Urgent carotid endarterectomy with distal mechanical thrombectomy
Authors: Muhammad Najib , Ramayya Ashwin , Burkhardt Jan Karl , Srinivasan Visish M 
Published: June 2024

We review the technique for carotid endarterectomy (CEA) and direct carotid access for distal thrombectomy after attempted proximal thrombectomy in the setting of tandem occlusions. A patient in their 70s presented with right facial droop and drooling and was found to have critical left carotid stenosis with filling defect in the cavernous segment of the left internal carotid artery consistent with vessel occlusion, Thrombolysis in Cerebral Infarction (TICI) 0, and left M2 middle cerebral artery (MCA) occlusion. After multiple attempts with different wire shapes guided by microcatheter injections within the carotid bulb, we were unable to cross the occlusion. Conversion to open CEA with distal thrombectomy was elected. Following closure of the arteriotomy, direct carotid access using a 5Fr radial artery sheath was achieved within the open surgical field for distal thrombectomy. A 5Fr aspiration catheter was navigated to the left M2 MCA where a stent retriever was then recaptured and TICI 2B reperfusion was achieved.

We present a case of urgent carotid endarterectomy (CEA) performed with distal thrombectomy.

A patient in his/her 70s with a past medical history including prior left middle cerebral artery (MCA) ischemic strokes presented with right facial droop and aphasia and a National Institutes of Health Stroke Scale (NIHSS) score of 7. The patient was brought to the angiography suite for a stat digital subtraction angiography (DSA) with possible thrombectomy and stenting. Three-dimensional reconstructions of the preoperative CT angiogram showed a left MCA territory occlusion.

A diagnostic angiogram showed a left common carotid artery occlusion at the carotid bifurcation. In video 1 it can be seen that the right common carotid artery injection with a head view demonstrates strong cross-filling across the anterior communicating artery (ACA) supplying the bilateral ACA territories over to the left MCA territory. The cervical left carotid angiogram shows an occlusion with various areas of plaque and calcification with a small area that was suspected to be a channel for distal wire catheterization. The left vertebral artery angiogram shows filling of the basal temporal lobe, especially in the area of the posterior cerebral artery (PCA)–MCA watershed, suggesting some chronicity to the hypoperfusion within this territory. Note the red arrow pointing at the left M2 occlusion in tandem with the proximal internal carotid artery (ICA) occlusion.

Video 1

Operative video of the case

The indications for the thrombectomy are as follows: the patient presented with right facial droop and drooling and an NIHSS score of 7 with no baseline neurological deficits; CT of the head did not show any hemorrhage with the CT angiogram (CTA) of the neck showing occlusion of the left ICA. On the diagnostic angiogram there was a filling defect within the cavernous segment of the left ICA consistent with an occlusion distally and within the left MCA territory as seen on CTA.

We first attempted to stent with this system, including a Walrus balloon guide catheter positioned in the cervical common carotid artery, an SL10 microcatheter, and a Synchro 014 support wire. Injections were performed via the balloon guide catheter positioned in the common carotid artery as well as a microcatheter positioned in the region of the plaque. Despite multiple attempts and a potential viable route through the plaque, none could be found. An additional option, not attempted here, includes the use of a stiffer system (eg, 0.035 inch wire with select catheter), with additional risk of dissection and/or vascular injury.

The angiosuite was then converted into an operating room. The subsequent operating room set-up is shown in video 1, with the table turned and the Mayo tray and operating tray brought in along with the operating microscope.

The standard surgical steps of the CEA are shown in the accelerated video 1. Clamps were placed in sequence on the ICA, common carotid artery, external carotid artery, and superior thyroid arteries. The plaque was circumferentially dissected from the normal arterial wall. The plaque was then removed en bloc, including the origin of the external carotid artery, which was also involved with the plaque. The distal ICA was then examined for additional plaque, and additional plaque was also removed from the external carotid artery origin, which was quite calcified. The arteriotomy was closed, primarily with a 6–0 Prolene suture, with eventual back bleeding of the ICA. The clamps were then removed in reverse sequence and hemostasis was achieved. We then prepared for access via the more proximal common carotid artery. A U-stitch was placed within the area prepared for proximal access. The sheath and the associated wire were able to pass freely within the open segment of the CEA site. A still photograph shows the set-up with a 5Fr radial sheath placed within the more proximal common carotid artery.

A radial micropuncture kit was used to access the proximal common carotid artery with a wire traversing the arteriotomy site, and then eventual placement of the 5Fr radial sheath within the proximal carotid artery up to the ICA. Through the 5Fr radial artery sheath a 5Fr Esperance aspiration catheter was advanced over a microcatheter and microwire into the left M2 MCA. A Trevo stent retriever was then deployed across the clotted segment and clot integration was allowed for 3 min. The stent retriever was then recaptured with simultaneous aspiration via the Esperance aspiration catheter and TICI 2B reperfusion was achieved.

The duration of the entire procedure was 6 hours and 31 min from transport of the patient into and out of the operating room. The decision to convert to open CEA was made 57 min after the beginning of the procedure. This portion of the procedure lasted 3 hours and 12 min before distal mechanical thrombectomy was performed. One hour and 26 min later, closing of the incision occurred.

In the video we then discuss the advantages of using direct carotid access. First, you can use a smaller system that is needed for femoral access. Second, you can avoid the use of a guide catheter and go directly with a microcatheter and an aspiration catheter. Third, you have an open surgical field in the case of complications and needing to do anything directly to the carotid.

We then continue to discuss the distal thrombectomy. The leftmost panel included in video 1 shows a pseudo-occlusion in the ICA with expected clot in the ICA as well as the M2. A microwire and microcatheter were advanced past the occlusion. The third panel shows the initial ICA and M1 recanalization, although a superior M2 division occlusion remained.

Three additional panels show the thrombectomy performed in the M2 superior division. The left panel shows the occlusion and the middle panel shows our microwire and microcatheter access. That branch is seen to open up with a contrast injection overlay with the roadmap. This is a useful technique to visualize smaller branch recanalizations. The single shot on the left shows the stent retriever and aspiration catheter position just proximal to it, which were both used in conjunction for the M2 thrombectomy. The middle and right panels in anteroposterior and lateral views show the final reperfusion of the MCA territory. The postoperative CTA demonstrates filling within the left M2 MCA territory.

The patient was medically stabilized and transferred to an acute rehabilitation facility on postoperative day 13. At discharge the patient had an NIHSS score of 3 for mild aphasia and dysarthria. Four weeks postoperatively the patient was progressing at rehab as expected with the wound healing well and pending Doppler ultrasounds to track the carotid artery post-endarterectomy.