Emergent Carotid Endarterectomy with Open Thrombectomy for Acute Carotid Stent Occlusion

Acute occlusion of a carotid stent is a rare complication that necessitates rapid diagnosis and treatment to prevent devastating neurologic injury. Management options may include thrombolysis, mechanical thrombectomy, or open surgical revascularization; however, the optimal treatment is unclear due to the low reported incidence of this complication. Video 1 illustrates the surgical technique for open revascularization with carotid stent removal, thrombectomy, and endarterectomy. We present the case of a 64-year-old woman who presented with expressive speech and right-sided motor deficits and was identified to have complete occlusion of the distal left M1 and proximal M2 branches, as well as near-occlusion of the left internal carotid artery. She underwent successful mechanical thrombectomy of the intracranial occlusion with complete reperfusion and also angioplasty and stenting of the carotid stenosis. She deteriorated overnight and was identified to have complete carotid stent occlusion but no large infarct, suggestive of collateral flow impairment. Cerebral reperfusion was established by emergent open stent removal and endarterectomy. An extended exposure of the carotid was required, as the stent extended beyond the typical sites of clamping both proximally and distally. Intraoperatively, the clot from the internal carotid artery was manually aspirated via a 5-French catheter. Postoperative imaging demonstrated appropriate vessel patency. In follow-up, the patient made a full neurologic recovery.