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Carotid artery stenting under flow arrest for the management of intraluminal thrombus: technical case report
Ramachandra P Tummala1, Babak S Jahromi, Junichi Yamamoto
1Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, University at Buffalo, State University of New York, Buffalo, New York 14209, USA.
Insights
A novel technique for carotid artery stenting in patients with intraluminal thrombus involves temporarily arresting blood flow to prevent embolism. This endovascular approach offers a potentially safer treatment option for managing complex carotid artery thrombus.
Area of Science:
- Vascular Surgery
- Interventional Neurology
- Endovascular Therapy
Background:
- Management of intraluminal carotid thrombus is challenging due to high thromboembolic risks with medical and surgical options.
- Endovascular approaches for carotid artery thrombus also carry risks of thromboembolism during lesion manipulation.
Observation:
- A 49-year-old female presented with transient ischemic attack symptoms including expressive dysphasia, right-sided weakness, and monocular blindness.
- Angiography revealed a large intraluminal thrombus within a chronic dissection of the left internal carotid artery.
Findings:
- A technique was developed to arrest antegrade flow in the internal carotid artery using balloon inflation in the common and external carotid arteries prior to crossing the thrombus.
- Overlapping carotid stents were successfully placed after internal carotid artery balloon inflation, completely excluding the thrombus from the lumen.
- The patient remained neurologically stable during the procedure, with mild deficits at 1-month follow-up and no restenosis or recurrent thrombus on imaging at 3 months.
Implications:
- This flow arrest technique appears to be a safe endovascular option for treating symptomatic intraluminal carotid thrombus.
- Further studies are needed to fully elucidate the risks and benefits of carotid stenting in the presence of intraluminal thrombus.
- This method may reduce thromboembolic complications associated with endovascular intervention in complex carotid artery lesions.
Objective:
The management of intraluminal carotid thrombus is not well defined. Medical and surgical management carry a relatively high risk of thromboembolism. Although endovascular options also carry the risk of thromboembolism from manipulation of the lesion, successful carotid stent placement using various methods of flow restriction has been reported anecdotally. We describe a technique to arrest antegrade flow before placement of carotid stents in the setting of symptomatic intraluminal thrombus.
Clinical Presentation:
A 49-year-old woman presented with expressive dysphasia, right-upper extremity weakness, and an episode of left monocular blindness. Angiography confirmed the presence of a large intraluminal thrombus in a chronic dissection of the left internal carotid artery.
Results:
We devised a configuration to arrest antegrade flow in the internal carotid artery before crossing the thrombus with a distal embolic protection device by inflating balloons in the common carotid artery and external carotid artery before crossing the lesion. After inflation of a balloon in the internal carotid artery, we completed overlapping stent placement to completely exclude the thrombus from the lumen.
Conclusion:
The patient remained neurologically unchanged during and immediately after the procedure. She had mild neurological deficits at the 1 month follow-up evaluation. Follow-up ultrasonography at 1 and 3 months and computed tomographic angiography at 3 months after the procedure showed patency of the stented carotid artery, with no evidence of restenosis or thrombus. Although the risks of carotid stent placement for intraluminal thrombus remain unclear, the technique of flow arrest seems to provide a safe endovascular treatment option.
