Use of transcarotid artery revascularization for mechanical thrombectomy and treatment of symptomatic high-grade carotid artery stenosis associated with free-floating thrombus: illustrative case.

Zachary K Christian,Huy Dang,Abdul B Khan,Zachary S Pallister,Omar Tanweer,Alex N Hoang,Daniel M.S Raper

doi:10.3171/case21553

Zachary K Christian, Huy Dang + Show 5 more

Open Access

https://doi.org/10.3171/case21553

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Abstract

BACKGROUNDPatients with symptomatic high-grade stenosis of the internal carotid artery (ICA) associated with a free-floating thrombus (FFT) present a significant clinical challenge. In general, for patients with moderate to severe symptomatic ICA stenosis, carotid revascularization is recommended within 2 weeks of symptom onset; however, some physicians suggest that revascularization should be delayed in cases with FFT because some data suggest that early surgery with carotid endarterectomy or carotid stent poses a higher risk for stroke. Likewise, delayed revascularization with anticoagulation may increase risk of recurrent stroke. Few reports on the management of FTT included the use of a transcarotid artery revascularization (TCAR) approach for carotid revascularization with mechanical aspiration thrombectomy.OBSERVATIONSThis report described the use of TCAR for direct mechanical thrombectomy and carotid stent placement for a patient with 80% right ICA stenosis along with a large FFT extending into the bulb and the external carotid artery.LESSONSThe TCAR approach for mechanical thrombectomy and carotid stenting is a safe alternative for early revascularization with low periprocedural stroke risks.

Highlights

Patients with symptomatic high-grade stenosis of the internal carotid artery (ICA) associated with a free-floating thrombus (FFT) present a significant clinical challenge
This report describes the use of transcarotid artery revascularization (TCAR) for direct mechanical thrombectomy and carotid stent placement for a patient with 80% right internal carotid artery (ICA) stenosis along with a large free-floating thrombus (FFT) extending into the bulb and the external carotid artery
Observations Techniques used for the treatment of patients with ICA stenosis associated with an FFT included carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), carotid sacrifice with vessel embolization, and carotid artery bypass.[2]

Summary

BACKGROUND

Patients with symptomatic high-grade stenosis of the internal carotid artery (ICA) associated with a free-floating thrombus (FFT) present a significant clinical challenge. For patients with moderate to severe symptomatic ICA stenosis, carotid revascularization is recommended within 2 weeks of symptom onset; some physicians suggest that revascularization should be delayed in cases with FFT because some data suggest that early surgery with carotid endarterectomy or carotid stent poses a higher risk for stroke. OBSERVATIONS This report described the use of TCAR for direct mechanical thrombectomy and carotid stent placement for a patient with 80% right ICA stenosis along with a large FFT extending into the bulb and the external carotid artery. This report describes the use of transcarotid artery revascularization (TCAR) for direct mechanical thrombectomy and carotid stent placement for a patient with 80% right internal carotid artery (ICA) stenosis along with a large free-floating thrombus (FFT) extending into the bulb and the external carotid artery

Illustrative Case

Discussion