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"Internal cross-clamping" for symptomatic internal carotid artery thrombus. Report of two cases
Robert D Ecker1, Ramachandra P Tummala, Elad I Levy
1Department of Neurosurgery and Toshiba Stroke Research Center, State University of New York, USA.
Insights
A novel endovascular technique, internal cross-clamping, offers a safer approach for treating internal carotid artery (ICA) stenosis with thrombus. This method provides effective embolic protection during stenting for high-risk patients.
Area of Science:
- Vascular Surgery
- Interventional Neurology
- Endovascular Techniques
Background:
- Carotid artery stenosis with intraluminal thrombus poses significant risks for both surgical endarterectomy and standard stent placement.
- Previous trials indicated surgical intervention may be superior to medical management for symptomatic patients, but intervention risks remain.
Observation:
- Two patients with symptomatic internal carotid artery (ICA) lesions containing intraluminal thrombus were treated.
- One patient presented with transient ischemic attack symptoms, while the other experienced stroke after a complicated carotid endarterectomy.
Findings:
- A novel endovascular "internal cross-clamping" technique was employed, involving proximal and distal flow occlusion for embolic protection during stent placement.
- This technique successfully treated symptomatic carotid stenosis with intraluminal thrombus in both cases, representing a first-in-report application.
Implications:
- This "internal cross-clamping" strategy provides a new option for endovascular surgeons managing selected high-risk patients with symptomatic carotid stenosis and intraluminal thrombus.
- It expands the armamentarium for treating complex carotid artery lesions, potentially improving patient outcomes.
Abstract:
Both carotid endarterectomy and carotid artery stent placement with filter embolic protection present a higher risk for patients with internal carotid artery (ICA) lesions containing intraluminal thrombus. Despite the risk associated with intervention, patients with symptomatic intraluminal thrombus who were enrolled in the North American Symptomatic Endarterectomy Trial did better with surgical than medical treatment. We describe the novel use of an endovascular "internal cross-clamping" technique in two patients with symptomatic intraluminal thrombus in the ICA. A 57-year-old woman presented with a history of multiple episodes of left upper-extremity numbness, mild dysarthria, and agraphia occurring over the previous 24 hours. Cranial magnetic resonance imaging revealed a scattered watershed infarction of the right hemisphere and a critical stenosis of the right ICA. An 81-year-old man awoke with hemiplegia and inability to follow commands after undergoing a complicated carotid endarterectomy. Computed tomographic perfusion imaging demonstrated an increased time to peak in the left middle cerebral territory, and emergent angiography demonstrated both intimal flaps and thrombus in the endarterectomy bed. The lesions in both patients were treated with endovascular stent placement using both proximal and distal flow occlusion--a functional "internal cross-clamping"--for embolic protection. To our knowledge, this is the first report of internal trapping and stent placement for symptomatic carotid stenosis containing intraluminal thrombus. This treatment strategy should be added to the armamentarium of endovascular surgeons in selected patients with symptomatic carotid intraluminal thrombus.
