Case report: Ultrasound-Assisted endovascular therapy for carotid artery floating thrombus

Abstract

BackgroundCarotid free-floating thrombus (CFFT) is a rare but sometimes emergent condition. There has been controversy over the optimal treatment strategy. Emerging evidence suggests that endovascular thrombectomy (EVT) may be an alternative to surgery. Accurate alignment of the aspiration catheter and thrombus during EVT is critical but has, so far, remained unresolved.Case summaryThis is a rare case of CFFT presenting with acute right-sided facial droop and moderate dysarthria in a 77-year-old man. He was in sinus rhythm with a blood pressure of 110/82 mmHg. Both non-contrast CT (NCCT) and head CT angiography (CTA) were unremarkable, while whole-brain CT perfusion (WB-CTP) suggested left hemisphere core infarction. Delayed imaging of the left internal carotid system by 4D-CTA suggested severe proximal obstructive disease, as confirmed by carotid CTA and ultrasonography. The initial two aspirations under DSA were invalid due to the challenging anatomical angle between the thrombus and the catheter. The success of CFFT removal was achieved with a pressure-assisted ultrasound-guided approach that helps to compress the catheter tip toward the thrombus.ConclusionWe innovatively report a successful ultrasound-guided EVT for CFFT. Ultrasound assistance can provide quick and effective guidance and may guide tailored aspirations during EVT.

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

“…Currently, there is insufficient data/evidence to compare the different procedural modalities in managing CFFTs. 6,7,10,13,14,[16][17][18]25,26 A retrospective study of 525 cases with CFFTs found no significant difference in outcomes of patients receiving antiplatelet and anticoagulant therapy versus procedural management with endovascular or surgical carotid endarterectomy (CEA). 5 With its minimally invasive nature and advanced modern catheters and devices, endovascular thrombectomy, as opposed to CEA, has become the preferred choice for the procedural management of CFFTs at many centers.…”

“…5 With its minimally invasive nature and advanced modern catheters and devices, endovascular thrombectomy, as opposed to CEA, has become the preferred choice for the procedural management of CFFTs at many centers. 6,25 Since the last major literature review conducted in 2019, 5 there have been an additional 27 cases managed with endovascular treatment in the literature. Although these reports have not demonstrated a standardized technique for the mechanical thrombectomy of CFFTs, numerous methods including stentrievers, reversal of carotid flow with occlusion balloons, and distal filter wire placement have been reported.…”

“…Although these reports have not demonstrated a standardized technique for the mechanical thrombectomy of CFFTs, numerous methods including stentrievers, reversal of carotid flow with occlusion balloons, and distal filter wire placement have been reported. [6][7][8][9][10][11][12][13][14][15][16][17] Recently, direct aspiration, with or without the utilization of proximal and distal protection devices have been described. 11,20,27 To harness all the benefits of previously reported techniques we employed a triple stentriever "bouquet" technique for the mechanical thrombectomy of a CFFT.…”

“…5 There have been several recent reports about the successful mechanical thrombectomy of CFFT. [6][7][8][9][10][11][12][13][14][15][16][17] These studies have demonstrated the challenges of safely performing mechanical thrombectomy due to significant clot burden, lack of tools, and techniques designed to perform cerebrovascular thrombectomy. In total, the literature to date has provided no conclusive techniques for safe and reliable removal of CFFTs.…”

“…In total, the literature to date has provided no conclusive techniques for safe and reliable removal of CFFTs. 5,18 Recent technological improvements in aspiration catheters and stentrievers has made mechanical thrombectomy of cerebral vessels increasingly safe [6][7][8][9][10][11][12][13][14][15][16][17] and effective. 19,20 Among these developments are large-bore aspiration catheters (0.088" ID) 21,22 that are built both with and without compliant balloons for flow arrest and aspiration/flow reversal.…”