Abstract Number ‐ 68: Thrombectomy Through Persistent Trigeminal Artery In A Patient With P2 Occlusion: Case Report

Introduction Mechanical thrombectomy for distal medium vessel occlusions (DMVO) of the posterior circulation has been shown to be safe and technically feasible. Additionally, mechanical thrombectomy through a persistent trigeminal artery (PTA) for occlusions near the superior bifurcation of the basilar artery has been described before. However, the safety and efficacy of such procedures for DMVO remain unclear. We present a case of thrombectomy through a Saltzman type 1 PTA in an acute P2 occlusion. Methods A woman in her 80s with atrial fibrillation was admitted after undergoing a thrombectomy for a left M1 occlusion. Two days post‐procedure, she developed a right P2 occlusion with severe motor deficit secondary to thalamic hypoperfusion. She underwent mechanical thrombectomy through a right PTA. A balloon guide catheter (BGC) was placed in the right internal carotid artery (ICA). Initially, a 4F catheter over a 0.014 microwire was introduced but failed to navigate through the PTA. Afterward, the system was exchanged for a 5F aspiration catheter over a 0.021 microcatheter and 0.014 microwire which successfully tracked up through the PTA to the face of the clot. Aspiration alone was attempted initially, followed by the combined technique of aspiration with stent‐retriever. Results Our initial attempt to navigate the 4F catheter over the microwire through the PTA and up the basilar artery was unsuccessful as it continued to herniate into the cavernous ICA. Switching to the triaxial approach with the 5F catheter over the microsystem allowed navigation to the clot, however, aspiration alone was not sufficient to recanalize the occlusion and led to significant vasospasm which later self‐resolved. Instead, the combined technique resulted in successful thrombectomy with no untoward emboli into the right anterior circulation. The post‐procedural MRI showed multiple, scattered infarcts which were not evident on the MRI after the patient’s initial M1 thrombectomy. These infarcts involved the cerebellar and cerebral hemispheres bilaterally as well as the right thalamus. There was no evidence of subarachnoid hemorrhage on MRI. The patient continued to have significant left‐sided hemiparesis and could not be extubated, at which point the decision was made to transition to comfort measures until she passed. Conclusions Mechanical thrombectomy of a posterior circulation DMVO through a Saltzman type 1 PTA using the combined technique can be performed safely and effectively.