Triple Stentriever “Bouquet” Deployment with Zoom 88 Large-Bore Aspiration and Walrus Balloon-Guide Catheter for the Definitive Thrombectomy of a Carotid Free-Floating Thrombus

Abstract

Formation of a carotid free-floating thrombus (CFFT) is a rare and life-threatening condition without an optimal management plan. A 78-year-old woman with a history of prior right internal carotid artery (ICA) mechanical thrombectomy and antiplatelet noncompliance presented with transient ischemic attacks secondary to a recurrent CFFT in the right ICA. Given her symptoms and recurrent CFFT, endovascular mechanical thrombectomy was performed. A balloon guide-catheter (BGC) and a Zoom 88 distal access catheter were brought into the right distal common carotid artery and proximal ICA bulb, respectively. Three 0.021-inch microcatheters, each loaded with a unique stentriever, were navigated beyond the thrombus into the upper cervical ICA and deployed in a bouquet fashion. The BGC was inflated to achieve flow arrest, and the Zoom 88 aspiration catheter was tracked over the three bouquet stentrievers to ingest the thrombus. Follow-up angiography demonstrated recanalization of the proximal cervical ICA without evidence of residual thrombus. Twenty-four-hour postoperative computed tomography imaging did not reveal any evidence of new infarction. The patient was discharged home with an intact neurological examination, compliant on aspirin and apixaban. We demonstrate a novel technique utilizing a large-bore catheter with a triple stentriever “bouquet” to thrombectomize a CFFT.

Keywords

carotid free-floating thrombus - triple stentriever - zoom bouquet - mechanical thrombectomy

Presentation

This material was accepted as an e-poster at the 2023 Annual Society of NeuroInterventional Surgery meeting in San Diego, California, United States.

Authors' Contribution

J.K.C., B.M.M., M.W.K., J.C.C.d.B. assisted with the conception and design of the manuscript. J.K.C., B.M.M., and D.A.Z. drafted and revised the manuscript for important intellectual content. J.K.C., B.M.M., and G.A. assisted with the data acquisition and analysis. L.M.L. and A.L.C. reviewed the important intellectual content presented in the manuscript. A.L.C., J.K.C., and M.W.K. performed treatment procedures and critically revised the important intellectual content. All authors read and approved the final manuscript.

Patient Consent

All individual identifying information, including age and sex, have been meticulously anonymized to achieve appropriate anonymity in the manuscript. The patient provided her informed consent to participate in this study and for the publication of his case report.

Publikationsverlauf

Eingereicht: 14. September 2023

Angenommen: 02. Dezember 2023

Artikel online veröffentlicht:
12. Februar 2024

• References

• 1 Dowlatshahi D, Lum C, Menon BK. et al. Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort. Stroke Vasc Neurol 2023; 8 (03) 194-196
• 2 Imahori T, Tanaka K, Arai A, Kohmura E. Surgical thromboendarterectomy for free-floating thrombus associated with cervical carotid artery dissection: a case report. Ann Vasc Surg 2020; 68: 572.e9-572.e14
• 3 Gülcü A, Gezer NS, Men S, Öz D, Yaka E, Öztürk V. Management of free-floating thrombus within the arcus aorta and supra-aortic arteries. Clin Neurol Neurosurg 2014; 125: 198-206
• 4 Vassileva E, Daskalov M, Stamenova P. Free-floating thrombus in stroke patients with nonstenotic internal carotid artery-an ultrasonographic study. J Clin Ultrasound 2015; 43 (01) 34-38
• 5 Fridman S, Lownie SP, Mandzia J. Diagnosis and management of carotid free-floating thrombus: a systematic literature review. Int J Stroke 2019; 14 (03) 247-256
• 6 Wang P, Wang Z, Pan J, Lu K, Sun L, Geng Y. Case report: ultrasound-assisted endovascular therapy for carotid artery floating thrombus. Front Cardiovasc Med 2022; 9: 961760
• 7 Christian ZK, Hoang AN, Dang H. et al. Use of transcarotid artery revascularization for mechanical thrombectomy and treatment of symptomatic high-grade carotid artery stenosis associated with free-floating thrombus: illustrative case. J Neurosurg Case Lessons 2022; 3 (10) CASE21553
• 8 Mareedu R, Hwang J, Vyakaranam S, Inkollu S. Use of transcarotid artery revascularization to treat symptomatic carotid artery stenosis associated with free-floating thrombus. Ann Vasc Surg 2021; 70: 568.e1-568.e3
• 9 Sugie A, Yamada M, Yokoyama K. et al. Carotid free-floating thrombus in a stent 6 months after carotid artery stenting. World Neurosurg 2020; 141: 236-239
• 10 Bhogal P, AlMatter M, Aguilar Pérez M, Bäzner H, Henkes H, Hellstern V. Carotid stenting as definitive treatment for free floating thrombus-review of 7 cases. Clin Neuroradiol 2021; 31 (02) 449-455
• 11 Denezpi TM, Green RS, Carlson AP. Use of distal protection filter device for rescue mechanical thrombectomy for symptomatic free-floating thrombus of the cervical internal carotid artery. Interv Neuroradiol 2021; 27 (03) 440-443
• 12 Toudou-Daouda M, Ouanounou G, Aghasaryan M. et al. Floating aortic arch thrombus involving the left common carotid artery complicated with ischemic stroke associated with cocaine use. Neurol Sci 2022; 43 (09) 5629-5632
• 13 Tomoyose R, Tsumoto T, Hara K. et al. Mechanical thrombectomy and carotid artery stenting for stenosis of the internal carotid artery with free-floating thrombosis: illustrative case. J Neurosurg Case Lessons 2021; 2 (09) CASE21338
• 14 Ali AB, Hui SH, Mouawad NJ. Mechanical thrombectomy of symptomatic carotid stenosis with free-floating thrombus in a patient with COVID-19 using transcarotid artery revascularization. J Vasc Surg Cases Innov Tech 2021; 7 (04) 725-729
• 15 Al-Jehani H, Alhamid MA, Alkhalaf Y, Alabbas F. A case of coincidental free floating thrombus in the vertebral artery in a patient presenting with an anterior circulation stroke and literature review. Neurointervention 2020; 15 (03) 144-153
• 16 Ojha P, Goel G, Chatterjee A, Singhal V, Mahajan A. “Double protection closed compartment” aspiration technique for left internal carotid artery (ICA) free floating thrombus. Ann Indian Acad Neurol 2022; 25 (02) 320-322
• 17 Inoue H, Oomura M, Nishikawa Y, Mase M, Matsukawa N. Direct advancement of balloon-guide catheter distal to the carotid free-floating thrombus achieves smart mechanical thrombectomy. Cureus 2022; 14 (02) e22439
• 18 Müller MD, Raptis N, Mordasini P. et al. Natural history of carotid artery free-floating thrombus-a single center, consecutive cohort analysis. Front Neurol 2022; 13: 993559
• 19 Fitzpatrick N, Motyer R, Gibney B. et al. Expanding the role of stent-retriever endovascular thrombectomy: a case series of free-floating thrombus. J Neurointerv Surg 2018; 10 (12) 1164-1167
• 20 Yamaoka A, Miyata K, Iihoshi S, Mikuni N. Endovascular treatment of asymptomatic free-floating thrombus in the carotid artery bifurcation: a direct aspiration first-pass technique under double balloon protection. BMJ Case Rep 2019; 12 (08) e230295
• 21 Lin LM, Bender MT, Colby GP. et al. Use of a next-generation multi-durometer long guide sheath for triaxial access in flow diversion: experience in 95 consecutive cases. J Neurointerv Surg 2018; 10 (02) 137-142
• 22 Lin L-M, Colby GP, Iyer RR. et al. Pentaxial access platform for ultra-distal intracranial delivery of a large-bore hyperflexible DIC (distal intracranial catheter): a technical note. Interdiscip Neurosurg 2016; 6: 29-34
• 23 Fischer S, Will L, Phung T, Weber W, Maus V, Nordmeyer H. The Tigertriever 13 for mechanical thrombectomy in distal and medium intracranial vessel occlusions. Neuroradiology 2022; 64 (04) 775-783
• 24 Sirakov A, Minkin K, Penkov M, Ninov K, Karakostov V, Sirakov S. Comaneci-assisted coiling as a treatment option for acutely ruptured wide neck cerebral aneurysm: case series of 118 patients. Neurosurgery 2020; 87 (06) 1148-1156
• 25 Xu W, Ma Q, Luo J, Tao W, Ma Y, Jiao L. Free-floating thrombus of internal carotid artery presenting as thromboembolism. J Vasc Surg 2023; 77 (06) 1804-1805
• 26 Cancer-Perez S, Alfayate-García J, Vicente-Jiménez S. et al. Symptomatic Common carotid free-floating thrombus in a COVID-19 patient, case report and literature review. Ann Vasc Surg 2021; 73: 122-128
• 27 Giragani S, Komal RNK, Potluri A, Sharma VK. Bilateral symptomatic carotid free floating thrombi. Neurol India 2021; 69 (03) 770-771