Tandem Extra- and Intracranial ICA “T” Occlusions Treated by Means of Double Stentriever (T Stent Array) Thrombectomy, and Cervical Stent-Assisted Balloon Angioplasty

The double stentriever technique, which employs two stentrievers simultaneously at the occlusion site, can be beneficial for sizeable neurovascular bifurcation occlusions. The two stents are deployed in different vessels, and each is used to integrate a clot extension within its structure. The theoretical rationale for the double devices is greater effectiveness for recanalization with fewer passes, and reduced risk of dislodging a clot in the unprotected vessel when retrieving with a single device. Due to the encouraging results of this technique, it has become our first-line strategy for terminal internal carotid artery (ICA-T) occlusions. The case presented here exemplifies its use. We present the case of a 74-year-old man with a history of dyslipidemia, diabetes, gout, ischemic heart disease, and known carotid artery atherosclerosis that had been managed conservatively. He developed dysphasia and right-side weakness and was brought by his family to the emergency room 100 min after stroke onset. Upon evaluation, he presented signs and symptoms of a major left hemispheric stroke. His initial National Institutes of Health Stroke Scale (NIHSS) score was 14. Admission non-contrast cranial CT showed hypodensity of the caudate nucleus, lenticular nucleus, internal capsule, and insular cortex, leading to the patient’s admission. His Alberta Stroke Program Early CT Score (ASPECTS) was 6 points. CT angiography (CTA) revealed tandem occlusions of the proximal and distal left ICA (ICA-T occlusion pattern). On CT perfusion (CTP) images, there was a 5-ml region of a total cerebral blood flow reduction to <30% of expected levels located predominantly in a deep zone. The region with a time-to-maximum prolongation >6 s had a volume of 76 ml. The patient received intravenous recombinant tissue plasminogen activator (rtPA) with no significant clinical effects. He was then transferred to the neuroangiography suite for urgent endovascular revascularization of the left ICA tandem occlusions. The procedure consisted of balloon angioplasty of the proximal left ICA atherothrombotic occlusion, double stentriever-assisted embolectomy of the ICA-T occlusions, and carotid artery stenting. The procedure allowed revascularization of the left ICA with filling of all proximal and distal branches (mTICI 3) and complete reperfusion of the region. The patient exhibited pronounced neurological improvement immediately after extubation, with a post-procedure NIHSS of 8. Post-procedural non-contrast CT revealed caudate and lenticular infarctions, but the hemispheric cortical structure was preserved. Dual antiplatelet therapy was maintained for 3 months. After intensive rehabilitation, the patient’s neurological recovery remained incomplete, with residual motor dysphasia and moderate right arm paresis, leaving him with a 90-day modified Rankin Scale (mRS) score of 2. Double stentriever thrombectomy is the main topic of this chapter.