Rescue of immediate post-transcarotid artery revascularization carotid stent thrombosis due to clopidogrel resistance using flow-reversal and aspiration thrombectomy

Figures

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  Fig 1. Initial transcarotid artery revascularization (TCAR). A, Preintervention angiogram. B, Completion angiogram. Note the “wire bias” causing vessel “accordioning.” C, Orthogonal view of carotid artery stent.

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  Fig 2. Immediate postoperative computed tomography angiogram of the head and neck demonstrating right internal carotid artery (ICA) stent occlusion after initial transcarotid artery revascularization (TCAR). A, Sagittal image selected to demonstrate lack of contrast opacity within the distal stent compared with the common carotid artery (note: not center-lined). B, Axial image demonstrating the occluded portion of the stent with the most apparent narrowing; however, it was not significantly narrow (<50%) compared with the distal aspect of the stent within the ICA.

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  Fig 3. Rescue procedure. A, Initial angiogram demonstrating carotid artery stent occlusion and reconstitution of the distal cavernous internal carotid artery (ICA). B, Angiogram after initial aspiration thrombectomy passes. C, Subsequent progression angiogram after additional thrombectomy passes. D, Angiogram after targeted aspiration thrombectomy (at yellow asterisks, seen in panels BandC) and nitroglycerin injection. Note the residual thrombus within the carotid artery stent. E, Predilation balloon angioplasty of carotid stent. F and G, Completion angiograms, orthogonal views. Yellow asterisks indicate thrombus within distal ICA; red arrows, areas of vasospasm.

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  Fig 4. Rescue procedure specimens. A, Aspirated platelet aggregates. B, Aspirated thrombus. C, ENROUTE filter contents with platelet aggregates.