Direct Carotid Artery Exposure for Mechanical Thrombectomy in a Patient with Marfan Syndrome and Prior Total Arch Replacement

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Marfan syndrome presents unique challenges for mechanical thrombectomy in acute ischemic stroke due to vascular fragility and complex aortic anatomy, often from prior surgeries. We describe the case of a man in his 50s with Marfan syndrome, total aortic arch replacement, mechanical valve replacement, and extensive chronic dissections, who presented with acute ischemic stroke due to right internal carotid artery occlusion. Conventional transfemoral access failed due to anomalous prosthetic brachiocephalic artery graft anatomy. Consequently, mechanical thrombectomy was performed via direct surgical exposure and puncture of the right common carotid artery. Despite initial avoidance of a stent retriever due to Marfan syndrome-related vessel fragility, an stent retriever was ultimately used in a combined technique with aspiration in the third pass, achieving partial recanalization (thrombolysis in cerebral infarction 2a) and retrieval of a fibrin-rich thrombus. This case highlights direct carotid access as a feasible alternative in Marfan syndrome patients with prohibitive conventional access and suggests stent retrievers can be used cautiously.