Endovascular Management of Embolic Cervical Tandem Occlusion: 2-Center Technical Series

Embolic cervical tandem occlusion (TO) requires rapid intracranial reperfusion while safely managing a friable cervical internal carotid artery thrombus. We describe the workflow logic, feasibility, and observed trade-offs of 4 endovascular treatment (EVT) strategies in a 2-center series.

We retrospectively analyzed a prospectively maintained 2-center registry of consecutive patients who underwent EVT for acute anterior circulation large-vessel occlusion between June 2015 and June 2024. Among 3526 screened patients, 45 with angiographically defined embolic cervical TO were included. Strategies were antegrade thrombectomy (n=21), pass-thrombectomy-protective thrombectomy (Double PT; n=7), stent cover thrombus (SCT; n=10), and balloon clear thrombus (BCT; n=7). Outcomes were successful reperfusion, distal embolization, puncture-to-reperfusion time, symptomatic intracranial hemorrhage, and 90-day outcome.

Successful reperfusion was achieved in 44 of 45 patients (98%). Distal embolization occurred in 38% of antegrade cases and 43% of Double PT cases, versus 0% of SCT cases and 14% of BCT cases. Median puncture-to-reperfusion time ranged from 45 minutes in SCT to 70 minutes in antegrade. Functional independence at 90 days was observed in 38%, 29%, 30%, and 57% of the 4 groups, respectively; symptomatic intracranial hemorrhage occurred in 33%, 29%, 10%, and 0%.

In this small descriptive series, SCT and BCT were technically feasible and showed low observed distal embolization rates. Because treatment allocation was nonrandomized and cohorts were small and imbalanced, these findings are hypothesis generating and may inform anatomy-driven procedural planning and future study.