Simultaneous revascularization of the occluded internal carotid artery using the Solitaire as a workhorse wire during acute ischemic stroke intervention

Abstract

Introduction: Tandem lesions involving a large vessel occlusion intracranially with concomitant cervical carotid critical stenosis or occlusion are a common presentation of acute ischemic stroke. These lesions are both challenging and time-consuming but can be extremely beneficial for patients when successful. We present a technique utilizing the pusher wire of the stent retriever used for intracranial thrombectomy as the workhorse wire for carotid intervention using a monorail system to perform cervical carotid angioplasty.

Methods: We reviewed four successive patients who presented with a tandem occlusion and underwent thrombectomy and simultaneous carotid artery intervention using this technique.

Results: All four patients had radiographically successful intracranial thrombectomy and cervical carotid revascularization. Time from groin puncture to intracranial stent retriever deployment was 63 min on average. Then, using the pusher wire as a monorail workhorse, time from stent retriever deployment to carotid angioplasty was on average 6 min.

Discussion: This technique allows for cervical carotid revascularization to begin during the recommended 5-min wait time after stent retriever deployment, allowing for rapid near-simultaneous revascularization across both lesions. This technique has been reported briefly in the past for management of a cervical dissection. There is continued debate regarding the management of tandem occlusions, as to which lesion should be managed first.

Conclusion: As the management paradigms of tandem occlusions continue to evolve, this technique may improve outcomes by expediting endovascular intervention. Using the stent retriever wire provides a method of expediting the management of the proximal lesion after addressing the more distal intracranial occlusion first.

Keywords: Acute ischemic stroke; Solitaire; neuroendovascular; occlusion; stent retriever; tandem lesions; thrombectomy.

Figure 1.

(a) Lateral view of the left cervical carotid artery demonstrating occlusion at the proximal origin of the internal carotid artery; (b and c) single-frame AP and lateral shots, which demonstrate a solitaire stent retriever deployed in the M1 segment with a Sterling balloon inflated across the cervical carotid occlusion. The cello guide catheter is also inflated during inflation of the cervical balloon to provide some proximal embolic protection; (d) final AP cranial view from the left common carotid artery which demonstrates complete recanalization of the MCA candelabra; (e) final lateral cervical view, which demonstrates recanalization of the origin of the internal carotid artery.