasty and stenting for the management of these challenging lesions. The main concern with the endovascular treatment of COICA patients is the significant risk of perioperative complications such as distal embolization, vessel perforation, pseudoaneurysm formation, vessel dissection, fistula formation, and hyperperfusion syndrome. In this report, we propose for the first time a COICA classification, which could offer the interventionalist a guide of the technical feasibility and safety of endovascular recanalization of symptomatic COICA. We will assess the success of this classification in predicting endovascular recanalization of symptomatic COICA in a single -institution pilot study.