Carotid artery stenting under flow arrest for the management of intraluminal thrombus: technical case report.
OBJECTIVE
The management of intraluminal carotid thrombus is not well defined. Medical and surgical management carry a relatively high risk of thromboembolism. Although endovascular options also carry the risk of thromboembolism from manipulation of the lesion, successful carotid stent placement using various methods of flow restriction has been reported anecdotally. We describe a technique to arrest antegrade flow before placement of carotid stents in the setting of symptomatic intraluminal thrombus.


METHODS
A 49-year-old woman presented with expressive dysphasia, right-upper extremity weakness, and an episode of left monocular blindness. Angiography confirmed the presence of a large intraluminal thrombus in a chronic dissection of the left internal carotid artery.


RESULTS
We devised a configuration to arrest antegrade flow in the internal carotid artery before crossing the thrombus with a distal embolic protection device by inflating balloons in the common carotid artery and external carotid artery before crossing the lesion. After inflation of a balloon in the internal carotid artery, we completed overlapping stent placement to completely exclude the thrombus from the lumen.


CONCLUSIONS
The patient remained neurologically unchanged during and immediately after the procedure. She had mild neurological deficits at the 1 month follow-up evaluation. Follow-up ultrasonography at 1 and 3 months and computed tomographic angiography at 3 months after the procedure showed patency of the stented carotid artery, with no evidence of restenosis or thrombus. Although the risks of carotid stent placement for intraluminal thrombus remain unclear, the technique of flow arrest seems to provide a safe endovascular treatment option.
Tummala
Ramachandra P
RP
Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, University at Buffalo, State University of New York, Buffalo, New York 14209, USA.
Jahromi
Babak S
BS
Yamamoto
Junichi
J
Levy
Elad I
EI
Siddiqui
Adnan H
AH
Hopkins
L Nelson
LN
D021721:Balloon Occlusion / Q000379:methods*; D001783:Blood Flow Velocity; D002341:Carotid Artery Thrombosis / Q000000981:diagnostic imaging / Q000601:surgery*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging / Q000601:surgery; D019468:Disease Management; D005260:Female; D006801:Humans; D008875:Middle Aged; D011859:Radiography; D015607:Stents