22 Percutaneous Transcarotid Endovascular Thrombectomy for Acute Ischemic Stroke
22.1 Case Description
22.1.1 Clinical Presentation
An 87-year-old male patient presented to the emergency department with a right hemispheric syndrome consisting of left-sided hemiplegia, left hemineglect, and a forced gaze deviation to the right.
22.1.2 Imaging Workup and Investigations
Noncontrast computed tomography (NCCT) of the head (Fig. 22.1) demonstrated a “hyperdense” right middle cerebral artery (MCA) sign, representing a thromboembolic occlusion. Low-attenuation changes, representing evolving perforator infarcts, were seen in the posterior aspect of the right lentiform nucleus as well as the right caudate body. No abnormalities in the right insula, or the remaining right cerebral cortex, were seen (ASPECTS score of 8).
Computed tomography angiography (CTA) of the arch to vertex confirmed an occlusive thrombus in the right M1 segment, as well as considerable tortuosity of the proximal right common carotid artery (CCA; Fig. 22.2).
Fig. 22.1 Noncontrast CT of the head in an 87-year-old patient with a right hemispheric syndrome showing (a) hyperdense right MCA sign (white arrow), (b) evolving perforator infarcts in the posterior right lentiform nucleus (*), (c) evolving perforator infarcts in the right caudate body (*), and (d) no abnormalities in the remaining right cerebral cortex (ASPECTS score of 8). 
Fig. 22.2 CT angiography arch to vertex in an 87-year-old patient with a right hemispheric syndrome showing (a) occlusive thrombus in the right M1 segment (white arrow). (b) Considerable tortuosity of the proximal right common carotid artery (*).
22.1.3 Diagnosis
Acute right MCA ischemic stroke due to right M1 thromboembolic occlusion.
22.1.4 Treatment
The patient was transferred immediately to the neuroangiography suite for angiography and emergency mechanical thrombectomy. An initial attempt at mechanical thrombectomy was conducted via a conventional right transfemoral arterial approach. Given the marked right common carotid arterial tortuosity, stable deployment of a stent retriever, or positioning of an aspiration catheter, at the level of the thromboembolic occlusion could not be carried out. A percutaneous right common carotid arterial puncture was then performed (Fig. 22.3).
Materials
5-Fr micropuncture kit.
6-Fr 45-cm straight Destination sheath (Terumo Medical, Somerset, NJ).
Rotating Tuohy Borst hemostatic valve (Merit Medical, South Jordan, UT) ACE 68 aspiration catheter (Penumbra, Alameda, CA).
3 Max aspiration catheter (Penumbra, Alameda, CA).
Fathom 16 microwire (Boston Scientific, Fremont, CA).
Vascular closure device (Angio-Seal, Terumo Medical, Somerset, NJ).
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