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Double stenting technique thrombectomy and PTA treatment for intracranial stenosis

Last update on September 10, 2024

Patient situation

  • A 65 year old man
  • Acute stroke symptoms
  • Smoker and drinker
  • Dislypemia
  • No medical treatments
  • NIHSS 20

 

Procedure technique set up for the mechanical thrombectomy

  • 9F short femoral sheath
  • Balloon guiding catheter
  • 2 Solitaire™ X stent retrievers distal to the occlusion in parallel Y configuration, with Phenom 21 microcatheters
  • Manual aspiration through the BGC with a 60 mL syringe

 

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 1

 

Procedure technique set up for the stenosis treatment

  • Two percutaneous transluminal angioplasty were performed, first with a small balloon (Elutax 2.5x10) and then with a greater one (Elutax 4x10)
  • 1g of AAS and the bolus of Tifofiban were intravenously administered
  • A stent (Credo 5x20) was deployed to stabilize the plaque

 

Non contrast CT

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 3

ASPECTS 9

 

CT Perfusion

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 4

 

Cervical CTA

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 5
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 6
  • Calcified plaques in both carotid bifurcations
  • Chronic carotid occlusion on the right side
  • Acute carotid occlusion on the left side

Intracranial CTA

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 7
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 8

 
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 9

No intracranial occlusions

DSA

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 10
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 11
  • Acute occlusion of the extracranial left carotid artery but not in the origin
  • Occlusion in the carotid cavernous segment suspected

Double ST technique

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 12

Phenom 21 in M2

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 13

Phenom 21 in A2

Solitaire™ 6x40 deployment in M2

Solitaire™ 6x40 deployment in A2

 

 

  • Physician maneuvers extracting both Solitaires™ simultaneously
  • Manual aspiration through the BGC with a 60 mL syringe 

 

  • Video of the fluoroscopy showing the extraction of the 2 ST
  • BGC balloon inflated

 
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 14
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 15
  • Recanalization of the carotid artery without distal embolisms after 1 pass
  • Underlying severe stenosis in the cavernous segment

Intracranial PTA

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 16
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 17

 

  • Two percutaneous transluminal angioplasty were performed, first with a small balloon (Elutax 2.5x10) and then with a greater one (Elutax 4x10)
  • 1g of AAS and the bolus of Tifofiban were intravenously administered
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 18
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 19
  • DSA control after PTA 1

 

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 20
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 21
  • DSA control after PTA 2
  • The result was quite good but with some irregularities and clots inside the plaque

Intracranial stent

 

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 22

A stent (Credo 5x20) was deployed to stabilize the plaque

 

 

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 23
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 24
  • AP and lateral DSA showing a good result

 

 

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 25

TICI 2c

DYNA CT

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 26
Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 27
  • No hemorrhagic complications in the DYNA CT after the treatment

 

Results: 24 hours CT scan

Double stenting technique thrombectomy and PTA treatment for intracranial stenosis - Figure 2

 

  • No ischemic lesions
  • NIHSS 2 at 24 hours
  • Asymptomatic at discharged

 

Supported by Medtronic

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