Arterial dissection following the use of remote aspiration thrombectomy

Abstract

Remote aspiration thrombectomy using a balloon guide catheter for acute carotid artery occlusion has been proposed as a safe and effective technique. We present a case of iatrogenic arterial dissection of the distal cervical segment in a patient with proximal vessel occlusion who underwent attempted revascularization using this strategy. A 57-year-old male patient presented with computed tomography (CT) angiogram evidence of a left carotid terminus and M1 segment occlusion. The patient was taken emergently for mechanical thrombectomy. Remote aspiration thrombectomy was attempted twice using manual aspiration through a balloon guide catheter in the common carotid artery; however, this resulted in minimal recanalization of the carotid terminus and a new iatrogenic dissection within the internal carotid artery (ICA) just proximal to the skull base. Despite multiple additional attempts at mechanical thrombectomy, only limited recanalization of the ICA terminus and anterior cerebral artery distribution was achieved, with no significant flow past the M1 segment. After the procedure, a large ischemic territory within the left middle cerebral artery distribution consistent with the continued M1 segment occlusion was apparent on CT. The patient died on the poststroke day 6. Although remote aspiration thrombectomy for thromboemboli in this location has potential benefits, it should be used cautiously given the potential risk of injury to the proximal vasculature.