Endovascular treatment of asymptomatic free-floating thrombus in the carotid artery bifurcation: a direct aspiration first-pass technique under double balloon protection

Abstract

Free-floating thrombus (FFT) in the carotid artery has been reported as a rare cause of acute ischaemic stroke. There are various treatment strategies, but higher risk of distal embolism may limit their applicability. A 77-year-old woman noticed right upper arm weakness. A CT angiogram revealed that a large floating thrombus had strayed across the carotid bifurcation, while another thrombus was present in the right axillary artery. As for the carotid FFT, in spite of anticoagulation therapy, the number of asymptomatic microthrombuses gradually increased on diffusion-weighted MRI. We performed endovascular therapy utilising two temporary occlusion balloon catheters and performed direct aspiration with a reperfusion catheter. The procedure was uneventful. We successfully performed a new endovascular technique for FFT in the carotid bifurcation. Our method is effective, minimally invasive and safe.

Mechanical thrombectomy and carotid artery stenting for stenosis of the internal carotid artery with free-floating thrombosis: illustrative case

“…In the absence of carotid stenosis with FFT, use of a stent retriever (SR) or a direct aspiration pass technique (ADAPT) with or without protection has been reported. 4,[11][12][13] In the case of stenosis, CAS alone or CAS and MT were performed using a protective device to prevent FFT migration, and many cases were treated without causing migration. The reports are summarized in Table 1.…”

Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines

“…The presence of FFT is particularly ominous as the thrombus itself may acutely occlude the ICA or detach and embolize intracranially with minimal or no manipulation [42]. The treatment of these lesions remains controversial, case reports and series have described successful strategies via direct aspiration or mechanical EVT under careful EPD deployment or flow reversal along with delicate CAS placement where systemic therapeutic anticoagulation was determined unreasonable [42,46,48,49,51,52,55,56].…”

Free-Floating Thrombus in the Distal Internal Carotid Artery Causing a Stroke

“…balloon protection, and stent-retriever mechanical thrombectomy have been reported with encouraging results. 5,6 These endovascular techniques appear efficient, but their role needs to be validated in larger trials. Regarding carotid artery stenting aiming to trap the thrombus between the stent and the arterial wall, there are concerns about development of new brain infarcts if the thrombus extends distally.…”

“…Direct aspiration of thrombus using distal and proximal balloon protection, and stent-retriever mechanical thrombectomy have been reported with encouraging results. 5,6 These endovascular techniques appear efficient, but their role needs to be validated in larger trials.…”