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Objective Recurrent skull-base malignancies that circumferentially encase the internal carotid artery (ICA) in previously irradiated fields pose major risk of vascular injury during repeat surgery. When balloon test occlusion (BTO) shows inadequate collateral supply, high-flow extracranial-intracranial (EC-IC) bypass are often necessary to facilitate repeat surgery. We evaluated a staged, segment-specific endoluminal ICA reinforcement strategy using covered and open-cell stents to enable carotid-preserving repeat-resection.Methods We performed a prospective single-center study of patients with recurrent clival or petroclival tumors after previous surgery and high-dose radiotherapy, in whom repeat surgery is planned. Patients with 360° ICA encasement, in whom BTO shows inadequate collateral supply, underwent pre-operative stenting. Preprocedural high-resolution MRI fused with 3D rotational angiography was used to map the tumor-ICA interface and plan segment-specific stent deployment (supraclinoid, cavernous, lacerum, petrous, distal cervical). Balloon-expandable PK Papyrus covered stents (Teleflex, Wayne PA) reconstructed the tumor-encased petrous/cavernous/lacerum segments; Neuroform Atlas or Surpass devices (Stryker, Kalamazoo MI) were selectively used in the supraclinoid ICA. Dual antiplatelet therapy was maintained for 3 months before microsurgical re-resection on aspirin monotherapy.Results Four consecutive patients (three chordomas, one adenoid cystic carcinoma; median age 47.5 years) underwent planned ICA reinforcement and carotid-preserving re-resection. Gross-total and near-total resections were achieved in three out of four patients (75%). In one case, stent thrombosis occurred after antiplatelet interruption after surgical resection and resolved with endovascular treatment without permanent neurologic deficits; no intraoperative carotid injuries or permanent stent-related deficits were observed.Conclusion In BTO-fail patients with recurrent irradiated skull-base tumors and circumferential ICA encasement, segment-specific endoluminal ICA reinforcement is feasible and may be an alternative strategy in whom high-flow EC-IC bypass is not possible. Validation in multicenter cohorts is warranted.Disclosures C. Young: None. J. Zuluaga-Garcia: None. E. Ramirez-Ferrer: None. F. Call-Orellana: None. S. Raza: None. F. DeMonte: None. S. Chen: None.