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      Retrograde thrombectomy of acute common carotid artery occlusion with mobile thrombus: illustrative cases

      case-report

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          Abstract

          BACKGROUND

          Acute embolic occlusion of the common carotid artery (CCA) alone is rare. However, once it occurs, recanalization is challenging due to the large volume of the clot, larger diameter of the CCA, and risk of procedure-related distal embolism into the intracranial arteries.

          OBSERVATIONS

          The authors report two cases of acute embolic occlusion of CCA alone, caused by a cardiac embolus trapped at the proximal end of a preexisting atherosclerotic plaque at the cervical carotid bifurcation. In both cases, the CCA was successfully recanalized using retrograde thrombectomy in a hybrid operating room. In case 1, a 78-year-old male with acute right CCA occlusion underwent retrograde thrombectomy, where the cervical carotid bifurcation was exposed and incised, and the entire embolus was retrieved with forceps. Despite successful revascularization, massive bleeding from the CCA just after the retrieval remained a concern. In case 2, a 79-year-old female with acute right CCA occlusion underwent retrograde thrombectomy in the same manner. Because manual retrieval failed, a Fogarty balloon catheter inserted from the arteriotomy successfully retrieved the entire thrombus with minimal blood loss.

          LESSONS

          Retrograde thrombectomy through the arteriotomy of the cervical carotid bifurcation safely and effectively recanalizes acute embolic occlusion of the CCA alone.

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          Most cited references11

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          Common carotid occlusion. Assessment of the distal vessels.

          T Riles, M Posner, B C Eikelboom … (1984)
          In patients with common carotid artery (CCA) occlusion, successful vascular reconstruction can be performed if there is a patent internal or external carotid distal to the occlusion. Preoperative selection of suitable candidates is often difficult because of the inability to visualize patent distal vessels with conventional angiography. In reviewing 24 patients operated upon for CCA occlusion since 1962, the distal internal or external carotid arteries were visualized in only four (17%) of the preoperative angiograms. When these 24 patients were explored, the internal carotid was found to be patent in 11 (46%) patients and the external patent in 15 (62%) cases. Of the 15 patients reconstructed, thromboendarterectomy was performed in six and saphenous vein bypass in nine. In the remaining nine patients, exploration revealed both the internal and external carotids to be thrombosed and unsuitable for CCA reconstruction. Recently we have used rapid sequential computerized tomography (RSCT) scanning to aid in the evaluation of the nonvisualized internal carotid artery (ICA). In two patients with CCA occlusion, RSCT correctly diagnosed patency of the ICA although it appeared to be occluded on angiography. Preliminary data suggest that RSCT will permit accurate preoperative selection of those CCA occlusion patients who are suitable surgical candidates and eliminate the need for surgical exploration.
          Article 0 comments Cited 14 times – based on 0 reviews     Review now
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            Predictive value of thrombus volume for recanalization in stent retriever thrombectomy

            Jang-Hyun Baek, Joonsang Yoo, Dongbeom Song … (2017)
            This retrospective study investigated whether the volume or density of the thrombus is predictive of recanalization in stent retriever (SR) treatment. Consecutive patients treated with SR thrombectomy as the first endovascular modality were enrolled. The thrombus volume and density were measured on thin-section noncontrast computed tomography using 3-dimensional software. The patients were grouped by recanalization status and the number of SR passes. Among 165 patients, recanalization was achieved with the first pass in 68 (50.0%), 2–3 passes in 43 (31.6%), and ≥4 passes in 25 (18.4%) patients. The thrombus volume was smaller in patients with (107.5 mm3) than without (173.7 mm3, p = 0.025) recanalization, and tended to be larger with increasing number of passes (p for trend = 0.001). The thrombus volume was an independent predictor of first-pass recanalization (odds ratio 0.93 per 10 mm3, 95% confidence interval 0.89–0.97). However, the thrombus density was not associated with recanalization success. Recanalization within 3 passes was associated with a favorable outcome. In conclusion, the thrombus volume was significantly related to recanalization in SR thrombectomy. Measuring the thrombus volume was particularly predictive of first-pass recanalization, which was associated with a higher likelihood of a favorable outcome.
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              Morphological Classification of Mobile Plaques and Their Association with Early Recurrence of Stroke

              Toshiyasu Ogata, Masahiro Yasaka, Yoshiyuki Wakugawa … (2010)
              Background: The present study investigated the frequency and morphological characteristics of carotid mobile plaques and examined the relationship between carotid mobile plaques and recurrent strokes. Methods: The study included 94 consecutive acute stroke patients with large-artery atherosclerosis associated with extracranial carotid stenosis. We investigated the presence of mobile plaques by carotid ultrasonography and classified patients into two groups (mobile group and non-mobile group). We compared backgrounds, MRI and ultrasonographic findings, neurological severity on admission and at discharge, and the rate of early recurrent stroke between both groups. Results: Mobile plaques were detected in 12 patients (12.8%). There were four types of mobile plaques: (1) the jellyfish-type plaque, in which the fibrous cap fluctuated like a jellyfish; (2) the streaming-band-type plaque, in which the string attached to the plaque was swaying; (3) the mobile-thrombus-type plaque, in which a mobile mass was attached to the plaque surface, and (4) the fluctuating-ulcer-type plaque, which contained a mobile substance in the plaque ulcer. Although National Institutes of Health Stroke Scale (NIHSS) scores on admission were less severe in the mobile group than in the non-mobile group (median 1 vs. 4, respectively; p = 0.004), the rate of early recurrent stroke was significantly higher in the mobile group than in the non-mobile group (33.3 vs. 7.3%, respectively; p = 0.022). There were no significant differences in NIHSS scores at discharge between groups. Conclusions: Morphologically, several types of mobile plaques were detected in consecutive patients with acute stroke associated with carotid stenosis. Mobile plaques are strongly associated with an early recurrence of stroke.
              Article 0 comments Cited 10 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Neurosurg Case Lessons
                Journal ID (iso-abbrev): J Neurosurg Case Lessons
                Journal ID (publisher-id): J Neurosurg Case Lessons
                Title: Journal of Neurosurgery: Case Lessons
                Publisher: American Association of Neurological Surgeons
                ISSN (Electronic): 2694-1902
                Publication date Collection: 26 February 2024
                Publication date (Electronic): 26 February 2024
                Volume: 7
                Issue: 9
                Electronic Location Identifier: CASE23694
                Affiliations
                [1 ]Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Kochi, Japan; and
                [2 ]Department of Neurosurgery, Chikamori Hospital, Kochi, Kochi, Japan
                Author notes
                CorrespondenceHitoshi Fukuda: Kochi Medical School Hospital, Nankoku, Kochi, Japan. fukudaharpseal@ 123456gmail.com .

                INCLUDE WHEN CITING Published February 26, 2024; DOI: 10.3171/CASE23694.

                DisclosuresThe authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

                Article
                Publisher ID: CASE23694
                DOI: 10.3171/CASE23694
                PMC ID: 10901119
                PubMed ID: 38408334
                SO-VID: 5ddc2f6f-1d03-4fd2-81ee-54eb26c0e645
                Copyright © © 2024 The authors
                License:

                CC BY-NC-ND 4.0 ( http://creativecommons.org/licenses/by-nc-nd/4.0/)

                History
                Date received : 25 November 2023
                Date accepted : 28 December 2023
                Page count
                Figures: 4, Tables: 0, References: 12, Pages: 5
                Categories
                Compound subject: Endovascular-Neurosurgery, Endovascular Neurosurgery
                Compound subject: Spine, Spine
                Compound subject: Cervical, Cervical
                Compound subject: Vascular-Disorders, Vascular Disorders
                Subject: Case Lesson

                Keywords: common carotid artery occlusion,retrograde thrombectomy,hybrid operating room,cardiac embolism,carotid endarterectomy,cca = common carotid artery,ct = computed tomography,eca = external carotid artery,ica = internal carotid artery,mri = magnetic resonance imaging,nihss = national institutes of health stroke scale,spect = single photon emission computed tomography
                Data availability:
                Keywords: common carotid artery occlusion, retrograde thrombectomy, hybrid operating room, cardiac embolism, carotid endarterectomy, cca = common carotid artery, ct = computed tomography, eca = external carotid artery, ica = internal carotid artery, mri = magnetic resonance imaging, nihss = national institutes of health stroke scale, spect = single photon emission computed tomography

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