This middle-aged patient had undergone surgical placement of a left subclavian to internal carotid artery bypass graft five years ago for treatment of symptomatic, chronic, bilateral carotid occlusions. The patient was neurologically intact after the procedure and until the day of presentation with symptoms of an acute left anterior circulation stroke. Initial workup confirmed acute occlusion of the graft as the cause of the patient\u27s symptoms. Endovascular recanalization of the bypass graft in the setting of chronic bilateral carotid occlusions was a technical and conceptual challenge. Simultaneous radial and femoral vascular access allowed for direct recanalization of the graft (through thrombectomy, angioplasty, and stent placement) with intraoperative patency surveillance of the circle of Willis via the posterior circulation. Most of the neurological deficits improved, and the patient was discharged to rehabilitation close to neurologic baseline

Kuhn, Anna L.

Marino Granados, Jose

Massari, Francesco

Puri, Ajit S.

Singh, Jasmeet

English

eScholarship@UMMS

UMass Chan Medical School eScholarship@UMassChan Radiology Publications Radiology 2022-01-02 Acutely Symptomatic Hypoperfusion Through an Occluded Subclavian to Internal Carotid Artery Bypass Graft: Salvage Mechanical Thrombectomy and Graft Revascularization Jose Marino Granados University of Maryland Medical Center Et al. Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/radiology_pubs  Part of the Cardiovascular Diseases Commons, Nervous System Diseases Commons, Neurology Commons, and the Radiology Commons Repository Citation Marino Granados J, Kuhn AL, Puri AS, Massari F, Singh J. (2022). Acutely Symptomatic Hypoperfusion Through an Occluded Subclavian to Internal Carotid Artery Bypass Graft: Salvage Mechanical Thrombectomy and Graft Revascularization. Radiology Publications. https://doi.org/10.7759/cureus.20881. Retrieved from https://escholarship.umassmed.edu/radiology_pubs/680 Creative Commons License This work is licensed under a Creative Commons Attribution 4.0 License. This material is brought to you by eScholarship@UMassChan. It has been accepted for inclusion in Radiology Publications by an authorized administrator of eScholarship@UMassChan. For more information, please contact Lisa.Palmer@umassmed.edu. Review began 12/27/2021 Review ended 12/28/2021 Published 01/02/2022© Copyright 2022Marino Granados et al. This is an openaccess article distributed under the terms ofthe Creative Commons Attribution LicenseCC-BY 4.0., which permits unrestricted use,distribution, and reproduction in anymedium, provided the original author andsource are credited.Acutely Symptomatic Hypoperfusion Through anOccluded Subclavian to Internal Carotid ArteryBypass Graft: Salvage Mechanical Thrombectomyand Graft RevascularizationJose Marino Granados  , Anna Luisa Kuhn  , Ajit S. Puri  , Francesco Massari  , Jasmeet Singh 1. Department of Neurology, University of Maryland Medical Center, Baltimore, USA 2. Division of NeurointerventionalRadiology, Department of Radiology, University of Massachusetts, Worcester, USACorresponding author: Jasmeet Singh, jasmeet.singh@umassmemorial.orgAbstractThis middle-aged patient had undergone surgical placement of a left subclavian to internal carotid arterybypass graft five years ago for treatment of symptomatic, chronic, bilateral carotid occlusions. The patientwas neurologically intact after the procedure and until the day of presentation with symptoms of an acuteleft anterior circulation stroke. Initial workup confirmed acute occlusion of the graft as the cause of thepatient’s symptoms. Endovascular recanalization of the bypass graft in the setting of chronic bilateralcarotid occlusions was a technical and conceptual challenge. Simultaneous radial and femoral vascularaccess allowed for direct recanalization of the graft (through thrombectomy, angioplasty, and stentplacement) with intraoperative patency surveillance of the circle of Willis via the posterior circulation. Mostof the neurological deficits improved, and the patient was discharged to rehabilitation close to neurologicbaseline.Categories: Neurology, Radiology, NeurosurgeryKeywords: carotid artery, stent, stroke, mechanical thrombectomy (mt), bypass graftIntroductionBypass surgeries of the brachiocephalic arteries are less prevalent today than they were in the past. Today,patients can be treated successfully using minimally invasive endovascular devices. However, thepresentation of an acute stroke secondary to a bypass graft occlusion can lead to enormous diagnostic andtherapeutic difficulties. Our case report offers a technical description of how to recanalize the graft andconcomitantly monitor for (and treat) emboli traveling from the distal end of the graft to the intracranialcirculation.Technical ReportThe patient was a middle-aged, right-handed man, with a history of hyperlipidemia, type 2 diabetes mellitus,hypertension, atrial fibrillation, a prior right cerebellar stroke without sequela, and known bilateral carotidocclusions. The patient was also status post placement of a left subclavian to left internal carotid artery(ICA) bypass graft approximately five years ago for treatment of symptomatic, bilateral carotid occlusions.Of note, the patient was noncompliant with several medications including antiplatelet therapy,anticoagulation, antihypertensives, and insulin. Despite the prior cerebellar stroke and bilateral carotidocclusions, the patient’s modified Rankin score was 0. Upon waking up on the morning of presentation, thepatient noticed right upper extremity weakness and pain. A blood pressure check at home showed a systolicblood pressure (SBP) of 190 mmHg. The patient then decided to take an unknown amount of metoprolol. Asthe blood pressure decreased, dysarthria, aphasia, right facial droop, right-sided neglect, and right upper andlower extremity weakness started to develop. Though the symptoms fluctuated, blood pressureenhancement failed to achieve a return to the patient’s neurologic baseline, and at its worse, the NationalInstitute of Health Stroke Scale (NIHSS) was 17. Initial workup included an unremarkable noncontrast headCT, CT perfusion imaging which showed a 3 cm x 3 cm infarct core in the posterior left temporal lobe and alarge ischemic penumbra involving the entire left anterior circulation as well as the right anterior cerebralartery territory (Figure 1A). CT angiogram of the head and neck demonstrated occlusion of the leftsubclavian to left ICA graft, occlusion of the right petrous and cavernous ICA, patency of all otherintracranial vessels (with a hypoplastic right A1), and moderate stenosis at the origin of the right vertebralartery with otherwise patent vertebrobasilar system (Figure 1B). The approach to the endovasculartreatment detailed below consisted of four consecutive stages: 1) initial diagnostic cerebral angiogram, 2)guidewire and catheter exploration of the occluded bypass graft, 3) mechanical thrombectomy of the left M1occlusion secondary to the instrumentation of the occluded bypass graft, and 4) revascularization of thebypass graft. The procedure was performed under general anesthesia. Dual arterial access was obtained with6-French arterial sheaths in the left radial and right common femoral arteries. Tight blood pressure controlwas maintained (140-180 mmHg systolic). Anesthesia team was able to use the arterial pressure recordings1 2 2 2 2 Open Access TechnicalReport  DOI: 10.7759/cureus.20881How to cite this articleMarino Granados J, Kuhn A, Puri A S, et al. (January 02, 2022) Acutely Symptomatic Hypoperfusion Through an Occluded Subclavian to InternalCarotid Artery Bypass Graft: Salvage Mechanical Thrombectomy and Graft Revascularization. Cureus 14(1): e20881. DOI 10.7759/cureus.20881from a transducer connected to the side port of the groin sheath. From the right groin approach, a 4-FrenchBerenstein catheter (Cordis, Miami Lakes, FL, USA) was navigated into the left subclavian artery. The leftvertebral artery was selected with the catheter. Cerebral angiogram through the left vertebral artery showedfilling of the entire intracranial vasculature via the posterior circulation with filling of the anteriorcirculation via the posterior communicating arteries. The angiogram of the left subclavian artery did notshow any opacification of the bypass graft (Figure 1C).FIGURE 1: Stroke ImagingCT perfusion demonstrates a large area of ischemic penumbra involving the entire left anterior circulation andright anterior cerebral artery territory (A). CT angiogram of head and neck (coronal plane) shows completeocclusion of the left subclavian to ICA bypass graft (B, arrow). Angiographic image confirms complete occlusion ofthe bypass graft (C, arrow).Another 4-French Berenstein catheter was navigated into the subclavian artery from the left radial approachdue to the more favorable angle for graft catheterization, as per the CT angiogram. The graft itself wasradiolucent and not visible on fluoroscopy. The expected take-off of the graft was gently, blindly probedwith a 0.035-inch Glidewire (Terumo, Fremont, CA, USA). The wire could be advanced into the graft againstsome minor resistance. The Berenstein catheter could then be navigated into the left cervical ICA across thegraft. Intraluminal position was confirmed with a gentle contrast injection.Follow-up angiography revealed an occlusion of the left M1 segment (Figure 2A). This was likely secondaryto the wire and catheter navigation through the thrombus filled bypass graft. The diagnostic catheter wasexchanged for a 6-French Benchmark catheter (Penumbra, Alameda, CA, USA) over a Glidewire Advantagewire (Terumo). Using a triaxial technique [1], a 5-French Sofia aspiration catheter (Microvention, Aliso Viejo,CA, USA) was navigated over a Trevo ProVUE 21 microcatheter (Stryker, Fremont, CA, USA) and a Synchro0.014″ microwire (Stryker) to reach the superior division of the left middle cerebral artery (MCA). Once there,a Trevo 6 mm x 40 mm thrombectomy device (Stryker) was deployed from the superior division M2 segmentinto the left M1 (Figure 2B). Mechanical aspiration thrombectomy was performed in a standard fashion.Follow-up angiogram evidenced patency of the left MCA (Figure 2C) with slow flow in a few distal corticalvessels (Thrombolysis in Cerebral Infarction (TICI) 2c).2022 Marino Granados et al. Cureus 14(1): e20881. DOI 10.7759/cureus.20881 2 of 5FIGURE 2: Salvage Mechanical ThrombectomyDespite initial patency, after manipulation of the graft’s thrombus, a distal embolus dislodges and occludes the leftmiddle cerebral artery (MCA) (A, arrow). Triaxial technique is used for thrombectomy of the left MCA occlusionwith deployment of a stent-retriever and aspiration catheter (B, arrow). Contrast injection from the left internalcarotid artery (ICA) immediately after thrombectomy shows recanalization of the MCA (C) with slow flow in a fewdistal cortical vessels (Thrombolysis in Cerebral Infarction (TICI) 2c).After flow through the MCA was restored, a 5-mm Spider embolic protection device (Medtronic, Irvine, CA,USA) was deployed at the level of the left cervical ICA. Multiple overlapping angioplasties of the graft werethen performed using a 5 mm x 20 mm over-the-wire balloon (Figure 3A). There was persistent angiographicevidence of extensive clot burden throughout the graft (Figure 3B). Multiple attempts at mechanicalaspiration thrombectomy were also performed leading to improvement of the caliber of the graft; however,persistent recoil of the graft kept resulting in reocclusion of the lumen.At that point, it was decided to trap the residual clot in the graft using closed-cell stents. Three overlappingself-expandable Carotid Wallstents (8 mm; Boston Scientific, Santa Clara, CA, USA) were placed along theentire length of the graft (Figure 3C). A balloon-mounted stent was deployed at the site of the proximalanastomosis with the native subclavian artery for anchoring purposes. Follow-up angiogram showedpatency of the bypass graft (Figures 3D, 3E). Regarding the intracranial recanalization, there was completeopacification of the distal left ICA and MCA. A small embolus was seen in a distal anterior cerebral arterybranch.The patient’s initial NIHSS was 17 (for dysarthria, aphasia, right facial droop, right-sided neglect, and rightupper and lower extremity weakness). At the time of discharge, the NIHSS had declined to 3 (right facialdroop, mild mixed aphasia, and mild disorientation). MRI was not obtained given the presence of metallichardware that precluded the patient from undergoing the study, but follow-up noncontrast head CT onlyshowed evolution of a left caudate stroke. The patient was discharged to a rehabilitation facility on dualantiplatelet therapy with aspirin 81 mg (lifelong) and clopidogrel 75 mg (for three months), in addition towarfarin for his atrial fibrillation. A clinical follow-up at three months showed that the patient has fullyrecovered. A follow-up CT angiogram 10 months after the procedure showed continued patency of thebypass graft (Figure 3F).2022 Marino Granados et al. Cureus 14(1): e20881. DOI 10.7759/cureus.20881 3 of 5FIGURE 3: Bypass Graft RecanalizationMultiple overlapping angioplasties are performed along the entire length of the bypass graft (A). Persistence ofhigh clot burden throughout the entire graft is seen (B, arrow). Placement of three overlapping self-expandingcarotid stents including a balloon-mounted stent at the site of the proximal anastomosis of the graft (C). Finalangiogram images show recanalization of the bypass graft (D and E). Ten-month follow-up CT angiogram showsa patent bypass graft (F, arrow).DiscussionPresentation of severe atherosclerotic disease of the carotid arteries leading to bilateral obstruction can varyfrom incidental asymptomatic findings to fulminant ischemic strokes, depending on the degree of collateralcirculation and the chronicity of the atherosclerotic lesions. Prior to the age of endovascular therapy, bypasstechniques of the brachiocephalic arteries were a standard therapeutic approach for management ofsymptomatic occlusions [2]. As these surgical options became less prevalent, the available data looking intothe rate of occlusion and the safest approaches for recanalization also became scarce. There are limited dataregarding the incidence of reocclusion of subclavian-carotid bypass grafts; earlier case series suggested thatsuch events are unlikely [3]. A retrospective study of 153 patients [4] showed that endovascular treatmentwith angioplasty and stenting of obstructed brachiocephalic bypass grafts was a viable alternative formanagement.In this case, the combination of multiple vascular risk factors and medication noncompliance led to anatypical anatomical presentation of an acute stroke. The symptomatology exhibited corresponded tohypoperfusion of the left anterior cerebral circulation on someone with known chronic bilateral carotid2022 Marino Granados et al. Cureus 14(1): e20881. DOI 10.7759/cureus.20881 4 of 5occlusions who had already undergone a bypass graft from the left subclavian artery to the left internalcarotid artery, distal to the native obstruction. This hypoperfusion was initially confirmed by angiographicfindings that showed nonopacification of the bypass graft and by perfusion imaging showing a smallischemic core with a large ischemic penumbra that correlated with the patient’s symptoms. Treatment ofacute ischemic stroke in the setting of an altered anatomy secondary to the placement of a surgical bypasscan be challenging, especially when the graft is the culprit “vessel” of the patient’s symptoms.Recanalization of the occluded vessel via mechanical thrombectomy is the gold standard for treatment ofischemic strokes; however, the specific approach and surgical planning in our case must take intoconsideration not only the occlusion of the graft but also the prior and permanent occlusions of the nativevessels. Endovascular recanalization of an acutely occluded subclavian-carotid graft for the treatment of anacute ischemic stroke has not been described previously. Given that any instrumentation of the thromboticsegment could lead to embolization from the distal end of the occluded graft to the anterior circulation,preprocedural planning was of paramount importance and it prioritized a dual access model that allowed forreal-time evaluation of the intracranial circulation via angiograms from the vertebrobasilar system whileconcomitantly using the left radial access to directly instrument the occluded bypass graft. Initialangiographic imaging via the posterior circulation showed initial patency throughout the circle of Willisthrough collateral flow from the posterior communicating arteries. As foreseen, initial manipulation of theoccluded graft led to an embolus that blocked flow through the MCA. Fortunately, this did not lead to furthercomplications as prompt mechanical thrombectomy was successfully performed. Further embolic eventswere prevented by deployment of a distal protection device within the cervical ICA. The high clot burdenwithin the graft made direct aspiration therapy insufficient for recanalization. Deployment of overlappingstents not only helped with “trapping” of the remaining clot but also conferred sustained patency of thegraft and optimal flow to the anterior circulation.ConclusionsRecanalization of a subclavian to carotid bypass graft via direct aspiration, angioplasty, and endovascularstenting should be considered as a feasible alternative for patients with a clinical presentation of an acuteischemic stroke.Additional InformationDisclosuresHuman subjects: Consent was obtained or waived by all participants in this study. Animal subjects: Allauthors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: Incompliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/servicesinfo: All authors have declared that no financial support was received from any organization for thesubmitted work. Financial relationships: All authors have declared that they have no financialrelationships at present or within the previous three years with any organizations that might have aninterest in the submitted work. Other relationships: All authors have declared that there are no otherrelationships or activities that could appear to have influenced the submitted work.References1. Massari F, Henninger N, Lozano JD, et al.: ARTS (Aspiration-Retriever Technique for Stroke): initial clinicalexperience. Interv Neuroradiol. 2016, 22:325-32. 10.1177/15910199166323692. Vitti MJ, Thompson BW, Read RC, Gagne PJ, Barone GW, Barnes RW, Eidt JF: Carotid-subclavian bypass: atwenty-two-year experience. J Vasc Surg. 1994, 20:411-7. 10.1016/0741-5214(94)90140-63. Illuminati G, Pizzardi G, Calio FG, Masci F, Pasqua R, Frezzotti F, Peschillo S: Results of subclavian tocarotid artery bypass for occlusive disease of the common carotid artery: a retrospective cohort study. Int JSurg. 2018, 53:111-6. 10.1016/j.ijsu.2018.03.0384. Anzuini A, Chiesa R, Vivekananthan K, et al.: Endovascular stenting for stenoses in surgically reconstructedbrachiocephalic bypass grafts: immediate and midterm outcomes. J Endovasc Ther. 2004, 11:263-8.10.1583/03-1111.12022 Marino Granados et al. Cureus 14(1): e20881. DOI 10.7759/cureus.20881 5 of 5

Acutely Symptomatic Hypoperfusion Through an Occluded Subclavian to Internal Carotid Artery Bypass Graft: Salvage Mechanical Thrombectomy and Graft Revascularization

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Acutely Symptomatic Hypoperfusion Through an Occluded Subclavian to Internal Carotid Artery Bypass Graft: Salvage Mechanical Thrombectomy and Graft Revascularization

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