Urgent carotid endarterectomy with distal mechanical thrombectomy.

IF 4.5 1区 医学 Q1 NEUROIMAGING
Najib Muhammad, Ashwin Ramayya, Jan Karl Burkhardt, Visish M Srinivasan
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Following closure of the arteriotomy, direct carotid access using a 5Fr radial artery sheath was achieved within the open surgical field for distal thrombectomy. A 5Fr aspiration catheter was navigated to the left M2 MCA where a stent retriever was then recaptured and TICI 2B reperfusion was achieved.We present a case of urgent carotid endarterectomy (CEA) performed with distal thrombectomy.A patient in his/her 70s with a past medical history including prior left middle cerebral artery (MCA) ischemic strokes presented with right facial droop and aphasia and a National Institutes of Health Stroke Scale (NIHSS) score of 7. The patient was brought to the angiography suite for a stat digital subtraction angiography (DSA) with possible thrombectomy and stenting. Three-dimensional reconstructions of the preoperative CT angiogram showed a left MCA territory occlusion.A diagnostic angiogram showed a left common carotid artery occlusion at the carotid bifurcation. In video 1 it can be seen that the right common carotid artery injection with a head view demonstrates strong cross-filling across the anterior communicating artery (ACA) supplying the bilateral ACA territories over to the left MCA territory. The cervical left carotid angiogram shows an occlusion with various areas of plaque and calcification with a small area that was suspected to be a channel for distal wire catheterization. The left vertebral artery angiogram shows filling of the basal temporal lobe, especially in the area of the posterior cerebral artery (PCA)-MCA watershed, suggesting some chronicity to the hypoperfusion within this territory. Note the red arrow pointing at the left M2 occlusion in tandem with the proximal internal carotid artery (ICA) occlusion.neurintsurg;jnis-2024-021662v2/V1F1V1Video 1Operative video of the caseThe indications for the thrombectomy are as follows: the patient presented with right facial droop and drooling and an NIHSS score of 7 with no baseline neurological deficits; CT of the head did not show any hemorrhage with the CT angiogram (CTA) of the neck showing occlusion of the left ICA. On the diagnostic angiogram there was a filling defect within the cavernous segment of the left ICA consistent with an occlusion distally and within the left MCA territory as seen on CTA.We first attempted to stent with this system, including a Walrus balloon guide catheter positioned in the cervical common carotid artery, an SL10 microcatheter, and a Synchro 014 support wire. Injections were performed via the balloon guide catheter positioned in the common carotid artery as well as a microcatheter positioned in the region of the plaque. Despite multiple attempts and a potential viable route through the plaque, none could be found. An additional option, not attempted here, includes the use of a stiffer system (eg, 0.035 inch wire with select catheter), with additional risk of dissection and/or vascular injury.The angiosuite was then converted into an operating room. The subsequent operating room set-up is shown in video 1, with the table turned and the Mayo tray and operating tray brought in along with the operating microscope.The standard surgical steps of the CEA are shown in the accelerated video 1 Clamps were placed in sequence on the ICA, common carotid artery, external carotid artery, and superior thyroid arteries. The plaque was circumferentially dissected from the normal arterial wall. The plaque was then removed en bloc, including the origin of the external carotid artery, which was also involved with the plaque. The distal ICA was then examined for additional plaque, and additional plaque was also removed from the external carotid artery origin, which was quite calcified. The arteriotomy was closed, primarily with a 6-0 Prolene suture, with eventual back bleeding of the ICA. The clamps were then removed in reverse sequence and hemostasis was achieved. We then prepared for access via the more proximal common carotid artery. A U-stitch was placed within the area prepared for proximal access. The sheath and the associated wire were able to pass freely within the open segment of the CEA site. A still photograph shows the set-up with a 5Fr radial sheath placed within the more proximal common carotid artery.A radial micropuncture kit was used to access the proximal common carotid artery with a wire traversing the arteriotomy site, and then eventual placement of the 5Fr radial sheath within the proximal carotid artery up to the ICA. Through the 5Fr radial artery sheath a 5Fr Esperance aspiration catheter was advanced over a microcatheter and microwire into the left M2 MCA. A Trevo stent retriever was then deployed across the clotted segment and clot integration was allowed for 3 min. The stent retriever was then recaptured with simultaneous aspiration via the Esperance aspiration catheter and TICI 2B reperfusion was achieved.The duration of the entire procedure was 6 hours and 31 min from transport of the patient into and out of the operating room. The decision to convert to open CEA was made 57 min after the beginning of the procedure. This portion of the procedure lasted 3 hours and 12 min before distal mechanical thrombectomy was performed. One hour and 26 min later, closing of the incision occurred.In the video we then discuss the advantages of using direct carotid access. First, you can use a smaller system that is needed for femoral access. Second, you can avoid the use of a guide catheter and go directly with a microcatheter and an aspiration catheter. Third, you have an open surgical field in the case of complications and needing to do anything directly to the carotid.We then continue to discuss the distal thrombectomy. The leftmost panel included in video 1 shows a pseudo-occlusion in the ICA with expected clot in the ICA as well as the M2. A microwire and microcatheter were advanced past the occlusion. The third panel shows the initial ICA and M1 recanalization, although a superior M2 division occlusion remained.Three additional panels show the thrombectomy performed in the M2 superior division. The left panel shows the occlusion and the middle panel shows our microwire and microcatheter access. That branch is seen to open up with a contrast injection overlay with the roadmap. This is a useful technique to visualize smaller branch recanalizations. The single shot on the left shows the stent retriever and aspiration catheter position just proximal to it, which were both used in conjunction for the M2 thrombectomy. The middle and right panels in anteroposterior and lateral views show the final reperfusion of the MCA territory. The postoperative CTA demonstrates filling within the left M2 MCA territory.The patient was medically stabilized and transferred to an acute rehabilitation facility on postoperative day 13. At discharge the patient had an NIHSS score of 3 for mild aphasia and dysarthria. Four weeks postoperatively the patient was progressing at rehab as expected with the wound healing well and pending Doppler ultrasounds to track the carotid artery post-endarterectomy.</p>","PeriodicalId":16411,"journal":{"name":"Journal of NeuroInterventional Surgery","volume":" ","pages":""},"PeriodicalIF":4.5000,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of NeuroInterventional Surgery","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1136/jnis-2024-021662","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"NEUROIMAGING","Score":null,"Total":0}
引用次数: 0

Abstract

We review the technique for carotid endarterectomy (CEA) and direct carotid access for distal thrombectomy after attempted proximal thrombectomy in the setting of tandem occlusions. A patient in their 70s presented with right facial droop and drooling and was found to have critical left carotid stenosis with filling defect in the cavernous segment of the left internal carotid artery consistent with vessel occlusion, Thrombolysis in Cerebral Infarction (TICI) 0, and left M2 middle cerebral artery (MCA) occlusion. After multiple attempts with different wire shapes guided by microcatheter injections within the carotid bulb, we were unable to cross the occlusion. Conversion to open CEA with distal thrombectomy was elected. Following closure of the arteriotomy, direct carotid access using a 5Fr radial artery sheath was achieved within the open surgical field for distal thrombectomy. A 5Fr aspiration catheter was navigated to the left M2 MCA where a stent retriever was then recaptured and TICI 2B reperfusion was achieved.We present a case of urgent carotid endarterectomy (CEA) performed with distal thrombectomy.A patient in his/her 70s with a past medical history including prior left middle cerebral artery (MCA) ischemic strokes presented with right facial droop and aphasia and a National Institutes of Health Stroke Scale (NIHSS) score of 7. The patient was brought to the angiography suite for a stat digital subtraction angiography (DSA) with possible thrombectomy and stenting. Three-dimensional reconstructions of the preoperative CT angiogram showed a left MCA territory occlusion.A diagnostic angiogram showed a left common carotid artery occlusion at the carotid bifurcation. In video 1 it can be seen that the right common carotid artery injection with a head view demonstrates strong cross-filling across the anterior communicating artery (ACA) supplying the bilateral ACA territories over to the left MCA territory. The cervical left carotid angiogram shows an occlusion with various areas of plaque and calcification with a small area that was suspected to be a channel for distal wire catheterization. The left vertebral artery angiogram shows filling of the basal temporal lobe, especially in the area of the posterior cerebral artery (PCA)-MCA watershed, suggesting some chronicity to the hypoperfusion within this territory. Note the red arrow pointing at the left M2 occlusion in tandem with the proximal internal carotid artery (ICA) occlusion.neurintsurg;jnis-2024-021662v2/V1F1V1Video 1Operative video of the caseThe indications for the thrombectomy are as follows: the patient presented with right facial droop and drooling and an NIHSS score of 7 with no baseline neurological deficits; CT of the head did not show any hemorrhage with the CT angiogram (CTA) of the neck showing occlusion of the left ICA. On the diagnostic angiogram there was a filling defect within the cavernous segment of the left ICA consistent with an occlusion distally and within the left MCA territory as seen on CTA.We first attempted to stent with this system, including a Walrus balloon guide catheter positioned in the cervical common carotid artery, an SL10 microcatheter, and a Synchro 014 support wire. Injections were performed via the balloon guide catheter positioned in the common carotid artery as well as a microcatheter positioned in the region of the plaque. Despite multiple attempts and a potential viable route through the plaque, none could be found. An additional option, not attempted here, includes the use of a stiffer system (eg, 0.035 inch wire with select catheter), with additional risk of dissection and/or vascular injury.The angiosuite was then converted into an operating room. The subsequent operating room set-up is shown in video 1, with the table turned and the Mayo tray and operating tray brought in along with the operating microscope.The standard surgical steps of the CEA are shown in the accelerated video 1 Clamps were placed in sequence on the ICA, common carotid artery, external carotid artery, and superior thyroid arteries. The plaque was circumferentially dissected from the normal arterial wall. The plaque was then removed en bloc, including the origin of the external carotid artery, which was also involved with the plaque. The distal ICA was then examined for additional plaque, and additional plaque was also removed from the external carotid artery origin, which was quite calcified. The arteriotomy was closed, primarily with a 6-0 Prolene suture, with eventual back bleeding of the ICA. The clamps were then removed in reverse sequence and hemostasis was achieved. We then prepared for access via the more proximal common carotid artery. A U-stitch was placed within the area prepared for proximal access. The sheath and the associated wire were able to pass freely within the open segment of the CEA site. A still photograph shows the set-up with a 5Fr radial sheath placed within the more proximal common carotid artery.A radial micropuncture kit was used to access the proximal common carotid artery with a wire traversing the arteriotomy site, and then eventual placement of the 5Fr radial sheath within the proximal carotid artery up to the ICA. Through the 5Fr radial artery sheath a 5Fr Esperance aspiration catheter was advanced over a microcatheter and microwire into the left M2 MCA. A Trevo stent retriever was then deployed across the clotted segment and clot integration was allowed for 3 min. The stent retriever was then recaptured with simultaneous aspiration via the Esperance aspiration catheter and TICI 2B reperfusion was achieved.The duration of the entire procedure was 6 hours and 31 min from transport of the patient into and out of the operating room. The decision to convert to open CEA was made 57 min after the beginning of the procedure. This portion of the procedure lasted 3 hours and 12 min before distal mechanical thrombectomy was performed. One hour and 26 min later, closing of the incision occurred.In the video we then discuss the advantages of using direct carotid access. First, you can use a smaller system that is needed for femoral access. Second, you can avoid the use of a guide catheter and go directly with a microcatheter and an aspiration catheter. Third, you have an open surgical field in the case of complications and needing to do anything directly to the carotid.We then continue to discuss the distal thrombectomy. The leftmost panel included in video 1 shows a pseudo-occlusion in the ICA with expected clot in the ICA as well as the M2. A microwire and microcatheter were advanced past the occlusion. The third panel shows the initial ICA and M1 recanalization, although a superior M2 division occlusion remained.Three additional panels show the thrombectomy performed in the M2 superior division. The left panel shows the occlusion and the middle panel shows our microwire and microcatheter access. That branch is seen to open up with a contrast injection overlay with the roadmap. This is a useful technique to visualize smaller branch recanalizations. The single shot on the left shows the stent retriever and aspiration catheter position just proximal to it, which were both used in conjunction for the M2 thrombectomy. The middle and right panels in anteroposterior and lateral views show the final reperfusion of the MCA territory. The postoperative CTA demonstrates filling within the left M2 MCA territory.The patient was medically stabilized and transferred to an acute rehabilitation facility on postoperative day 13. At discharge the patient had an NIHSS score of 3 for mild aphasia and dysarthria. Four weeks postoperatively the patient was progressing at rehab as expected with the wound healing well and pending Doppler ultrasounds to track the carotid artery post-endarterectomy.

紧急颈动脉内膜剥脱术与远端机械血栓切除术。
我们回顾了颈动脉内膜剥脱术(CEA)和在串联闭塞情况下尝试近端血栓切除术后直接进入颈动脉进行远端血栓切除术的技术。一名 70 多岁的患者出现右侧面部下垂和流口水,被发现左侧颈动脉严重狭窄,左侧颈内动脉海绵段充盈缺损,符合血管闭塞、脑梗塞溶栓治疗 (TICI) 0 和左侧 M2 大脑中动脉 (MCA) 闭塞的情况。在颈动脉球内注射微导管引导下,我们使用不同形状的导线进行了多次尝试,但仍无法穿过闭塞处。于是我们选择了开放式 CEA 并进行远端血栓切除术。关闭动脉切口后,在开放手术野内使用 5Fr 桡动脉鞘直接进入颈动脉,进行远端血栓切除术。一根 5Fr 抽吸导管被导引至左侧 M2 MCA,然后在该处重新植入支架回流器,实现了 TICI 2B 再灌注。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
9.50
自引率
14.60%
发文量
291
审稿时长
4-8 weeks
期刊介绍: The Journal of NeuroInterventional Surgery (JNIS) is a leading peer review journal for scientific research and literature pertaining to the field of neurointerventional surgery. The journal launch follows growing professional interest in neurointerventional techniques for the treatment of a range of neurological and vascular problems including stroke, aneurysms, brain tumors, and spinal compression.The journal is owned by SNIS and is also the official journal of the Interventional Chapter of the Australian and New Zealand Society of Neuroradiology (ANZSNR), the Canadian Interventional Neuro Group, the Hong Kong Neurological Society (HKNS) and the Neuroradiological Society of Taiwan.
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