Mechanical Thrombectomy with Difficult Access Due to Tortuous Carotid Artery Anatomy: The Use of Walrus, a More Navigable, Large-Bore Balloon Guiding Catheter (Dual Wire Navigation, Microguidewire Looping Technique, and Stentriever Thrombectomy)

Thrombectomy has become established as a successful treatment strategy for ischemic stroke, and an increasing number of patients are undergoing this procedure. Due to comorbidities and advanced age, many patients have anatomy that complicates revascularization, particularly difficult aortic arch anatomy or supra-aortic trunks or both. Any combination of the above anatomic parameters is associated with decreased treatment success. Balloon guide catheters (BCGs) have been widely adopted in the endovascular treatment of acute stroke based on evidence they are associated with optimized procedural metrics and outcomes. Initial technical constraints associated with previous devices resulted in limitations due to difficulty in device navigation and incompatibility of BGCs with large-bore aspiration catheters. The recently introduced Walrus BGC has overcome these limitations; it’s navigability is greatly improved, and it is compatible with most leading large-bore aspiration catheters. A 79-year-old woman presented to the Emergency Department with a history of arterial hypertension, hyperlipidemia, and ischemic heart disease (three percutaneous transluminal coronary angioplasty [PTCA] procedures and one coronary artery bypass graft [CABG]), peripheral vascular disease (right iliac artery stenting), a left hemispheric ischemic stroke that had caused right hemiparesis 2 years earlier, a gastrointestinal malignancy in remission after chemotherapy, and atrial fibrillation treated with apixaban. She had stopped anticoagulation for 3 days for a planned colonoscopy and had forgotten to resume the medication as recommended. She was found lying on the floor at home by a paramedic who reported that she had complete aphasia and right hemiplegia. She was admitted with a large left hemispheric ischemic stroke (baseline National Institutes of Health Stroke Scale (NIHSS) score of 22). She was last seen well 8 h before presenting. Admission head CT showed advanced microvascular brain disease and left cortico-subcortical parietal and caudate-lenticular infarcts. The Alberta Stroke Program Early CT Score (ASPECTS) on noncontrast head CT was 7. CT perfusion (CTP) imaging revealed a left hemispheric perfusion deficit consistent with the patient’s neurological examination findings (left gaze deviation, global aphasia, and right hemiparesis). The volume of the area with cerebral blood flow (CBF) <30% of predicted was 82 ml, and the volume of the area with time to peak concentration (Tmax) >6 s was 235 ml, for a mismatch ratio of 2.9. The core was located primarily in the left parietal and watershed regions. The penumbra extended through middle cerebral artery (MCA) terrritory. CT angiography (CTA) showed a left MCA/M1 segment occlusion. The patient did not receive intravenous thrombolysis and was transferred from the Emergency Department to the neuroangiography suite for endovascular intervention. An 8F introducer sheath was placed in the right femoral artery under general anesthesia. Angiograms of the right and left common carotid artery (CCA) and internal carotid artery (ICA) showed significant tortuosity that complicated diagnostic catheterization and advancement of the BGC. After attempting unsuccessfully to advance an 8F Cello BGC, we used an 8F Walrus BGC that was advanced through the CCA using a standard technique and through the ICA using a double guidewire technique. With the BGC in place, successful endovascular revascularization of the left MCA was achieved in a single pass using the NeVa 5.5/37 mm stentriever (Vesalio). After a post-procedural head CT ruled out hemorrhagic complications, anticoagulant therapy was resumed on day 3 after thrombectomy. She had a good clinical course, with improvement of her NIHSS score to 9 at 7 days and a modified Rankin Scale (mRS) score of 3 at discharge. Because difficult access anatomy is common in patients undergoing emergency thrombectomy, it is important for the treating physician to be prepared and to adapt access strategies to increase the likelihood of successful revascularization. In this chapter, we focus on the implications of tortuous CCA and ICA, which until recently were considered limiting factors for BGC advancement, the use of a novel BGC with improved navigation capabilities and a larger inner lumen, and our growing technical options to overcome tortuosity.