PMC10481818_01
A 64-year-old man with symptomatic left carotid artery stenosis and free-floating thrombus (FFT). (a) Magnetic resonance imaging (MRI) shows diffuse spotty infarctions in the left hemisphere. (b) MRA shows stenosis in the left internal carotid artery (ICA). (c) Digital subtraction angiography (DSA) shows moderate ICA stenosis with a FFT (white arrow). (d) Tron FX 6 x 50 mm (Microvention, Tustin, CA, USA, black arrows) is deployed to cover the thrombus. (e) After stent retriever retrieval, the thrombus image on DSA disappears. (f) Carotid Wallstent (Stryker, Kalamazoo, MI, USA) is deployed. (g) Postprocedural MRI shows increased diffuse infarcts. (h) White thrombus retrieved by the stent retriever. (i) Microscopic, the retrieved thrombi contain fibrin, red blood cells, inflammatory cells, and cholesteric clefts.
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F1
Scattered infarction in the left hemisphere and a stenotic lesion in the origin of the left internal carotid artery (ICA) were noted [Figures 1a and b]. Emergency angiography showed 60%-70% stenosis of the left ICA origin and a 3-4 mm mobile thrombotic shadow attached to the distal part of the stenosis lesion [Figure 1c]. Then, a 0.021-inch Trevo Trak 21 (Stryker, Kalamazoo, MI, USA) microcatheter was passed through the lesion, and a stent retriever, Tron FX 6 x 50 mm (Microvention), was deployed to cover the thrombus at the distal part of the stenosis [Figure 1d]. When the stent retriever was recovered, a white-toned thrombus was extracted, and the thrombus shadow disappeared on angiography [Figure 1e]. After additional PTA using a Sterling Balloon Dilatation Catheter 4.5 x 30 mm (Boston Scientific Co., Natick, MA, USA), the lesion was confirmed to be well-dilated, and the procedure was completed [Figure 1f]. Although postoperative magnetic resonance imaging (MRI) showed new lesions on diffusion-weighted imaging [Figure 1g], the patient's right-hand paralysis and aphasia symptoms improved significantly. Microscopic evaluation revealed that the retrieved thrombi contained fibrin, red blood cells, inflammatory cells, and cholesteric clefts and were consistent with detached plaques from atherosclerotic lesions [Figures 1h and i].
Schematic illustration of the device and procedure applied in case 1. (a) Lateral view of pretreatment angiography, (b) schema after completion of protection, and (c) schema with the stent retriever deployed.
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F2
A schematic illustration of the device and procedure is presented in Figures 2a-c.
PMC10481818_02
An 81-year-old man with symptomatic right carotid artery stenosis and free-floating thrombus (FFT). (a) Magnetic resonance imaging (MRI) shows diffuse spotty infarctions in the patient's right hemisphere. (b) MRA shows stenosis in right internal carotid artery (ICA). (c) Digital subtraction angiography (DSA) shows severe ICA stenosis with FFT (white arrow). (d) EMBOTRAP III 6.5 x 44 mm (Johnson and Johnson, Miami, FL, USA, black arrows) is deployed to cover the thrombus. (e) A balloon dilatation catheter guided to the lesion along the push wire of the stent retriever is inflated. (f) After stent retriever retrieval, the thrombus image on DSA disappears. (g) Carotid Wallstent (Stryker, Kalamazoo, MI, USA) is deployed. (h) White thrombus retrieved by the stent retriever. (i) Postoperative MRI shows no increase in infarction. (j) DSA shows recurrence of in-stent plaque protrusion after additional stent placement. (k) Balloon dilation with proximal balloon protection and distal filter protection. (l) Final image after placement of the third stent (10 x 30 mm CASPER Rx, Microvention, Tustin, CA, USA).
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F3
MRI showed diffuse infarction in the right cerebral hemisphere and severe stenosis of right ICA origin [Figures 3a and b]. Emergency angiography showed 90% stenosis of the origin of the right ICA with small FFTs attached to the distal part of the stenotic lesion [Figure 3c]. Then, a 0.021-inch Trevo Trak 21 microcatheter (Stryker) was passed through the lesion, and a stent retriever, EMBOTRAP III 6.5 x 45 mm (Cerenovus, Irvine, CA, USA), was deployed to cover the thrombus at the distal part of the stenosis [Figure 3d]. An Rx-Genity Balloon Dilatation Catheter (3.5 x 40 mm; Kaneka medics) was guided to the lesion along the push wire of the stent retriever [Figure 3e]. Angiography confirmed the disappearance of the FFT, and a 10 x 31-mm Carotid Wallstent (Stryker) was placed [Figures 3f and g]. A white-toned thrombus was extracted, postoperative MRI showed no increase in cerebral infarction, and the patient's neurological symptoms improved [Figures 3h and i]. After 2 weeks, in-stent plaque protrusion was observed again; therefore, disruption of the thrombus by balloon and additional stent placement (10 x 30 mm CASPER Rx, Microvention) was performed [Figures 3j-l].
Schematic illustration of the device and procedure applied in case 2. (a) Lateral view of pretreatment angiography. (b) Schema after completion of protection. (c) Schema with the stent retriever deployed and the dilatation balloon expanded along the push wire.
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F4
A schematic illustration of the device and procedure is presented in Figures 4a-c.