Distal Internal Carotid Thrombo-Embolectomy Using a Fogarty Catheter in Total Occlusion* Technical Note

J. CLAYTON DAVIE, M.D., AND RXxr RICHARDSON, M.D.t Section on Neurosurgery, Medical College of Alabama, Birmingham, Alabama

NVALUABLE information concerning the ~7%; and in 1~+ days, 4%. They concluded problems of carotid occlusive disease has from their study that "the results suggest I been published. 1-3,6,7,9,12,13,15-17,2~ Yet, in that there is probably little to be gained by general, the results of surgical treatment of operating on an occluded artery, even in total occlusions of the cervical internal ca- patients without severe deficit when the con- rotid artery have been disappointing. Sur- tralateral vessel is not significantly stenosed. gical intervention has rarely produced neuro- ttowever, until this matter is settled by fur- logical benefits either in the presence or ab- ther experience, we shall no doubt continue sence of neurological deficit. We are reporting to operate upon these individuals without the use of a special intravaseular catheter profound deficit when the occlusion is which has facilitated the extraction of distal thought to be of recent onset." They also thrombi in patients with totally occluded ca- advocated surgical intervention in those pa- rotid arteries. tients with bilateral carotid occlusions. Some of the uncertainties associated with Techniques for the extraction of thrombi this lesion relate to the duration of occlusion, from the distal internal carotid artery, such peripheral embolization to the cerebral ves- as the insertion of small sucker tips and rub- sels, proximal and distal propagation of the ber catheters, have met with varying results, thrombus from the site of occlusion, and usually unfavorable. Anmng these have been stenotie lesions in the region of the carotid the retrograde "milking technique" of siphon. Fisher 4 reported a 45% incidence of Keeley and Rooney, TM retrograde flushing of severe neurological deficit in a series of 45 the artery as described by Lerman, et al., 11 autopsies in which total occlusion of a carotid and the use of various endarterectomy in- artery was present. In 31% of the eases with struments and guides such as a corkscrew de- deficit, there was extension or emboli to ves- vice advocated by Shaw. '9 None of these sels beyond the circle of Willis. This inci- techniques is applicable to the extraction of dence of cerebral propagation corresponds to throlnbi in the distal portion of the inter- a 35% and 46% incidence reported by Lues- nal carotid artery. senhop 14 and Hultquist 8 respectively. In 1963, Fogarty a described a special in- Murphey and Maeeubin TM reported that 80 travascular catheter with an inflatable bal- of 194 patients operated on for carotid oc- loon applied to the tip for extraction of clusive disease had totally occluded vessels; thrombi in peripheral arteries (Fig. 1). The arterial back flow and circulation were re- catheter is made of pliable rubber, 80 cm in stored in 35 of these eases. These authors length, and is available in several diameters found an indirect correlation between the from 1 to 3 ram. The catheter is threaded duration of the occlusion and the number of into the artery to pass through a soft throm- arteries in which flow could be re-established. bus or between the thrombus and the arterial From 0-~ days, 90% of the arteries could be wall to a point distal to the thrombus. The opened; in 3-7 days, 56%; in 8-11 days, balloon is inflated with fluid and the catheter gently and firmly withdrawn, extracting the Received for pul)lieation January 3, 1967. * This work was supported in part by the Allen P. thrombus or embolus ahead of the balloon. and Josephine B. Green Foundation, Division of Neuro- The rubber inflatable balloon is 1 cm long surgery, Washington University, Barnes Hospital, St. and constructed as a small jacket so that Louis, Missouri, and the United States Public IIealth maximal inflation occurs in the middle of the Service. t Present address: 6860 Brockton, Riverside, Cali- jacket. Increased resistance encountered by fornia. small alterations in the intraluminal dia- 171 17~ J. Clayton Davie and Ray Richardson unsuccessful in October, 1964, and further study was refused at that time. Twelve days before admission, he developed pneumonia and a right hemil)aresis. Examination. The patient was mute and did not respond to commands. There was conjugate gaze of the eyes with the pupils equal and reactive, and a right hemiplegia with a spastic paralysis of the left leg. A retrograde right arteriogram revealed bila- teral internal carotid artery occlusions with good filling of both vertebral arteries (Fig. ~). There was very minimal delayed retrograde filling of the left middle cerebral and left an- terior cerebral arteries, by way of the poster- ior circulation. Operation. A left carotid endarterectomy was undertaken, even though the prognosis was poor. Arteriotomy was performed over the carotid bifurcation revealing total occlu- sion of the left internal carotid artery by thick, yellowish, ulcerating, hard atheromat- ous plaque. There was no soft thrombus and no "back or retrograde bleeding" from the FIG. 1. Fogarty catheter (No. 6) illustrating unin- internal carotid. flated distal bulb in top photograph and inflated bulb in A Fogarty catheter (No. 4, 1 mm) was in- lower photograph. serted into the proximal internal carotid as far as possible (13 cm) from the carotid meter or by atherosclerotic plaque causes dis- bifurcation. The balloon was filled with 1 cc placement of the fluid within the balloon, al- of 50% Hypaque, and a semilateral skull film lowing the catheter to glide past, supposedly was obtained, showing the distal catheter to without undue trauma to the vessel. The be within the carotid siphon (Fig. S A). circumference of the balloon can be altered The catheter was withdrawn without back according to the size of the vessel and the bleeding, and a lateral x-ray was obtained area of constriction by increasing or decreas- during injection of 5 cc of Hypaque into the ing the volume of liquid in the balloon. common carotid artery. There was filling of We are reporting two cases of total carotid the internal carotid artery to the supraclinoid occlusions at the bifurcation in which we level without filling of the intracranial cere- used the Fogarty catheter; the balloon was bral arteries (Fig. 3 B). However, there was filled with 0.5 to 1 cc of 50% Hypaque for filling of the cavernous sinus and internal radiographic visualization of the distal cath- jugular vein almost immediately, indicating eter. The first case illustrates a complication that a traumatic carotid cavernous fistula of the technique, and the second illustrates had formed (Fig. 3 B). its usefulness. The patient's condition deteriorated im- mediately, and he died 18 hours after sur- Case Reports gery. Case 1. A 48-year-old white man with a 19- Postmortem examination. Attempts to in- month history of intermittent carotid in- ject the carotid and vertebral arteries at their sufficiency with known bilateral reduction of origin indicated no flow (intracranially) from retinal artery pressures was adnfitted to the either the carotid arteries or the left verte- Cochran Veterans Hospital in May, 1965. bral artery. The carotid arteries were re- He had previously developed a left hemi- moved, and examination revealed total oc- paresis with a residual spastic paresis of the clusion of both internal carotids by an old, left leg. A retrograde femoral aortogram was completely fibrous, thrombotic process. The