Rheolytic thrombectomy of the occluded internal carotid artery in the setting of acute ischemic stroke

BACKGROUND AND PURPOSE: Acute thromboembolic stroke complicated by ipsilate ral carotid occlusion may present both mechanical and inflow-related barrie rs to effective intracranial thrombolysis. We sought to review our experien ce with a novel method of mechanical thrombectomy, in such cases, using the Possis AngioJet system, a rheolytic thrombectomy device. METHODS: A review of our interventional neuroradiology database revealed th ree patients in whom an occluded cervical internal carotid artery was encou ntered during endovascular treatment for acute stroke and in whom thrombect omy was attempted, using the 5F Possis AngioJet thrombectomy catheter. The medical records and radiographic studies of these patients were reviewed. RESULTS: Three patients were identified (ages, 52-84 years). Two patients h ad isolated occlusion of the internal carotid artery; in one patient, throm bus extended down into the common carotid artery. Treatment was initiated w ithin 190 to 360 minutes of stroke onset. Thrombectomy of the carotid arter y was deemed necessary because of poor collateral flow to the affected hemi sphere (chronic contralateral internal carotid artery occlusion [one patien t] and thrombus extending to the carotid "T" [one patient]) or inability to pass a microcatheter through the occluded vessel (one patient). Adjunctive therapy included pharmacologic thrombolysis with tissue plasminogen activa tor (all patients), carotid angioplasty and stenting (two patients), and mi ddle cerebral artery angioplasty (one patient). Patency of the carotid arte ry was reestablished in two patients, with some residual thrombus burden. I n the third patient, the device was able to create a channel through the co lumn of thrombus, allowing intracranial access. CONCLUSION: Rheolytic thrombectomy shows potential for rapid, large-burden thrombus removal in cases of internal carotid artery thrombosis, allowing e xpedient access to the intracranial circulation for additional thrombolytic therapy.