Introduction: Acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the anterior circulation occurs with tandem stenosis of the cervical internal carotid artery (ICA) in 15-20% of cases. Tandem lesions often have a fragile clot in the carotid artery with a distal middle cerebral artery (MCA) occlusion. The “Kitchen-sink” technique utilizes a balloon occlusion guide catheter proximally with aspiration and stent retrieval (SR) to remove clot from the ICA and MCA., respectively.
Methods: We report a single-surgeon case-series identifying anterior circulation tandem stenosis LVOs treated with an multiple simultaneous endovascular techniques (so called, the “Kitchen-Sink”) from December 2016-May 2017. The often fragile clot in the ICA is removed with contact aspiration under proximal protection of a balloon guide. The distal MCA clot is removed with SR with an aspiration catheter. The SR is pulled with the aspiration catheter remaining in place, which allows rapid access for a 2nd pass, but also maintains access distal to the ICA plaque. This prevents repeated crossing of a fragile ICA plaque and may serve as a catheter for deployment of a distal embolic protection device in the event that a carotid stent is needed.
Results: Three patients received IV-tPA therapy. Three patients had M1 occlusion, one had M2. Intra-arterial tPA was used in 2 patients. Machine assisted aspiration was utilized in all 4 patients. ICA stenosis was treated with balloon angioplasty in one patient, angioplasty and stenting in one patient, and endarterectomy in one patient. Complete revascularization (mTICI=3) was achieved in all patients. The mean improvement in NIHSS was 4.25. All patients were discharged with good functional outcome (mRS 2).
Conclusions: Simultaneous implementation of multiple revascularization techniques (i.e. “the kitchen-sink”) may provide an efficient and effective approach to patients presenting with tandem cervical ICA and distal occlusion.
Patient Care: By introducing a protocol to challenging cases, it results in a timely revascularization rate with a high rate of success.
Learning Objectives: We introduce a novel and timely way to manage difficult stroke cases. The "kitchen sink" protocol resolves some technical nuances that accompany challenging stroke cases with tandem occlusions.