Endovascular Thrombectomy for Large Vessel Occlusions in Covid-19 Patients: Technical Challenges and Lessons

ABSTRACT

INTRODUCTION: Covid 19 infections has been shown to be associated with a range of thromboembolic disease that has implications for the neuro-endovascular management of large vessel occlusions. METHODS: Five consecutive Covid-19 positive patients presented with large vessel occlusions to our institution. Covid-19 testing was performed using nasal swab. All thrombectomy cases was performed under general endotracheal anesthesia using a stent-aspiration combination as primary thrombectomy technique. The technical details of each case and the angiographic outcome are described. Routine labs including D-dimer, platelet count, coagulation panel (aPTT, INR), Interleukin 6 (IL-6), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) were evaluated in all patients. Rotational thrombelastography (ROTEM) was performed on the patients' blood samples to assess real-time clot formation/dissolution properties. RESULTS: Four patients had anterior circulation large vessel occlusions and one patient had both anterior and posterior circulation occlusions. Mean age was 52.8 years and 80% were males. TICI 3 revascularization was achieved in one patient, TICI 2B achieved in two patients and TICI 2A in two patients. In our cohort, patients were on average 52.8 years old and presented with a median NIHSS of 27. All our patients had very proximal occlusions. Three patients presented with intra-cranial ICA occlusions. Two patients presented with a tandem carotid bulb thrombus in conjunction with an intracranial vessel occlusion. One patient had an ICA terminus occlusion with a concomitant basilar occlusion. Second, the intravascular clots in all our patients were prone to fragment and migrate into both new vascular territories and into distal downstream vasculature. Distal emboli into a different territory (anterior cerebral artery occlusion) was seen in two two of our five patients (40%) and distal emboli into a downstream territory was seen in all five patients (100%). An average of 2.7 pstent-retriever passes was needed to achieve a final TICI revascularization of IIb or better. CONCLUSION: Covid-19 patients are predisposed to a hypercoagulable state. When presenting with large vessel occlusions, these patients present unique challenges that make successful revascularization difficult.