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  • Trans-anterior Communicating Artery Approach for Acute M1 Stroke Thrombectomy in the Setting of Chronic Contralateral Internal Carotid Occlusion

    Final Number:

    Gursant Atwal MD; Kunal Vakharia MD; Vernard S Fennell MD, MSc; Jeffrey Beecher; Hakeem Shakir; Jason Davies MD PhD; Elad I. Levy MD, FACS, FAHA, FAANS

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Several trials have shown the benefit of mechanical thrombectomy for large-vessel occlusion (LVO) with and without intravenous (IV) tissue plasminogen activator (tPA). However, these trials did not look at chronic occlusions with tandem plaques. This is likely due to access issues.

    Methods: A 70 year-old man with a history of coronary artery disease and diabetes was brought to the hospital with the acute onset of global aphasia. The patient was being treated for left carotid occlusion and was taking aspirin and clopidogrel. On arrival, the patient had a National Institutes of Health Stroke Scale (NIHSS) score of 4 and was treated with IV tPA. 45 minutes later the patient deteriorated to NIHSS of 26.

    Results: Using a 9Fr Concentric balloon catheter (Stryker), a Vitek catheter (Cook), and .038-inch exchange wire, the left CCA was cannulated and angiographic runs were obtained. There was no filling of the left ICA. Subsequently, the balloon guide catheter was used to cannulate the right ICA. Via the balloon guide catheter, a 3 Max and Velocity microcatheter (Penumbra Inc.) was advanced over a Synchro2 microwire (Stryker) and brought to the right A1 segment of the ACA. Using fluoroscopic guidance, the wire was advanced through the ACOM to the left A1 and all the way to the left M1 bifurcation. Thereafter, the Synchro2 wire was exchanged for a Solitaire 4mm × 40mm stent retriever. The 3 max catheter was advanced to engage the clot. Using the Penumbra aspiration system, the stent retriever and 3 max was pulled as a unit under fluoroscopy and the clot was retrieved. A run was obtained through the guide catheter that showed thrombolysis in cerebral infarction (TICI) 3 recanalization.

    Conclusions: In the setting of a chronic ipsilateral occlusion and a tandem MCA occlusion, the trans-ACOM artery approach can be used for stroke thrombectomy.

    Patient Care: It will provide alternate access for MCA thrombectomies in the case of chronic internal carotid occlusions.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) understand technical nuances of trans-anterior communicating artery approaches for thrombectomy; 2) thrombectomy of anterior circulation in setting of chronic ICA occlusion; 3) understand the management of acute ischemic stroke in the setting of chronic cervical ICA occlusion.

    References: 1. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015;372:2285-95 2. Goyal M, Demchuk AM, Menon BK, et al. for the ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. New Engl J Med 2015;372:1019-30 3. Jovin TG, Chamorro A, Cobo E, et al. for the REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015;372:2296-306 4. Mokin M, Snyder KV, Siddiqui AH, et al. Recent endovascular stroke trials and their impact on stroke systems of care. J Am Coll Cardiol 2016;67:2645-55 5. Smith WS, Lev MH, English JD, et al. Significance of large vessel intracranial occlusion causing acute ischemic stroke and TIA. Stroke 2009;40:3834-40 6. Berkhemer OA, Fransen PSS, Beumer D, et al. for the MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. New Engl J Med 2015;372:11-20 7. Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015;372:1009-18 8. Saver JL, Goyal M, van der Lugt A, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: A meta-analysis. JAMA 2016;316:1279-88 9. Dargazanli C, Consoli A, Barral M, et al. Impact of modified TICI 3 versus modified TICI 2b reperfusion score to predict good outcome following endovascular therapy. AJNR Am J Neuroradiol 2016 10. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association Focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015;46:3020-35 11. Pierot L, Pereira VM, Cognard C, et al. Teaching lessons by MR CLEAN. AJNR Am J Neuroradiol 2015;36:819-21 12. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016;387:1723-31 13. Hauck EF, Natarajan SK, Langer DJ, et al. Retrograde trans-posterior communicating artery snare-assisted rescue of lost access to a foreshortened pipeline embolization device: complication management. Neurosurgery 2010;67:495-502 14. Navarro R, Yoon J, Dixon T, et al. Retrograde trans-anterior communicating artery rescue of unopened Pipeline Embolization Device with balloon dilation: complication management. J Neurointerv Surg 2015;7:e7 15. Padalino DJ, Deshaies EM. Tandem middle cerebral artery-internal carotid artery occlusions: reduced occlusion-to-revascularization time using a trans-anterior communicating artery approach with a penumbra device. J Neurosurg 2012;116:665-71

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