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Abstract
Introduction/Purpose Intraluminal carotid free-floating thrombus (CFFT) is a rare but potentially devastating condition. Current literature provides no conclusive evidence for endovascular techniques that can safely and reliably remove CFFTs. Historically, CFFTs have been managed medically with or without carotid thromboendarterectomy. In this report, we demonstrate a novel technique utilizing a combined approach of direct 0.088’ aspiration with a triple stent retriever (SR) ‘bouquet’ deployment under balloon guide flow arrest with concomitant 0.088’ flow reversal aspiration to safely thrombectomize a proximal cervical CFFT.
Materials and Methods A 78-year-old woman with a history of prior right internal carotid artery (ICA) mechanical thrombectomy and antiplatelet noncompliance presented with transient ischemic attacks secondary to a recurrent CFFT in the right ICA. Given her symptomatic presentation and recurrent CFFT, the decision was made to proceed with endovascular mechanical thrombectomy. An 8-Fr Walrus balloon guide catheter (BGC; Q’Apel Medical, Fremont, CA) and an 8-Fr Zoom88™ (Imperative Care, Campbell, CA) distal access catheter was brought into the right distal common carotid artery and proximal ICA bulb, respectively. Three 0.021-inch microcatheters were navigated beyond the CFFT into the upper cervical ICA, taking care to avoid disrupting the thrombus. Each 0.021-inch catheter was loaded with a unique SR and they were deployed in a bouquet fashion: Tigertriever (Rapid Medical, Yokneam, Israel), Trevo (Stryker Neurovascular, Fremont, CA), SolitaireX (Medtronic Neurovascular, Irvine, CA), from distal to proximal, respectively. BGC was inflated to achieve flow arrest, and under concomitant BGC aspiration, the Zoom88 aspiration catheter was tracked over the three bouquet SRs to partially ingest and ‘cork’ the thrombus. The Walrus balloon was deflated under continued aspiration, while the Zoom88 was synchronously removed with the SRs and CFFT.
Results Immediate follow-up angiography demonstrated recanalization of the proximal cervical ICA without evidence of residual thrombus. Twenty-four-hour postoperative CT imaging did not reveal any evidence of new frank infarction. The patient was discharged home 8-days postprocedurally with an intact neurological examination, compliant on aspirin and apixaban.
Conclusion Endovascular mechanical thrombectomy of CFFTs utilizing a combined technique of a multiple SR ‘bouquet’ deployment with simultaneous flow arrest/aspiration may offer a safe and curative technique for historically difficult-to-treat lesions.
(A) AP DSA view of the right CCA and visualized CFFT (arrows). (B) AP native view of the inflated Walrus BGC (black), Zoom88 (orange), and deployment of the triple-SR ‘bouquet’ intercalated within the thrombus of the common carotid artery
Disclosures B. Meyer: None. J. Campos: None. M. Khan: None. D. Zarrin: None. J. Collard de Beaufort: None. G. Amin: None. L. Lin: 2; C; Medtronic Neurovascular, Stryker Neurovascular, MicroVention-Terumo, Rapid Medical, Balt. A. Coon: 2; C; Medtronic Neurovascular, MicroVention-Terumo, Stryker Neurovascular, Rapid Medical, Avail MedSystems, Imperative Care, InNeuroCo, Q’apel, Sequent Medical.