Introduction/Purpose Acute stroke due to carotid plaque rupture with free-floating clot is a challenging endovascular procedure. Proper planning of the treatment approach is needed to minimize the risk of intracranial embolic shower or even large vessel occlusion during vessel manipulation. Closed-cell carotid stent placement in such cases is preferred to trap the free-floating thrombus against the vessel wall. However, despite a closed-cell design, the risk of ‘cheese grating’ of the soft thrombus through the stent struts remains. Placement of a second, telescopic closed-cell stent will add an additional layer of protection. The closed-cell Carotid Wallstent (Boston Scientific) as the first layer of protection has a lower profile delivery system which reduces the risk of intracranial embolization during stent placement. Additionally, its radial force is less than that of an Xact (Abbott) stent which allows trapping of the clot but minimizes the ‘cheese grating’ effect. The Xact stent with its larger delivery system and higher radial force will provide the second closed-cell layer of protection with now higher radial force to gain luminal diameter.

Materials and Methods Retrospective review of our carotid stenting database and identification of all patients who were treated for acute carotid plaque rupture in the emergency setting between November 2022 and January 2023. Patient characteristics, procedural information and patient outcome was collected.

Results We identified 5 patients (1 female) with mean age of 69 years (range 64 - 88 years) who underwent emergent carotid artery stenting for plaque rupture with associated free-floating thrombus. Patients were either acutely or intermittently symptomatic with NIHSS at the time of the procedure ranging between 0-3. The degree of carotid stenosis ranged from 50% to 87%. Four procedures were performed via femoral access and one transradial. All stenting procedures were carried out with use of a cerebral protection device. The first carotid stent placed to trap the free-floating thrombus was a Carotid Wallstent in all cases, either 8 x 21 mm or 8 x 36 mm. The second stent placed within the Wallstent was an Xact stent which provided a second mesh layer across the free-floating thrombus and provided sufficient radial force to expand the stent lumen to an at least satisfactory result in which no post-stent angioplasty was needed. Three patients were loaded with dual antiplatelet medications prior to the procedure (ASA + Ticagrelor in 2 cases and ASA + Plavix in 1 case). Two patients received a Cangrelor bolus and infusion during the procedure. One of the patients required switching to Integrilin intraprocedurally due to acute clot formation within the stent. Both patients were later transitioned to ASA + Ticagrelor on post-operative day 1.

Conclusion Use of the Carotid Wallstent as the first stent to secure the free-floating thrombus allows save delivery of the Xact stent which then adds a second closed-cell mesh layer as well as the needed radial force to expand the stent construct. This approach may decrease if not eliminate the need for post-stent angioplasty in the acute setting thus decreasing risk of thromboembolic complication.

Disclosures A. Kuhn: None. J. Singh: None. S. Sarid: None. M. Garcia: None. A. Puri: 1; C; NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular. 2; C; Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical. 4; C; InNeuroCo, Agile, Perfuze, Galaxy and NTI.