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(A) Preoperative right common carotid angiogram (lateral view) showed a free-floating thrombus located across the carotid bifurcation, antegrade flow in the right internal carotid artery (ICA) and right external carotid artery (ECA) occlusion. (B) Postoperative right common carotid angiogram (lateral view) showed complete patency of the right ICA and the ECA.
Source publication
Free-floating thrombus (FFT) in the carotid artery has been reported as a rare cause of acute ischaemic stroke. There are various treatment strategies, but higher risk of distal embolism may limit their applicability. A 77-year-old woman noticed right upper arm weakness. A CT angiogram revealed that a large floating thrombus had strayed across the...
Contexts in source publication
Context 1
... angiography of the right CCA showed partial contrast defect in the carotid bifurcation and complete occlusion of the external carotid artery (ECA) ( figure 2A). Through the GW, a 5MAX ACE068 Reperfusion Catheter (ACE) (Penumbra, Alameda, California, USA) was inserted into the lumen of the BGC and was guided to the proximal right carotid bifurcation. ...
Citations
... 5,18 Recent technological improvements in aspiration catheters and stentrievers has made mechanical thrombectomy of cerebral vessels increasingly safe [6][7][8][9][10][11][12][13][14][15][16][17] and effective. 19,20 Among these developments are large-bore aspiration catheters (0.088" ID) 21,22 that are built both with and without compliant balloons for flow arrest and aspiration/flow reversal. Stentriever technology has evolved to include devices that can be opened and closed to control tension and expansion at the clot interface. ...
... [6][7][8][9][10][11][12][13][14][15][16][17] Recently, direct aspiration, with or without the utilization of proximal and distal protection devices have been described. 11,20,27 To harness all the benefits of previously reported techniques we employed a triple stentriever "bouquet" technique for the mechanical thrombectomy of a CFFT. This stentriever technique was combined with flow reversal aspiration with an 088-balloon-guide and direct thromboaspiration with a Zoom 88 thrombectomy catheter. ...
Formation of a carotid free-floating thrombus (CFFT) is a rare and life-threatening condition without an optimal management plan. A 78-year-old woman with a history of prior right internal carotid artery (ICA) mechanical thrombectomy and antiplatelet noncompliance presented with transient ischemic attacks secondary to a recurrent CFFT in the right ICA. Given her symptoms and recurrent CFFT, endovascular mechanical thrombectomy was performed. A balloon guide-catheter (BGC) and a Zoom 88 distal access catheter were brought into the right distal common carotid artery and proximal ICA bulb, respectively. Three 0.021-inch microcatheters, each loaded with a unique stentriever, were navigated beyond the thrombus into the upper cervical ICA and deployed in a bouquet fashion. The BGC was inflated to achieve flow arrest, and the Zoom 88 aspiration catheter was tracked over the three bouquet stentrievers to ingest the thrombus. Follow-up angiography demonstrated recanalization of the proximal cervical ICA without evidence of residual thrombus. Twenty-four-hour postoperative computed tomography imaging did not reveal any evidence of new infarction. The patient was discharged home with an intact neurological examination, compliant on aspirin and apixaban. We demonstrate a novel technique utilizing a large-bore catheter with a triple stentriever “bouquet” to thrombectomize a CFFT.
... Recently, in addition to conventional treatments, endovascular thrombectomy for carotid FFT has been reported [2,4,5,[7][8][9][10][11][12][13][14]. However, when balloon protection is used for distal protection, complete interruption of the ICA flow is undesirable in patients without hemodynamic intolerance. ...
Carotid free-floating thrombus (FFT) is a rare condition in patients with acute ischemic stroke. Recently, endovascular therapy for carotid FFT has been increasingly reported, but the strategy has not yet been established. We report a case of an acute stroke patient with a carotid FFT, who was successfully treated with a combination of the direct aspiration first-pass technique (ADAPT) and the Embotrap III (Cerenovus, Irvine, CA), specifically designed to prevent distal embolization. We propose the utility of distal embolic protection with Embotrap III for the treatment of patients with carotid FFT. A 71-year-old man who presented with sudden left hemiparesis was admitted to our hospital. Ultrasonography on admission revealed severe stenosis and an FFT at the origin of the right internal carotid artery. Thrombectomy with an aspiration catheter, accompanied by a stent retriever with distal basket Embotrap III for distal protection, was performed. After the FFT was safely aspirated, a carotid Wallstent (Boston Scientific, Marlborough, MA) was deployed in the stenosis. Follow-up ultrasonography showed neither FFT nor in-stent protrusion. The patient did not experience recurrence, as per clinical or radiological findings, and was discharged on day 11 without any neurological deficits. Embotrap III may be useful for a patient with a carotid FFT as distal protection during mechanical thrombectomies.
... 10 Similarly, direct aspiration thrombectomy with or without distal protection has been shown to be effective and safe in several ILT case reports. [11][12][13] Alternatively, in a small series of six patients, thromboendarterectomy has also been shown to be an effective management option. 14 Given that these studies are small case reports/series, further research is required regarding optimal interventional strategies when intervention might be indicated. ...
Background
Carotid artery intraluminal thrombus (ILT), or free-floating thrombus, is an uncommon cerebrovascular entity with considerable equipoise regarding its clinical management. Likewise, in patients treated with medical management (MM), distal embolization and/or intracranial hemorrhage (ICH) may still occur.
Methods
All patients with symptomatic ILT from 2016 to 2023 were identified from our tertiary care institution. Patients with MM failure (recurrent cerebral ischemia and/or symptomatic ICH) were compared with patients with MM non-failure. Differences in ILT volume and length were calculated. Receiver operator characteristic (ROC) curve analysis was used to identify the cut-off volume and length for risk of MM failure.
Results
In total, 45 patients with ILT were identified with 41 treated with frontline MM. Of these 41 patients treated with MM, seven (17%) had MM failure with six (14.6%) having new embolic stroke and one (2.3%) with symptomatic ICH. Patients with MM failure had a significantly higher mean thrombus volume than MM non-failure patients (257 mm ³ vs 59.6 mm ³ , P=0.0006). Likewise, patients with MM failure had significantly longer thrombus on average (21 mm vs 6.6 mm, P=0.0009). ROC curve analysis showed that an ILT volume of 90 mm ³ resulted in a sensitivity of 71.4% and specificity of 85.3% for MM failure (AUC 0.775; CI 0.55 to 1.0, P=0.023).
Conclusions
Carotid ILTs that fail MM are significantly larger and longer. These findings suggest that a thrombus volume of 90 mm ³ may serve as a guide for intervention with good sensitivity and specificity for risk of MM failure.
... Successful thrombus retrieval using a stent retriever or aspiration catheter has been reported in cases involving FFT without moderate or severe stenotic lesions. [3,4,8,12] However, few reports have described a combination of mechanical thrombectomy and CAS in cases of carotid artery stenosis with FFT. Tomoyose et al. reported a case of FFT attached to severe stenosis of the ICA origin, in which the thrombus was removed by an aspiration catheter after PTA against the stenotic lesion. ...
Background
We report two cases who underwent mechanical thrombectomy using a stent retriever in advance of urgent carotid artery stenting (CAS) for carotid artery stenosis with free-floating thrombus (FFT).
Case Description
Two patients showing symptomatic carotid artery stenosis with FFT underwent urgent endovascular surgery due to progressive neurological symptoms. The first case showed an FFT with 70% internal carotid artery (ICA) stenosis. After the completion of the common and external carotid artery balloon and distal ICA filter protection, we deployed a 6-mm-diameter stent retriever in the distal part of the stenosis. The white thrombus was retrieved; the angiographic shadow of the FFT disappeared; and CAS was performed. In the second case, due to a 90% severe stenosis lesion with FFT, balloon angioplasty was performed on the lesion using the push wire of the stent retriever. After angioplasty, the stent retriever was smoothly retrieved, and CAS was performed. Postoperative magnetic resonance imaging showed an increase in cerebral embolism in the first case; however, the patient’s neurological symptoms improved. The second case showed in-stent plaque protrusion and required two additional stent placements; the patient showed no worsening of his neurological symptoms.
Conclusion
In cases of carotid artery stenosis with FFT, it is technically possible to retrieve a thrombus with a stent retriever. Although thrombus removal may help reduce the risk of ischemic complications in a series of urgent CAS procedures, there are concerns such as mechanical irritation to the carotid artery plaque, and its indications and alternative treatments should be carefully considered.
... Recently, with the development of endovascular treatment of acute ischemic stroke with intracranial large artery occlusion and the introduction of minimally invasive and non-implantation concepts, more centers begin to try mechanical thrombectomy to treat CFFT (11). However, procedures of direct aspiration are extremely rare (12); there are limited reports regarding an ultrasound-guided approach to resolving CFFT. Otawa et al. (13) and Giragani et al. (14) have reported that ultrasonography helped localize CFFT during endovascular therapy. ...
Background
Carotid free-floating thrombus (CFFT) is a rare but sometimes emergent condition. There has been controversy over the optimal treatment strategy. Emerging evidence suggests that endovascular thrombectomy (EVT) may be an alternative to surgery. Accurate alignment of the aspiration catheter and thrombus during EVT is critical but has, so far, remained unresolved.Case summaryThis is a rare case of CFFT presenting with acute right-sided facial droop and moderate dysarthria in a 77-year-old man. He was in sinus rhythm with a blood pressure of 110/82 mmHg. Both non-contrast CT (NCCT) and head CT angiography (CTA) were unremarkable, while whole-brain CT perfusion (WB-CTP) suggested left hemisphere core infarction. Delayed imaging of the left internal carotid system by 4D-CTA suggested severe proximal obstructive disease, as confirmed by carotid CTA and ultrasonography. The initial two aspirations under DSA were invalid due to the challenging anatomical angle between the thrombus and the catheter. The success of CFFT removal was achieved with a pressure-assisted ultrasound-guided approach that helps to compress the catheter tip toward the thrombus.Conclusion
We innovatively report a successful ultrasound-guided EVT for CFFT. Ultrasound assistance can provide quick and effective guidance and may guide tailored aspirations during EVT.
... The treatment strategy for carotid free-floating thrombus (CFFT) has yet to be established. Although the efficacy of carotid artery stenting (CAS), mechanical thrombectomy (MT), or carotid endarterectomy (CEA) has been reported in small cases [1][2][3], those with acute ischemic stroke with a tandem lesion due to CFFT treated with neuro intervention remain unelucidated. Therefore, we report a case of acute ischemic stroke having a tandem lesion with CFFT treated successfully by a novel technique-direct advancement of a balloon-guide catheter (BGC) distal to the CFFT. ...
... The clinical nature and management of stroke associated with CFFT have yet to be established yet. There are previous reports of CFFT treatment with CEA [1] or endovascular treatment (stenting or thrombectomy) [2,3]; however, there have been very few reports on hyperacute tandem lesions in association with CFFT. To our knowledge, our study is the first to report tandem lesions with CFFT, treated by our novel method: direct advancement of a BGC distal to the CFFT. ...
A 68-year-old man with bladder cancer developed sudden dysarthria and left hemiplegia. MRI revealed occlusion of the right middle cerebral artery (MCA). Cerebral angiography revealed a large carotid free-floating thrombus (CFFT) at the origin of the right internal carotid artery (ICA) and right M1 occlusion. A balloon-guide catheter (BGC) was directly guided distal to the CFFT. Mechanical thrombectomy (MT) was performed on the M1 occlusion while the balloon was inflated to block antegrade blood flow, and good recanalization was achieved. To continue processing the CFFT, the deflated BGC was pulled to the common carotid artery, and the thrombus dispersed into the external carotid artery (ECA). Subsequently, the patient's symptoms improved. Directly advancing a BGC distally to a CFFT may be a useful treatment strategy for tandem lesions with carotid free-floating thrombi.
... In the absence of carotid stenosis with FFT, use of a stent retriever (SR) or a direct aspiration pass technique (ADAPT) with or without protection has been reported. 4,[11][12][13] In the case of stenosis, CAS alone or CAS and MT were performed using a protective device to prevent FFT migration, and many cases were treated without causing migration. The reports are summarized in Table 1. ...
BACKGROUND
The authors report a case in which mechanical thrombectomy and carotid artery stenting (CAS) were performed for acute cerebral infarction with free-floating thrombosis (FFT) in left internal carotid artery (ICA) stenosis. Good results were obtained.
OBSERVATIONS
A 63-year-old man developed sudden disturbance of consciousness and right hemiplegia. He was transported to the authors’ hospital by an emergency vehicle. Head magnetic resonance imaging showed acute cerebral infarction in the left middle cerebral artery region, and magnetic resonance angiography showed poor vascular flow beyond the left ICA. Emergency angiography revealed severe stenosis at the origin of the left ICA and a free-floating thrombus attached to the stenosis and extending to the peripheral side. Percutaneous transluminal angioplasty (PTA) was performed on the stenosis with proximal protection, the thrombus was aspirated under reversal flow, and CAS was performed without exacerbation of clinical symptoms.
LESSONS
PTA, thrombus aspiration, and CAS under reversal flow may be effective treatments for FFT caused by ICA stenosis.
... Antithrombotic therapy, endovascular aspiration, urgent CEA, and IV tissue plasminogen activator have all been used. 7,8,10,23,24 Of these, antithrombotic therapy appears to be the preferred treatment for FFT with a 75% to 86% resolution rate according to the literature. 8,10,11,13 The optimal choice of medical therapy (anticoagulation, antiplatelet, or combination therapy) appears unclear. ...
Objective
To validate a previously proposed filling defect length threshold of >3.8 mm on CT-angiography (CTA) to discriminate between free-floating thrombus (FFT) and plaque of atheroma.
Methods
Prospective multicenter observational study of 100 participants presenting with TIA/stroke symptoms and a carotid intraluminal filling defect on initial CTA. Follow-up CTA was obtained within one week, and at weeks 2 and 4 if the intraluminal filling defect was unchanged in length. Resolution or decreased length was diagnostic of FFT, whereas its static appearance after 4 weeks was indicative of plaque. Diagnostic accuracy of FFT length was assessed by receiver operating characteristic analysis.
Results
Ninety-five participants (mean age [standard deviation], 68 [13] years; 61 men; 83 participants with FFT; 12 participants with a plaque) were evaluated. The >3.8 mm threshold had a sensitivity of 88% (73/83) (95% confidence interval {CI}: 78%, 94%) and specificity of 83% (10/12) (95% CI, 51%, 97%) (area under the curve [AUC], 0.91, p<.001) for the diagnosis of FFT. The optimal length threshold was >3.64 mm with a sensitivity of 89%( 74/83) (95% CI, 80%, 95%) and specificity of 83% (10/12) (95% CI, 51%, 97%). Adjusted logistic regression showed that every 1 mm increase in intraluminal filling defect length is associated with an increase in odds of FFT of 4.6 ([95% CI] 1.9-11.1; p =.01).
Conclusion
CTA enables accurate differentiation of FFT versus plaque using craniocaudal length thresholds.
Trial Registration Information
Clinical trial identifier: www.clinicaltrials.gov NCT02405845
Classification of Evidence
This study provides Class I evidence that in patients with TIA/stroke symptoms, the presence of CTA-identified filling defects of length >3.8 mm accurately discriminates free-floating thrombus from atheromatous plaque.
... En la actualidad, predominan en la literatura los casos tratados mediante dispositivos de aspiración, en asociación o no con dispositivos de protección distal. 11,13,14 En el tratamiento quirúrgico por endarterectomía, la mayoría de los casos publicados coindicen en su realización de forma diferida una vez estabilizado el trombo o desaparecido el mismo tras un periodo variable de tratamiento médico en el caso de que subyazca una estenosis moderada a severa a nivel carotídeo o una placa ulcerada. 15 En las series más antiguas 1 se recoge una frecuencia de tratamiento quirúrgico más elevado (95 de 145 = 65%) con predilección por la endarterectomía carotídea (85 de 95), siendo realizada en la mayoría de los casos (71 de 85) de forma urgente (primeros 7 días) y en los 14 casos restantes de forma diferida tras tratamiento anticoagulante previo durante al menos una semana. ...
Resumen Un trombo flotante libre (TFL) en arteria carótida es una entidad rara que habitualmente se detecta durante el estudio etiológi-co del evento isquémico agudo. No existe claro consenso en cuanto al manejo más adecuado dada la falta de estudios aleatorizados. Los autores presentan el caso de un varón de 83 años que presenta clínica ictal consistente en paresia de hemicuerpo dere-cho y disartria. Realizado AngioTC de troncos supraaórticos se aprecia trombo impactado con componente flotante sobre placa ateromatosa a nivel de Arteria carótida interna izquierda. En monitorización electrocardiográfica continua se detecta fibrilación auricular paroxística no conocida previamente. Se realiza resonancia magnética craneal con hallazgo de infartos múltiples a nivel de hemisferio izquierdo, sugestivos de etiología embólica. Dados los hallazgos se inicia perfusión de heparina sódica y se realiza seguimiento ecográfico del trombo en arteria carótida interna izquierda. Al alta, se aprecia disminución >50% con respecto al tamaño basal del trombo, con tratamiento anticoagulante oral (rivaroxaban 20mg/día). Control ecográfico a los dos meses con desaparición completa del trombo flotante. La anticoagulación es en la actualidad la primera medida recomendada ante el hallazgo de un trombo flotante carotídeo, asociándose antiagregación simple en algunas series. El tratamiento quirúrgico por endarterectomía tiene un papel terapéutico de forma diferida cuando subyace una placa ulcerada o estenosis significativa. El tratamiento mediante trombectomía quirúr-gica aparece reportado en muy pocos casos en la literatura. Las técnicas endovasculares, han ido progresivamente ocupando un papel importante en el tratamiento de estos pacientes, con frecuencia asociados a la utilización de dispositivos distales de protección para minimizar el riesgo de embolización distal. Palabras clave: Trombo flotante. Fibrilación auricular. Heparina sódica. Arteria Carótida interna. Summary Carotid free-floating thrombus (FFT) is a rare cause of ischemic stroke, usually detected during etiologic vascular studies. There is no consensus regarding the management of carotid free-floating thrombi in those patients. A 83-year-old male presented to the emergency department with right hemiparesis and dysarthria, consistent with finding of multiple left hemispheric brain infarcts on neuroimaging. Contrast CT showed a free-floating thrombus fixed to an atheroma plaque in left internal carotid artery (ICA). Holter monitorization registered a not previously noticed paroxystic atrial fibrilla-tion. Due to findings, sodic heparinization was started and serial ecosonographic monitoring of the thrombus was performed. He was discharged home with a clot reduction >50% with oral anticoagulant therapy (rivaroxaban 20mg daily). At 2 months, ecographic control was realized without residual clot in left ICA. Oral anticoagulation is currently the first therapeutic option that should be considered when a FFT is detected. In some reported case series, simple antiplatelet therapy was associated. Deferred surgical endarterectomy has a limited therapeutic gap in these patients when an ulcerated atheroma plaque or a significant stenosis carotid stenosis are detected. Surgical thrombectomy is reported only in few cases series. Endovascular therapies are steadily growing as an effective option when a FFT is detected, usually associated with distal protection devices to avoid distal embolization.
... En la actualidad, predominan en la literatura los casos tratados mediante dispositivos de aspiración, en asociación o no con dispositivos de protección distal. 11,13,14 En el tratamiento quirúrgico por endarterectomía, la mayoría de los casos publicados coindicen en su realización de forma diferida una vez estabilizado el trombo o desaparecido el mismo tras un periodo variable de tratamiento médico en el caso de que subyazca una estenosis moderada a severa a nivel carotídeo o una placa ulcerada. 15 En las series más antiguas 1 se recoge una frecuencia de tratamiento quirúrgico más elevado (95 de 145 = 65%) con predilección por la endarterectomía carotídea (85 de 95), siendo realizada en la mayoría de los casos (71 de 85) de forma urgente (primeros 7 días) y en los 14 casos restantes de forma diferida tras tratamiento anticoagulante previo durante al menos una semana. ...
Carotid free-floating thrombus (FFT) is a rare cause of ischemic stroke, usually detected during etiologic vascular studies. There is no consensus regarding the management of carotid free-floating thrombi in those patients. A 83-year-old male presented to the emergency department with right hemiparesis and dysarthria, consistent with finding of multiple left hemispheric brain infarcts on neuroimaging. Contrast CT showed a free-floating thrombus fixed to an atheroma plaque in left internal carotid artery (ICA). Holter monitorization registered a not previously noticed paroxystic atrial fibrillation. Due to findings, sodic heparinization was started and serial ecosonographic monitoring of the thrombus was performed. He was discharged home with a clot reduction >50% with oral anticoagulant therapy (rivaroxaban 20mg daily). At 2 months, ecographic control was realized without residual clot in left ICA. Oral anticoagulation is currently the first therapeutic option that should be considered when a FFT is detected. In some reported case series, simple antiplatelet therapy was associated. Deferred surgical endarterectomy has a limited therapeutic gap in these patients when an ulcerated atheroma plaque or a significant stenosis carotid stenosis are detected. Surgical thrombectomy is reported only in few cases series. Endovascular therapies are steadily growing as an effective option when a FFT is detected, usually associated with distal protection devices to avoid distal embolization.
