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

Abstract

BACKGROUND The authors report a case in which mechanical thrombectomy and carotid artery stenting (CAS) were performed for acute cerebral infarction with free-floating thrombosis (FFT) in left internal carotid artery (ICA) stenosis. Good results were obtained. OBSERVATIONS A 63-year-old man developed sudden disturbance of consciousness and right hemiplegia. He was transported to the authors’ hospital by an emergency vehicle. Head magnetic resonance imaging showed acute cerebral infarction in the left middle cerebral artery region, and magnetic resonance angiography showed poor vascular flow beyond the left ICA. Emergency angiography revealed severe stenosis at the origin of the left ICA and a free-floating thrombus attached to the stenosis and extending to the peripheral side. Percutaneous transluminal angioplasty (PTA) was performed on the stenosis with proximal protection, the thrombus was aspirated under reversal flow, and CAS was performed without exacerbation of clinical symptoms. LESSONS PTA, thrombus aspiration, and CAS under reversal flow may be effective treatments for FFT caused by ICA stenosis.

Triple Stentriever “Bouquet” Deployment with Zoom 88 Large-Bore Aspiration and Walrus Balloon-Guide Catheter for the Definitive Thrombectomy of a Carotid Free-Floating Thrombus

“…Currently, there is insufficient data/evidence to compare the different procedural modalities in managing CFFTs. 6,7,10,13,14,[16][17][18]25,26 A retrospective study of 525 cases with CFFTs found no significant difference in outcomes of patients receiving antiplatelet and anticoagulant therapy versus procedural management with endovascular or surgical carotid endarterectomy (CEA). 5 With its minimally invasive nature and advanced modern catheters and devices, endovascular thrombectomy, as opposed to CEA, has become the preferred choice for the procedural management of CFFTs at many centers.…”

“…Although these reports have not demonstrated a standardized technique for the mechanical thrombectomy of CFFTs, numerous methods including stentrievers, reversal of carotid flow with occlusion balloons, and distal filter wire placement have been reported. [6][7][8][9][10][11][12][13][14][15][16][17] Recently, direct aspiration, with or without the utilization of proximal and distal protection devices have been described. 11,20,27 To harness all the benefits of previously reported techniques we employed a triple stentriever "bouquet" technique for the mechanical thrombectomy of a CFFT.…”

“…5 There have been several recent reports about the successful mechanical thrombectomy of CFFT. [6][7][8][9][10][11][12][13][14][15][16][17] These studies have demonstrated the challenges of safely performing mechanical thrombectomy due to significant clot burden, lack of tools, and techniques designed to perform cerebrovascular thrombectomy. In total, the literature to date has provided no conclusive techniques for safe and reliable removal of CFFTs.…”

“…In total, the literature to date has provided no conclusive techniques for safe and reliable removal of CFFTs. 5,18 Recent technological improvements in aspiration catheters and stentrievers has made mechanical thrombectomy of cerebral vessels increasingly safe [6][7][8][9][10][11][12][13][14][15][16][17] and effective. 19,20 Among these developments are large-bore aspiration catheters (0.088" ID) 21,22 that are built both with and without compliant balloons for flow arrest and aspiration/flow reversal.…”

Carotid Free-Floating Thrombus Treated With a Combined Technique Using Embotrap III for Distal Protection

“…Recently, in addition to conventional treatments, endovascular thrombectomy for carotid FFT has been reported [2,4,5,[7][8][9][10][11][12][13][14]. However, when balloon protection is used for distal protection, complete interruption of the ICA flow is undesirable in patients without hemodynamic intolerance.…”