Exploration into Endovascular Therapy of Symptomatic Carotid Free-floating Thrombus

doi:10.3969/j.issn.1673-5765.2023.10.006

Abstract

Abstract: Objective This study aimed to explore safety and efficiency of endovascular therapy for symptomatic carotid free-floating thrombus (CFFT).
Methods Patients admitted to the Department of Neurology, the Second Affiliated Hospital of Xi´an Jiaotong University from August 2008 to November 2022 and diagnosed with symptomatic CFFT and treated with carotid artery stenting were retrospectively enrolled. For each patient clinical presentation, risk factors, location of the thrombus, type of carotid stent and adjunctive devices, surgical approach, clinical efficacy were recorded and analyzed.
Results A total of 6 patients with acute cerebral infarction caused by CFFT were included, with 4 females (66.7%) , the median age at onset was 63.5 (48.0-68.7) years. The median NIHSS was 3.0 (0-3.5) and mRS was 2.0 (1.0-3.0) at pre-operation. The CFFT was located in the distal segment of right common carotid artery in 1 case, the C1 segment of left internal carotid artery in 1 case and right internal carotid artery in 4 cases. 2 cases with CFFT had severe carotid stenosis. All patients were treated with carotid stenting under protection of distal filter device. Balloon predilation was used in 2 cases with severe carotid stenosis before carotid stenting. The Wallstent closed-cell stent was used in 5 patients with the Precise open-cell stent being used in 1 patient. None of the patients had clot migration or distal intracranial large vessel occlusion. In one case (16.7%) in-stent thrombosis occurred and this induced brain edema and symptom aggravation. The median NIHSS was 1.0 (0-3.0) at 7 days after operation, and mRS was 1.0 (0-2.0) at 90 days follow-up.
Conclusions Carotid artery stenting may be a feasible approach for symptomatic CFFT with good safety and efficiency profile.

Key words: Free-floating thrombus; Ischemic stroke; Endovascular therapy; Carotid stenting; Carotid

摘要： 目的探索症状性颈动脉漂浮血栓（carotid free-floating thrombus，CFFT）血管内治疗的临床疗效与安全性。
方法回顾性纳入2008年8月—2022年11月在西安交通大学第二附属医院神经内科住院诊断为症状性CFFT，并行颈动脉支架置入术的患者，分析CFFT患者临床表现、危险因素、病变部位、颈动脉支架器材、手术方式及临床效果。
结果共纳入6例CFFT导致急性脑梗死的患者，其中女性4例（66.7%），发病年龄中位数63.5（48.0～68.7）岁。术前NIHSS评分中位数3.0（0～3.5）分，mRS评分中位数2.0（1.0～3.0）分。6例患者中，血栓位于右侧颈总动脉中远段1例，左侧颈内动脉C1段1例，右侧颈内动脉C1段4例，2例患者合并颈动脉原位重度狭窄。患者均接受了远端保护装置下的支架置入术，2例合并原位狭窄者支架置入前进行了球囊预扩张。5例患者置入了Wallstent闭环支架，1例患者置入了Precise开环支架。所有患者术中均未发生血栓脱落、远端大血管闭塞事件。1例（16.7%）患者术后12 h因支架内血栓发生脑水肿及病情加重。所有患者术后7 d NIHSS评分中位数减至1.0（0～3.0）分，术后90 d mRS评分中位数为1.0（0～2.0）分。
结论颈动脉支架置入术可能是治疗症状性CFFT的一种可行的安全有效的方法。

关键词: 漂浮血栓; 缺血性卒中; 血管内治疗; 颈动脉支架置入术; 颈动脉

ZHANG Lei, WANG Xiaoya, JIAN Yating, GAO Zhen, FAN Hong, FAN Songhua, WANG Huqing, SUN Hong, ZHANG Ru, ZHAN Shuqin, ZHANG Guilian. Exploration into Endovascular Therapy of Symptomatic Carotid Free-floating Thrombus[J]. Chinese Journal of Stroke, 2023, 18(10): 1136-1142.

张磊, 王小雅, 坚雅婷, 高震, 樊洪, 范松华, 王虎清, 孙宏, 张茹, 展淑琴, 张桂莲. 症状性颈动脉漂浮血栓的血管内治疗探索[J]. 中国卒中杂志, 2023, 18(10): 1136-1142.

References

[1] BHATTI A F，LEON LR J R，LABROPOULOS N，et al. Free-floating thrombus of the carotid artery：literature review and case reports[J]. J Vasc Surg，2007，45（1）：199-205.
[2] BILLER J，ADAMS H P JR，BOARINI D，et al. Intraluminal clot of the carotid artery. A clinical-angiographic correlation of nine patients and literature review[J]. Surg Neurol，1986，25（5）：467-477.
[3] MULLER M D，RAPTIS N，MORDASINI P，et al. Natural history of carotid artery free-floating thrombus-a single center，consecutive cohort analysis[J/OL]. Front Neurol，2022，13：993559[2023-01-15]. https://doi.org/10.3389/fneur.2022.993559.
[4] FRIDMAN S，LOWNIE S P，MANDZIA J. Diagnosis and management of carotid free-floating thrombus：a systematic literature review[J]. Int J Stroke，2019，14（3）：247-256.
[5] SACCO R L，KASNER S E，BRODERICK J P，et al. An updated definition of stroke for the 21st century：a statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke，2013，44（7）：2064-2089.
[6] DOWLATSHAHI D，LUM C，MENON B K，et al. Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort[J]. Stroke Vasc Neurol，2023，8（3）：194-196.
[7] VASSILEVA E，DASKALOV M，STAMENOVA P. Free-floating thrombus in stroke patients with nonstenotic internal carotid artery-an ultrasonographic study[J]. J Clin Ultrasound，2015，43（1）：34-38.
[8] FERRAÙ L，COTRONEO M，DELL'AERA C，et al. Carotid free-floating thrombus during COVID-19 vaccine era：causality or not?[J]. Neurol Sci，2022，43（11）：6179-6183.
[9] EMAMIKHAH M，YAZDI N，MOHEBI N，et al. Anemia：an unusual cause of free-floating thrombus of carotid artery[J]. Iran J Neurol，2019，18（2）：87-89.
[10] DOWLATSHAHI D，LUM C，MENON B K，et al. Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort[J]. Stroke Vasc Neurol，2023，8（3）：194-196.
[11] AFSHARFARD A，GHOLIZADEH B，ABDOLALIAN Y，et al. Carotid free-floating thrombus causing stroke in a young woman with lupus anticoagulant：a case report and review of the literature[J/OL]. Int J Surg Case Rep，2017，33：35-37[2023-01-15]. https://doi.org/10.1016/j.ijscr.2017.01.067.
[12] TATSUTA Y，OGINO T，MATSUDA M，et al. A case of internal carotid artery occlusion caused by en bloc distal embolization of carotid free-floating thrombus treated by mechanical thrombectomy[J]. J Neuroendovasc Ther，2022，16（2）：93-99.
[13] YAMAMOTO Y，YAMAMOTO N，MATSUDA T，et al. Stent retrieval for free-floating thrombus attached to carotid artery stenosis：a report of two cases[J/OL]. Surg Neurol Int，2023，14：274[2023-01-15]. https://doi.org/10.25259/SNI_513_2023.
[14] WANG P，WANG Z，PAN J，et al. Case report：ultrasound-assisted endovascular therapy for carotid artery floating thrombus[J/OL]. Front Cardiovasc Med，2022，9：961760[2023-01-12]. https://doi.org/10.3389/fcvm.2022.961760.
[15] VELLIMANA A K，KADKHODAYAN Y，RICH K M，et al. Symptomatic patients with intraluminal carotid artery thrombus：outcome with a strategy of initial anticoagulation[J]. J Neurosurg，2013，118（1）：34-41.
[16] SHIOZAKI E，MOROFUJI Y，KAWAHARA I，et al. Free-floating thrombus in the carotid artery without atherosclerosis dissolved by antithrombotic therapy[J]. Neurol India，2021，69（5）：1269-1270.
[17] GIRAGANI S，KOMAL R N K，POTLURI A，et al. Bilateral symptomatic carotid free floating thrombi[J]. Neurol India，2021，69（3）：770-771.
[18] GRAHAM B R，MENON B K. Clopidogrel load reduces emboli in carotid artery stenosis with free-floating thrombus[J]. Can J Neurol Sci，2017，44（5）：594-596.
[19] 张锐利，魏晓珊，秦晓丰，等. 替罗非班治疗颈动脉漂浮血栓相关脑梗死[J]. 国际神经病学神经外科学杂志，2021，48（1）：99-102.
ZHANG R L，WEI X S，QIN X F. Tirofiban in the treatment of cerebral infarction associated with carotid artery floating thrombus：a case report and literature review[J]. J Int Neurol Neurosurg，2021，48（1）：99-102.
[20] FERRERO E，FERRI M，VIAZZO A，et al. Free-floating thrombus in the internal carotid artery：diagnosis and treatment of 16 cases in a single center[J]. Ann Vasc Surg，2011，25（6）：805-812.
[21] CHAKHTOURA E Y，GOLDSTEIN J E，HOBSON R W. Management of mobile floating carotid plaque using carotid artery stenting[J]. J Endovasc Ther，2003，10（3）：653-656.
[22] BHOGAL P，ALMATTER M，AGUILAR PÉREZ M，et al. Carotid Stenting as definitive treatment for free floating thrombus-review of 7 cases[J]. Clin Neuroradiol，2021，31（2）：449-455.
[23] SUGIE A，YAMADA M，YOKOYAMA K，et al. Carotid free-floating thrombus in a stent 6 months after carotid artery stenting[J/OL]. World Neurosurg，2020，141：236-239[2023-01-15]. https://doi.org/10.1016/j.wneu.2020.06.100.