Successful carotid thrombus aspiration, middle cerebral mechanical thrombectomy, and axillary artery clot disruption attempt in a patient with acute ischemic stroke and critical upper limb ischemia.

Acute thrombotic occlusions of the large vessels, such as internal carotid artery, arms and legs arteries, and intracranial vessels, frequently require multiple techniques such as selective thrombolysis, manual aspiration, and stent retrievers for mechanical thrombectomy with combination of the mentioned techniques. Because of the massive thrombotic burden associated with these conditions, the response to systemic intravenous thrombolysis is poor. We present a case of a successful massive thrombi aspiration in a single attempt using an 8Fr guide catheter with aspiration syringe, subsequent ipsilateral middle cerebral artery mechanical thrombectomy, and axillary artery clot disruption attempt in a patient with acute ischemic stroke, right arm critical ischemia, and persistent atrial fibrillation.

An 80-year-old woman presented with numbness and severe pain in her right arm. The patient has persistent atrial fibrillation and has been taking warfarin with international normalized ratio less than 1.5. Ultrasound study confirmed the diagnosis of right axillary thrombosis, and the patient was scheduled to emergent thrombectomy because of critical limb ischemia. During preoperative preparation, the patient's condition quickly deteriorated with acute neurologic symptoms, left hemiparesis, and National Institutes of Health Stroke Scale score (NIHSS) of 21. Her native computed tomography showed no signs of hemorrhage or hyperdense intracranial arteries. Because of rapid progression of symptoms, history of AFib, and critical condition, we performed urgent thrombolysis with simultaneous angiography, which showed massive right internal carotid thrombosis. The patient was intubated because of outstanding agitation and active limb movements. A successful direct endovascular thrombus aspiration with MPA 1 8Fr guide catheter (Cordis) and aspiration syringe was performed, and multiple heterogenic thrombi were evacuated. Control angiography revealed intact internal carotid artery and M1 middle cerebral artery occlusion. MPA 1 was changed to single-balloon proximal cerebral protection device MoMa 8F (Medtronic), cerebral wire and microcatheter were passed through the occlusion, and successful single-pass Solitaire stent (Medtronic) mechanical thrombectomy was performed (Fig. 1). Because of critical limb ischemia, we also performed right upper limb angiography, and total axillary occlusion was revealed. We performed mechanical clot disruption with 0.035-inch J-tip wire and direct aspiration with MPA 1 to restore minimally required blood flow to the limb (Fig. 2). After several attempts, angiographic picture was still far from ideal, but due to achieving poor brachial antegrade blood flow, appearance of patient's right radial artery pulse, and high risks of “ADAPT” thrombus aspiration technique, we decided to stop the procedure. In 20 minutes, the patient was awake and extubated after 2 hours, with significant improvement in left arm and leg movements. After 6 hours, her NIHSS improved to 1 (mild dysarthria) and control computed tomography after 24 hours showed minimal cerebral infarct (Fig. 3). Right upper limb restored its function without pain and numbness for 12 hours after the procedure. Her modified Rankin scale was 0 at 90 days follow-up.

Fig. 1

Angiography during and after the intervention. View of massive thrombus and slow flow in the right internal carotid artery (arrows) (A). External carotid artery occlusion (arrowhead) and M1 middle cerebral artery occlusion (arrow) (B). Pictures of carotid (upper) and middle cerebral (lower) arteries thrombi (C). Final angiography demonstrating full TICI 3 restoration of right middle cerebral artery blood flow (D).

Fig. 2

Upper limb intervention. Massive thrombus in the right upper limb (arrow) (A). MPA 1 8Fr catheter tip obstructed by thrombus (asterisk) (B). Poor antegrade brachial blood flow after the thrombus aspiration attempt (arrowheads) (C).

Fig. 3

Patient's computed tomography at presentation (A) and after 24 hours (B). Asterisk shows minimal cerebral infarct.

Recent strategy of combined endovascular acute stroke management with intravenous thrombolysis and mechanical thrombectomy or aspiration has grown rapidly through the last 5 years [1], [2]. Acute occlusions of intracranial and extracranial vessels remain an important cause of acute ischemic stroke especially in patient with atrial fibrillation and without proper anticoagulation with warfarin of novel oral anticoagulants [3], [4]. Massive thrombotic occlusions are very challenging object to treat because of large thrombus burden, poor response to systemic thrombolysis, and frequently require multiple techniques such as selective thrombolysis, manual aspiration, and stent retrievers for mechanical thrombectomy with combination of the mentioned techniques [5]. Because of invalidating consequences of acute ischemic stroke caused by major vessel occlusion, endovascular management should be utilized as first step in patient's therapy [6].

This case underscores the complexity of arterial thromboembolic events, the beneficial role of endovascular intervention in massive carotid-cerebral occlusions, and the necessity for prospective studies that identify optimal methods of thrombus evacuation from extra- and intracranial vessels and their effectiveness and safety.