OPERATOR: Nasser Razack, MD, JD

INDICATION: None

COMPARISON: None

CONTRAST: None

RADIATION EXPOSURE-DAP: (µGy•m²)

EQUIPMENT: 9 Fr sheath, 8 French BMX 96/Zoom 88 (guide catheter), 6 French Sophia (intermediate/aspiration catheter), marksman 160 CM (microcatheter), Synchro2 soft 014/Aristotle 018 (microwire), 6 mm x 40 mm/ 4mm x 40 mm/ 3 mm x 40 mm Solitaire (mechanical thrombectomy device), 8Fr/6 Fr Angioseal (vascular closure device), 5 Fr vertebral/JB2 (diagnostic catheter), 035 Bentson guidewire, 035 Terumo guidewire, micropuncture set.

CONSCIOUS SEDATION: Pre-procedure evaluation confirmed that the patient was an appropriate candidate for conscious sedation. Adequate sedation was maintained during the entire procedure. Vital signs, pulse oximetry, and response to verbal commands were monitored and recorded by the nurse throughout the procedure and the recovery period. The flow sheet was placed in the medical record including the medications and dosages used. No immediate sedation related complications were noted.

MANAGED ANESTHESIA CARE: Pre-procedure evaluation confirmed that the patient was an appropriate candidate for MAC sedation. Adequate sedation was maintained during the entire procedure by the anesthesia team. Vital signs and pulse oximetry were monitored and recorded by the anesthetist throughout the procedure and the recovery period. The flow sheet was placed in the medical record including the medications and dosages used. No immediate sedation related complications were noted.

GENERAL ANESTHESIA: Pre-procedure evaluation confirmed that the patient was an appropriate candidate for general anesthesia. Adequate anesthesia was maintained during the entire procedure by the anesthesia team. Vital signs and pulse oximetry were monitored and recorded by the anesthetist throughout the procedure and the recovery period. The flow sheet was placed in the medical record including the medications and dosages used. No immediate sedation related complications were noted.

CONSENT: The risks, benefits, and alternatives of the procedure were explained to the patient/patient's family and informed consent was obtained. Given the patient's condition, the patient was not able to sign their own consent. For this reason, this procedure was done emergently without consent. Risks include but are not limited to infection, bleeding, hematoma, retroperitoneal hemorrhage, vascular injury, intracranial hemorrhage, stroke, severe stroke, contrast reaction including allergic reaction and contrast induced encephalopathy, reperfusion hemorrhage and death.

TIMEOUT: Prior to the start of the procedure, a time-out was performed in the presence of the Neurointerventionalist, the Nurse, and the Technologist. This identified the correct patient, site, and procedure to be performed.

PROCEDURE: The patient was placed supine on the angiographic table, and the right groin was prepped and draped in the usual sterile manner. The skin and subcutaneous tissues were anesthetized with 5 mL of lidocaine. Using a 5F micropuncture set the common femoral artery was punctured and cannulated and a 9 French arterial sheath was placed over a guidewire. The sheath was attached to continuous heparinized saline flush. A diagnostic catheter was placed through the guide catheter and advanced over a Bentson guidewire into the aortic arch.

Selective catheterization of the following blood vessels was performed (see below). At the end of the procedure, hemostasis was achieved. After observing that there was no significant hematoma, the skin was cleaned and dried, and protected with a dressing.

DIAGNOSTIC ARTERIOGRAPHY AND SUPERVISION AND INTERPRETATION OF DIAGNOSTIC ARTERIOGRAMS:

LEFT INTERNAL CAROTID ARTERY: The guide and diagnostic catheter was advanced into the left internal carotid artery and DSA was performed in the AP and lateral projections with filming over the intracranial circulation. Normal antegrade flow of contrast identified in the visualized segments of the left internal carotid artery. There is complete occlusion of the left MCA M1 segment without any antegrade filling distal to the obstruction. There is angiographic evidence of leptomeningeal collateralization from the ACA to the MCA territory.

SUPERSELECTIVE ARTERIOGRAPHY, THROMBECTOMY, AND CONTROL ANGIOGRAMS; SUPERVISION AND INTERPRETATION OF SUPERSELECTIVE ARTERIOGRAPHY, THROMBECTOMY, AND CONTROL ANGIOGRAMS:

MECHANICAL THROMBECTOMY: The guide catheter was advanced over a diagnostic catheter and placed into the proximal left internal carotid artery over a wire and under continuous roadmap guidance. Next, the intermediate/aspiration catheter was advanced into the distal cervical segment of the left internal carotid artery through the guide catheter in a coaxial fashion. Next, in a coaxial fashion, the microcatheter and microwire were advanced into the left MCA and advanced through the thrombus under continuous roadmap guidance. Contrast injection through this microcatheter confirmed intraluminal placement beyond the obstructive clot. Then, the mechanical thrombectomy device was advanced through the microcatheter and deployed in standard fashion within the left MCA, spanning the obstructive thrombus. A control angiogram was then performed.

LEFT ICA, STENT-TRIEVER DEPLOYED: A control angiogram was performed in the AP and lateral working projections with filming over the intracranial circulation after the mechanical thrombectomy device had been deployed within the MCA branch. This demonstrated a reperfusion channel containing clot. No obvious arterial injury or complicating feature.

The device was then removed from the MCA in standard fashion and pulled into the guiding catheter while continuous aspiration was performed at the hub of the guiding catheter. Following removal of the device, a second control angiogram was performed. Visual inspection of the removed thrombectomy system identified large clot debris on the thrombectomy device.

LEFT ICA POST MECHANICAL THROMBECTOMY: A control angiogram was performed from the guiding catheter the left ICA with filming over the intracranial circulation in the AP and lateral working projections. This demonstrates marked improvement in antegrade flow through the target left MCA branch and distal territory with removal of the previous thrombotic occlusion and a TICI score of x. No evidence of contrast extravasation, dissection, or other obvious complication.

CONCLUSION:

1. Recanalization of the left MCA

2. Mechanical thrombectomy of the above occlusion with a single pass of mechanical thrombectomy device with successful removal of the thrombus to TICI-3 grade reperfusion.