Major Stroke in a Patient with Abdominal Aortic Tortuosity, Type III Aortic Arch, and Supra-Aortic Redundancy: A Limitation of Current Catheters

In 20% of cases where mechanical thrombectomy fails, the thrombus cannot be reached or passed, resulting in a “technical-mechanical” failure. The most common reasons for not reaching the thrombus are access limitations and arterial elongation. Access may be limited for several reasons, including peripheral vascular disease. Arterial elongation may be due to compromised femoro-iliac, aortic, or supra-aortic vesselsSupra-aortic vessels. Not infrequently, elongation or redundancy affects all arterial segments of the arterial tree to varying degrees, negatively impacting our ability to reach the occlusion site. Available options include radial access or direct carotid puncture, and even surgical arterial access can be considered. We present the case of an 83-year-old woman with a past medical history of arterial hypertension, dyslipidemia, gout, multiple coronary interventions, and breast and uterine malignancies that had required surgical interventions. These conditions were all under medical control. Over the past 3 years, she had begun to show signs of cognitive decline and had been diagnosed with early signs of dementia; however, prior to the current admission, she had led an active and completely independent life. The patient was admitted to the hospital after being found unresponsive at home with signs and symptoms of a large right hemisphere stroke (National Institutes of Health Stroke Scale [NIHSS] score of 17). She had last been seen well 11 h before she was found. Noncontrast head CT showed basal ganglia hypodensity corresponding to an automated ASPECTS score of 7. CT perfusion (CTP) confirmed a large area of right hemispheric hypoperfusion. CT angiography (CTA) revealed a “T” occlusion of the distal right internal carotid artery (ICA). Previous coronary interventions via a radial approach had resulted in occlusion of both radial arteries. Due to previous cardiac and oncologic conditions and interventions, we had access to previous abdominal and thoracic studies that revealed iliac, aortic, and supra-aortic tortuosity, making an endovascular procedure particularly challenging in terms of access to the clot. The 95 cm balloon-guiding catheter remained short at the right common carotid artery (CCA), and the 132 cm aspiration catheter reached only the proximal siphon of the internal carotid artery. The aspiration catheter was then used as an intermediate catheter for an 0.021″, 167 cm microcatheter to effectively reach the clot. This long catheter construct, although not ideal, allowed us to achieve successful endovascular revascularization of the right ICA and all its branches. Effective thrombectomy required multiple passes with different stent retrievers. The patient was discharged to a rehabilitation facility after 9 days with an NIHSS score of 8 and a modified Rankin Scale (mRS) score of 3. The use of long catheter systems to overcome tortuosity is the main topic of this chapter.