Initial Clinical Experience of Repeat Thrombectomy with a Retrieval Stent (RTRS) with Continuous Proximal Flow Arrest by Balloon Guide Catheter for Acute Intracranial Carotid Occlusion

Figure 2

An elderly presented with left hemiparesis and a history of atrial fibrillation postcardiac valve replacement. The patient regularly took warfarin, and admission NIHSS was 18. (a) Computed tomography angiography (CTA) shows total occlusion of the right ICA occlusion and the anterior communicating artery open; the right anterior cerebral artery is supplied by the left ICA. (b) A Solitaire 6-30 mm stent was unsheathed at the occlusion site (shown as a black arrow). DSA showed ICA intracranial segment occlusion with a large clot burden, and the CBS was 3. (c) After at least 3 minutes, the balloon (shown as a black arrow) was inflated to arrest the anterograde flow from the ICA. Then, the fully deployed Solitaire stent was partially resheathed, and together with the delivery microcatheter, it was gently pulled back under continuous suction achieved with a syringe. This procedure is called primary clot retrieval. (d) The BGC remained inflated for there is no blood out of BGC, and continuous suction was applied via a syringe; the microcatheter and stent are advanced together directly into the site, which is close to the distal tip of the BGC. (e) The stent is unsheathed at the site close to the distal tip of the BGC, and then the stent together with the delivery microcatheter is retrieved back under continuous suction. This procedure is called rescue clot retrieval. (f) Rescue clot retrieval is repeated until there is blood flow without a thrombus through the BGC; contrast is gently injected via the BGC to confirm that successful reperfusion is achieved. The balloon is deflated, and DSA shows that the right ICA is totally patent and the anterior communicating artery is open; the bilateral MCA and ACA are supplied by the right ICA. NIHSS: NIH stroke scale; CTA: CT angiography; DSA: digital subtraction angiography; ICA: internal carotid artery; BGC: balloon guide catheter; CBS: clot burden score; MCA: middle cerebral artery; ACA: anterior cerebral artery.

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