Neuro-rescue during Carotid Stenting

Overview of some of the devices currently available for mechanical retrieval of macro-emboli from the intracranial circulation. (a), Merci retriever device (Concentric Medical, Mountain View, CA). (b), Catch thrombus retriever system (Balt Extrusion, Montmorency, France). (c), Proboscis Rx catheter (Medical Braiding AG, Giswil, Switzerland). Note the large inner lumen with a separate channel for rapid exchange wire and kink resistance due to micro-braiding.

How to deal with acute embolic occlusion of the middle cerebral artery (MCA) using the Merci retriever device. (a), Selective angiography of the left internal carotid artery in a patient with acute occlusion of the left MCA (arrowhead) that was not related to a carotid stenting procedure. Note the poor distal perfusion (arrow). (b), Supra-selective angiography demonstrating tip of microcatheter (arrowhead) beyond the point of occlusion. Distal MCA flow is better demonstrated (arrow). (c), Fluoroscopic image demonstrating deployment of Merci retriever device in the left MCA (arrow). Note the balloon guiding catheter, with balloon inflated (arrowhead). (d), Completion angiography demonstrating complete restoration of flow after mechanical thrombectomy. (Images provided courtesy of Jan Albert Vos, MD, Nieuwegein, The Netherlands.)

How to deal with acute occlusion of the basilar artery using the Merci retriever device. (a) Selective angiogram of the vertebrobasilar system demonstrating occlusion of the basilar artery (arrowhead). The tip of the microcatheter lies within the occlusion (arrow). Note the hypoplastic left vertebral artery (curved arrow). (b), Selective angiography performed with the Merci retriever in place (arrowhead). (c), Completion angiography showing recanalization of the basilar artery (arrowhead), and its distal branches. (d), Image of removed clot and Merci retriever after removal from guiding catheter. (Images provided courtesy of Jan Albert Vos, MD, Nieuwegein, The Netherlands.)

How to deal with acute occlusion of the middle cerebral artery using the Catch device (a), Selective angiography of the right internal carotid artery in a patient presenting with acute stroke (not related to a carotid stenting procedure) demonstrating occlusion of the right middle cerebral artery (arrowhead). (b), Selective angiography of the right internal carotid artery after passage of microguidewire (arrow) and microcatheter (arrowhead) beyond the point of occlusion. (c), Fluoroscopic image demonstrating position of microcatheter (arrow) and retrieval device (Catch) with its markers (arrowheads), the retrieval device is still in its non-deployed state. (d), Selective angiography after deployment of the retrieval device (markers indicated with arrowheads) and after withdrawal of the device and microcatheter (arrow) into the siphon of the right internal carotid artery. (e), Image of Catch retriever device and guiding catheter after complete withdrawal, demonstrating the presence of fresh clot in the basket. (f), Selective control angiography of the right internal carotid artery demonstrating complete restoration of flow. (Images courtesy of Professor René Chapot, Limoges, France.)

Aspiration thrombectomy. (a), Patient with acute vertebrobasilar stroke; coronal MPR reconstruction of CT angiography demonstrating occlusion of the basilar artery (arrow). (b), Digital subtraction angiography in the same patient confirming embolic occlusion of the basilar artery (arrow); a microcatheter has been advanced into the basilar artery (arrowhead). (c), Fluoroscopic image in lateral projection after advancement of the catheter with tip of the catheter now against the embolus (arrowhead); note the tortuosity in the distal part of the vertebral artery (arrow). (d), Completion angiography demonstrating complete restoration of flow. (Images How to deal with acute embolic occlusion of the middle cerebral artery using the Merci retriever device courtesy of Professor Gerhard Schroth, Bern, Switzerland.)

Intra-arterial thrombolysis. (a), Selective angiography of the left internal carotid artery (lateral projection) in a patient suffering from an acute hemispheric neurological deficit after coronary angiography. The arrowhead marks the embolus occluding the left middle cerebral artery. (b), Selective angiography of the left internal carotid artery (antero-posterior projection) in the same patient; note presence of flow in the anterior cerebral artery (arrow) and absence of flow in the middle cerebral artery (arrowhead). (c), Fluoroscopic image after positioning of microcatheter (arrowhead) for local, intra-arterial thrombolysis. (d), Angiographic image after administration of 500,000U of urokinase; partial recanalization (arrowhead) of the M1 segment of the middle cerebral artery is seen with flow into peripheral (M2) branches (arrow). (e), Completion angiography demonstrating complete restoration of flow. The clinical course was uneventful with complete regression of neurological symptoms.

Treatment of thrombus forming within an embolic protection device after CAS. (a), Periprocedural angiography demonstrating filling defect (arrow) proximally from embolic protection device (arrowhead); filling defect represents thrombus. (b), Non-subtracted image of stent and filter device; the guiding catheter has already been advanced to the level of the stent. (c), Angiogram after thromboaspiration and retrieval of the embolic protection device using the guiding catheter confirming patency of the internal carotid artery. (d), Close-up of embolic protection device (arrowhead) showing presence of thrombotic material (arrow) on the guidewire despite full antiplatelet and anticoagulation therapy.