Abstract
A 76-year-old hypertensive man with previous bilateral iliac stenting was admitted in our center for acute stroke with an NIH score of 20 at 6 h from symptoms onset. The common carotid occlusion with a huge thrombus and a very calcified plaque has been successfully recanalyzed with a combination of coronary total occlusion technique, filter-aided coronary manual thrombectomy and Penumbra vacuum thrombectomy systems.
A 76-year-old hypertensive man with previous bilateral iliac stenting was admitted in our center for acute stroke with an NIH score of 20 at 6 h from symptoms onset. A Doppler ultrasonography scan revealed a thrombotic occlusion the right common carotid artery: plaque appearance was hypercalficic with a huge thrombus burden. A diffusion cerebral magnetic resonance imaging demonstrated two focal hyperacute ischemic lesions in the right semioval region ( Fig. 1 , panel A, red stars). A Neuron Max 6F (Penumbra Inc., Alameda, CA, USA) long sheath was advanced through the femoral artery approach over a .035″ Supracor guide wire (Boston Scientific Inc., USA) and a 4F Multipurpose diagnostic catheter was subsequently used to engage the right carotid artery. Angiography confirmed the thrombotic occlusion of the common carotid artery with a hypercalcific plaque appearance ( Fig. 1 , Panel B). The occlusion was crossed with coronary technique using a Heavy weight .014″ guidewire over an over-the-wire 1.25 × 20 mm balloon and an injection through the balloon confirmed the position into the carotid siphon ( Fig. 1 , Panel C). Gentle predilation of the lesion was performed at 12 atm ( Fig. 1 , Panel D, red arrow). Because the Penumbra vacuum system couldn’t be passed through this complex calcific and thrombotic lesion, a 4 mm SpiderX filter (EV3 Inc., Plymouth, MN, USA) was released distally to the lesion and a full high atmosphere (20 atm) predilation was performed with a non compliant coronary 3.5 × 20 mm balloon ( Fig. 1 , panel D, red arrow). A manual thrombectomy with an Export 6F thromboaspiration catheter (Medtronic Inc., USA) was passed multiple times ( Fig. 1 , Panel E, red arrow) with removal of a huge thrombus ( Fig. 2 , panel A) and partial recanalization was obtained. Then, final recanalization was obtained with suction for 2 min by a Penumbra Catheter ( Fig. 2 , panel B–C). A new 4 mm SpiderX filter was then released distally to the lesion and a 7.0 × 40 mm Wallstent (Boston Scientific Corporation, Galway, Ireland) was finally implanted ( Fig. 2 , Panel D). After postdilation with a Sterling 5.0 × 20 at 12 atm, the angiography control confirmed the complete recanalization of the artery with a good cerebral flow ( Fig. 2 , Panel E). Doppler ultrasound showed good flow within the stent and the middle cerebral artery ( Fig. 2 , panel F). The patient almost fully recovered on day 1 (NIH 4) with no sign of intracranial bleeding on computed tomography scan and was discharged on day 9 with no further sequelae. The case demonstrates that combined use of both coronary and neuroradiological techniques and equipment can be effective in selected cases of acute stroke in order to achieve vessel complete recanalization when faced with complex mixed thrombotic and calcific plaques.
