How to Escape Stentriever Wedging in an Open-cell Carotid Stent during Mechanical Thrombectomy for Tandem Cervical Internal Carotid Artery and Middle Cerebral Artery Occlusion

Bailout technique for entangled stent retriever and carotid stent during tandem large vessel occlusion endovascular therapy

BACKGROUND AND IMPORTANCE

Endovascular thrombectomy for patients with tandem occlusions could be challenging. Exposure to potential technical complications and bailout rescue techniques are of utmost importance.

CLINICAL PRESENTATION

A 73-year-old woman with tandem internal carotid artery and middle cerebral artery lesions underwent an unsuccessful retrograde revascularization approach in the setting of tortuous anatomy. Antegrade approach revascularization was then pursued. Following cervical internal carotid artery revascularization, a triaxial system of aspiration catheter, microcatheter and micro guidewire was navigated through the stented curved cervical ICA and intracranial stent retriever pass was performed. Upon retrieving the clot-incorporated stent retriever with the intention to retrieve the entire stent retriever into the locally placed aspiration catheter, the triaxial system collapsed into the distal common carotid artery. Large thrombus was recovered from the aspiration catheter aspirate however the proximal end of stent retriever and distal internal carotid artery stent got tangled. After unsuccessful maneuvering to disentangle stent retriever from the internal carotid artery stent, we decided to attempt safe separation of the stent retriever from its pusher wire and leave behind the patent internal carotid artery stent/stent retriever metal construct in place. Gradual pulling pressure was applied to the stent retriever wire while maintaining distal exchange-length microwire access and fully inflated extracranial balloon over the entangled portion to ensure continuous vascular access. The stent retriever wire was then safely separated from the stent retriever and fully retracted outside the body. Delayed angiographic runs continued to demonstrate full patency of the internal carotid artery lumen. No residual dissection, spasm, or thrombus was noted.

CONCLUSION

This case illustrates a novel bailout endovascular salvage technique that could be considered in such cases. These techniques minimize intraoperative complication, focus on patient safety, and promote efficiency for endovascular thrombectomy in unfavorable anatomy.

Carotid Revascularization: Current Practice and Future Directions

Carotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.

Simultaneous revascularization of the occluded internal carotid artery using the Solitaire as a workhorse wire during acute ischemic stroke intervention

INTRODUCTION

Tandem lesions involving a large vessel occlusion intracranially with concomitant cervical carotid critical stenosis or occlusion are a common presentation of acute ischemic stroke. These lesions are both challenging and time-consuming but can be extremely beneficial for patients when successful. We present a technique utilizing the pusher wire of the stent retriever used for intracranial thrombectomy as the workhorse wire for carotid intervention using a monorail system to perform cervical carotid angioplasty.

METHODS

We reviewed four successive patients who presented with a tandem occlusion and underwent thrombectomy and simultaneous carotid artery intervention using this technique.

RESULTS

All four patients had radiographically successful intracranial thrombectomy and cervical carotid revascularization. Time from groin puncture to intracranial stent retriever deployment was 63 min on average. Then, using the pusher wire as a monorail workhorse, time from stent retriever deployment to carotid angioplasty was on average 6 min.

DISCUSSION

This technique allows for cervical carotid revascularization to begin during the recommended 5-min wait time after stent retriever deployment, allowing for rapid near-simultaneous revascularization across both lesions. This technique has been reported briefly in the past for management of a cervical dissection. There is continued debate regarding the management of tandem occlusions, as to which lesion should be managed first.

CONCLUSION

As the management paradigms of tandem occlusions continue to evolve, this technique may improve outcomes by expediting endovascular intervention. Using the stent retriever wire provides a method of expediting the management of the proximal lesion after addressing the more distal intracranial occlusion first.