Hybrid surgical rescue of failed stent retrieval with acute middle cerebral artery occlusion

Failure of stent retrieval and periprocedural embolization of plaque are rare complications of carotid artery stenting, which need emergency surgical treatment. In this video, we demonstrate failed stent retrieval with acute middle cerebral artery occlusion that was treated with carotid endarterectomy and stent-assisted thrombectomy in a hybrid operating room. A 65-year-old man underwent carotid artery stenting for symptomatic left internal carotid artery stenosis with severe calcification. Immediately after placement of the open-cell carotid stent, left middle cerebral artery M1 segment occlusion was detected. A self-expanding retrievable intracranial stent was used for mechanical thrombectomy. However, the retrievable stent was blocked by the carotid stent and could not be retrieved. We attempted various ways to retrieve the device to avoid embolic complications, including neck rotation and neck compression, but they all failed. Therefore, we decided to perform surgical retrieval. Surgery was performed in a hybrid operating room under general anesthesia, and intraoperative neuromonitoring was used. The surgical field was deployed according to standard procedure. A longitudinal incision was then made through the adventitia on the anterolateral surface of the carotid artery. We pulled both stents out of the vessel and mobilized the plaque from the adventitia. The arteriotomy was closed with a double 6/0 monofilament suture. Angiogram was performed after vessel suturing to confirm there was not vessel wall damage or flow problems. After carotid endarterectomy, the stent-assisted thrombectomy was performed. Postoperative digital subtraction angiography confirmed the recanalization of the middle cerebral artery. The patient's neurologic function dramatically improved after hybrid treatment.