Zenith device used in this case:

Patient Information

• Male, 58 years old
• Dizziness accompanied by right limb weakness and dysphasia for over 20 days

Preoperative Angiography

MRI from another hospital showed acute cerebral infraction in the left frontal and parietal lobes.

CTA from another hospital left carotid artery occlusion.

Devices

• 5F VER diagnostic catheter
• Glidewire
• 5F 125cm MPA1 Catheter
• 6F 90cm Long Sheath
• 6F 115cm Zenith Distal Access Catheter
• 2m Micro Guidewire, Transend™ 300 Micro Guidewire
• Echelon-10 Microcatheter
• 2mm*15mm Intracranial Balloon Dilatation Catheter
• 3mm*20mm Intracranial Drug-eluting Stent
• Spider FX 5.0mm Embolic Protection System

Procedure

Right femoral artery puncture with insertion of an 8F femoral sheath. Angiography indicated complete occlusion of the left ICA from the C1 segment to the intracranial portion. Collateral circulation was observed via the right ICA through the anterior communicating artery, and via the left external carotid artery through the ophthalmic artery to the left MCA territory.

Using a Loach guidewire, a 125 cm MPA1 catheter and a 6F 90 cm guiding sheath in coaxial fashion, the left CCA was superselected. The long sheath was advanced to the proximal segment of the left CCA bifurcation. Angiography revealed occlusion at the left ICA C1 segment with a “flame sign,” suggesting recent occlusion. The Loach guidewire and 125 cm MPA1 catheter successfully crossed the occlusion.

A 6F 115 cm Zenith Distal Access Catheter was advanced into the left ICA C1–C4 segment for repeated aspiration, retrieving a large amount of dark red organized thrombus. After aspiration until no more thrombus was retrieved, repeat angiography demonstrated severe stenosis (~70%) at the ICA C1 segment, with poor visualization distal to the cavernous segment.

The Zenith Distal Access Catheter was advanced to the cavernous segment of the left ICA. A 2 m microguidewire with an Echelon-10 microcatheter was superselected across the ophthalmic segment occlusion into the left MCA M1. The Echelon-10 was exchanged for a Transend™ 300 microguidewire.

Manual injection showed vessel recanalization, with severe stenosis at the cavernous segment of the left ICA. A 2.0 mm × 15 mm balloon dilation catheter was exchanged over the Transend™ 300 wire for stepwise, incremental angioplasty of the ICA.

Using the balloon shuttle technique, the distal access catheter was advanced across the stenosis. With the Trellis technique, a 3.0 mm × 20 mm intracranial drug-eluting stent was deployed at the stenotic site. Angiographic positioning and inflation achieved successful stent release. Post-deployment angiography showed significant improvement, with residual stenosis of approximately 20%.

Under roadmap guidance, a Spider FX 5.0 mm embolic protection device was delivered through the Zenith Distal Access Catheter and deployed at the ICA C2 segment under fluoroscopy, confirming good opening and wall apposition. The Zenith Distal Access Catheter was then withdrawn. Over the protection device wire, a 2.0 mm × 15 mm balloon dilation catheter was advanced to the C1 stenosis. Angiography confirmed positioning, followed by balloon angioplasty at nominal pressure. The balloon was removed, and the protection device retrieved. No visible embolic debris was noted within the filter.

Postoperative Angiography

Anteroposterior and lateral angiography demonstrated smooth flow in the left ICA, with good opacification of the MCA and ACA, without flow limitation.