Direct Carotid Puncture Mechanical Thrombectomy in Medium Vessel Occlusion (MEVO) Stroke Using Obtura Closure Device for Hemostasis.

Abstract

BackgroundMechanical thrombectomy (MT) is the gold standard treatment for acute ischemic stroke (AIS) patients with large vessel occlusion. Direct cervical carotid puncture is a recognized approach in unfavorable aortic arch anatomy. However, manual compression/ surgical closure of the access site can be challenging if the International Normalized Ratio (INR) is high and the patient is taking anticoagulation.Case SummaryWe present a case of Stanford type A (STA) aortic dissection (status post Bentall procedure) presenting with acute ischemic stroke (AIS) with left M2-MCA thrombotic occlusion. Conventional transfemoral or transradial approach for MT was deferred due to replaced ascending aorta & arch debranching and a residual thoraco-abdominal aortic dissection flap. Risk of soft tissue blood loss was high with open neck access (surgical cut down) due to high INR of 2.9. So, MT was performed through direct left common carotid artery (CCA) puncture achieving mTICI 3 flow. Due to high INR, manual compression was deferred, puncture site haemostasis was achieved with use of collagen based Obtura vascular closure device (VCD). Patient made substantial neurological recovery with no puncture site complications and MRS-0 at discharge.ConclusionObtura femoral VCD can be an alternative haemostatic device for direct carotid puncture mechanical thrombectomy for AIS.