Endovascular treatment of acute tandem occlusion of the left internal carotid and middle cerebral arteries, which is a complication of carotid endarterectomy

Abstract

Case of endovascular treatment of a patient with tandem left internal carotid artery (ICA) and middle cerebral artery (MCA), which was a complication of carotid endarterectomy, are presented. The rupture at the location of the suture in the bulb of the ICA during endovascular intervention required implantation of a graft-stent and subsequent removal of the hematoma in the neck soft tissues. A 51 year old man in the residual period of ischemic stroke in the left carotid basin with elements of sensory speech disorders, with subtotal stenosis in the bulb of the left ICA, stenosis 35 % in the bulb of the right ICA and severe hypoplasia of the A1-segment of the left anterior cerebral artery underwent left-side carotid endarterectomy. The next morning after surgery, 1 hour after awakening, a right-sided hemiparesis progressing to hemiplegia, total aphasia. The level of consciousness deteriorated to the sopor. A computer tomography was performed immediately. New ischemic lesions were not identified. Cerebral angiography revealed the occlusion from the mouth of the left ICA, occlusion in the M1-segment of the left MCA. Thrombospiration from MCA and ICA was performed with Sofia Plus distal approach catheter. The MCA was recanalized in one pass (mTICI 3), but the patency of the left ICA was not recovered. The anti-embolic device SpiderFX was introduced and opened in the C2-segment of the left ICA. Then, a slow inflation of the Submarine 5 × 20 mm balloon catheter was performed in the left ICA bulb. At a pressure of 4.0 atm, the balloon opened like an hourglass, indicating a rough rigid stenosis in the ICA bulb. At a pressure of 4.5 atm, the balloon fully opened. Immediately after balloon deflation, intense contrast extravasation is determined at the level of the ICA bulb. Inflation of the balloon at a pressure of 4 atm was performed again. Intubation of the trachea of ​​the patient was performed. Intravenous administration of 300 mg acetylsalicylic acid was initiated. The balloon catheter is deflated and withdrawn from vessels, the carotid stent Protégé 8–6×40 mm was implanted into the left ICA bulb and the left common carotid bifurcation segment. The bloodstream above the stent is not determined, but extravasation through the stent cells at the level of the former defect is determined. Stent graft Graftmaster 4×15 mm was implanted into the carotid stent at the level of the defect in the ICA. Stent graft was additionally opened in its lower part by a 5×20 mm balloon-catheter. Thrombaspiration from the left ICA was performed again. Patency of the ICA and intracranial arteries was totally restored – mTICI3, stenosis in the left ICA bulb was completely eliminated. The patient’s neurological status was restored to baseline. A large hematoma in the soft tissues of the neck to the left was determined. Only “old” ischemic foci in the left temporal lobe were determined on brain CT, a large hematoma laterally and anteriorly to the carotid artery was determined in the soft tissues of the left side of the neck on computer tomography. Ticagrelor was added to aspirin therapy. Hematoma was removed surgically. The postoperative period was unremarkable. The patient was discharged from the clinic in good condition with an level modified Rankin scale 1. In the presented case, the friendly work of different profiles specialists avoided the devastating consequences of such a relatively rare complication of carotid endarterectomy as cerebral arteries tandem thrombosis. The availability of graft-stents in access to interventional neuroradiologists is extremely important in such cases.