Crossing double stent retriever technique for refractory terminal internal carotid artery occlusion

Abstract

Mechanical thrombectomy is highly effective for the recovery of acute ischemic stroke with large vessel occlusion. However, refractory occlusions are still encountered despite the use of currently available devices. In this article, we present a case of refractory terminal internal carotid artery occlusion treated with the "crossing double stent retriever technique." Two thrombectomy procedures with the combined technique using a stent retriever and aspiration catheter failed to recanalize the terminal internal carotid artery occlusion that involved the dominant anterior cerebral artery. We then applied the crossing double stent retriever technique as a rescue technique. Two microcatheters were advanced across the occlusion: one to the anterior cerebral artery and the other to the middle cerebral artery. First, a Trevo NXT 4 mm stent retriever was deployed from the anterior cerebral artery. Next, an additional Trevo NXT 4 mm stent retriever was deployed from the middle cerebral artery, and full immediate restoration of flow was achieved on angiography. Intraprocedural radiological images showed that the 2 microcatheters traversed different pathways, and the 2 stent retrievers completely covered the entire vessel with apparent in-stent clot sign. Both stent retrievers were then pulled back together, and a hard clot was retrieved. Subsequent angiography revealed complete recanalization. The crossing double stent retriever technique seems an effective rescue technique for treating refractory terminal internal carotid artery occlusion, especially with the anatomical feature of branching of the dominant anterior cerebral artery. This technique can facilitate the device-clot-vessel interaction by engaging the clot via 2 different device pathways.

Keywords: ACA, anterior cerebral artery; Acute ischemic stroke; Device-clot-vessel interaction; Endovascular treatment; ICA, internal carotid artery; Large vessel occlusion; MRI, magnetic resonance imaging; MT, mechanical thrombectomy; Mechanical thrombectomy; SR, stent retriever; Stent retriever.

Fig. 1

Preprocedural image (A and B) Emergency magnetic resonance imaging showing slight acute ischemic changes and occlusion of the left internal carotid artery. The bilateral anterior cerebral arteries were not visualized.

Fig. 2

Intraprocedural image (A) Initial angiography showing occlusion of the left terminal internal carotid artery (ICA). (B) After 2 unsuccessful thrombectomy procedures, we applied the “crossing double SR technique.” Two microcatheters were advanced across the occlusion, one to A1 of the anterior cerebral artery (arrow) and the other to the distal M1 of the middle cerebral artery (double arrow). Note the apparent difference in the course of the 2 microcatheters at the occlusion site (arrowhead). (C) A Trevo NXT 4 × 28 mm stent retriever (SR) was deployed from the A1 to ICA. (D) Angiography showing partial immediate restoration of flow. (E) One more Trevo NXT 4 × 28 mm SR was deployed from the M1 to ICA (F) Angiography showing full immediate restoration of flow. Native angiography image showing that the 2 SRs in total fully covered the inside of the vessel. (G) Digital subtraction angiography image showing the “in-stent clot sign,” which is the filling defect of the clot in the strut and the sign indicating the device-clot interaction (arrow). Thereafter, both deployed SRs were pulled back together, and a hard clot was retrieved. (H) Subsequent angiography revealing complete recanalization.

Fig. 3

Postprocedural image (A and B) Magnetic resonance imaging performed on the day after the procedure, showing successful revascularization but extensive infarction.

Fig. 4

Crossing double SR technique (A) Single stent retriever (SR). The dotted line indicates the area covered by the SR, and the solid line indicates the clot. (B) Double SR. (C) Native angiography image. Note that the 2 SRs notably covered the entire vessel, traversing different pathways. (D) Digital subtraction angiography (DSA) image showing the “in-stent clot sign,” which is the filling defect of the clot in the strut and the sign indicating the device-clot interaction (arrow). (E) Schematic of the crossing double SR technique for a terminal internal carotid artery. This technique can facilitate the device-clot-vessel interaction by intentionally changing the course of the device across the clot to better match the vessel geometry.