Rescue Glue Embolization of Vessel Perforation During Mechanical Thrombectomy for Acute Ischemic Stroke: Technical Note Haowen Xu1, Sheng Guan1, Chao Liu1, Li Wang2, Baojun Yan1, Hongjie Han3, Tao Quan1
BACKGROUND: Vessel perforation is a serious technical complication during mechanical thrombectomy (MT) for the treatment of acute ischemic stroke with large vessel occlusion. Routine rescue strategy includes balloon occlusion for tamponade, procedure suspension, and lowering or normalizing blood pressure. However, this complication is still associated with poor outcome and high mortality.
METHODS: In this paper, the authors report their experience by using glue to embolize the ruptured vessel secondary to microcatheter/microwire perforation, preventing further deterioration in clinical outcome. Rescue glue embolization was attempted in 2 patients who developed intraprocedural vessel perforation while trying to gain access through the blocked artery with a microcatheter/microwire.
RESULTS: The ruptured vessels were effectively occluded. Stent retriever thrombectomies were then continued, and TICI 2b and 3 recanalizations were achieved. Both patients’ neurologic status improved.
CONCLUSIONS: The key benefit of this method exists in embolizing the ruptured vessel without affecting the following MT. We propose the rescue glue embolization is simple yet effective in managing vessel perforation complication during MT.
Key words Glue - Ischemic stroke - Mechanical thrombectomy - Vessel perforation -
Abbreviations and Acronyms AIS: Acute ischemic stroke BA: Basilar artery CT: Computed tomography MCA: Middle cerebral artery mRS: modified Rankin Scale MT: Mechanical thrombectomy NIHSS: National Institutes of Health Stroke Scale
WORLD NEUROSURGERY 121: 19-23, JANUARY 2019
everal randomized controlled trials have demonstrated the efficacy of mechanical thrombectomy (MT) for the treatment of acute ischemic stroke (AIS) with large vessel occlusion. These trials were able to show that MT with stent retrievers alone or in combination with intravenous tissue plasminogen activator administration could increase recanalization rate and acute stroke outcome.1-6 Intraprocedural vessel perforation is a complication of major concern, occurring in 1%10% of MT, and might be fatal.7-11 In the TREVO 2 study, this complication occurred in 9 of 90 patients (10%) who underwent Meci retriever thrombectomy.11 Shi et al12 reported that vessel perforation is an independent predictor of subarachnoid hemorrhage after endovascular therapy of AIS. When vessel perforation occurred, routine rescue strategy includes balloon occlusion for tamponade, procedure suspension, and lowering or normalizing blood pressure. However, this complication is still associated with high mortality. Obviously, urgent controlling of bleeding from ruptured vessel is crucial to prevent worsening of the brain damage. Thus far, no effective method has been introduced to address this complication. In this paper, we describe a method of rescue glue embolization to occlude the ruptured vessel secondary to microcatheter/microwire perforation for preventing further neurologic deterioration. To the best of our knowledge, the aforementioned technique has not been previously reported.
MATERIALS AND METHODS We reviewed our prospectively collected database of MT for AIS due to large vessel occlusion, from January 2011 to
From the Departments of 1Neurointerventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou; 2Neurology, Children’s Hospital, Zhengzhou City; and 3 Neurosurgery, The Second People’s Hospital, Pingdingshan City, China To whom correspondence should be addressed: Tao Quan, M.D. [E-mail: [email protected]
] Citation: World Neurosurg. (2019) 121:19-23. https://doi.org/10.1016/j.wneu.2018.09.131 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
January 2018. A total of 387 consecutive patients with acute large vessel occlusion underwent MT during this time in our institution. The technique was similar for all, involving stent retriever thrombectomy, direct aspiration, intraarterial thrombolysis, balloon angioplasty, and stent placement when necessary. Intraprocedural vessel perforation occurred in 5 patients, procedure was aborted without any rescue endovascular treatment in 3 patients, and 2 of these 3 eventually died in the hospital. The other 2 patients who received rescue glue embolization to address this complication had good clinical outcome. The modified Rankin Scale (mRS) scores at 3 months after MT were 1 and 2. The description of these 2 cases follows. Case 1 A 65-year-old male patient presented with left hemiplegia and somnolence for 5 hours. The initial National Institutes of Health Stroke Scale (NIHSS) score was 19. Brain computed tomography (CT) ruled out intracranial hemorrhage. Intravenous tissue plasminogen activator (a total dose of 63 mg of t-PA) was administered at 5.5 hours after the symptom onset. The patient’s neurologic status further deteriorated at the end of the
infusion of t-PA (NIHSS score was 22). The patient was rapidly transported to the neurointerventional suite for MT. Cerebral angiography showed complete occlusion of the basilar artery (BA) at the level of the anterior inferior cerebellar arteries (Figure 1A); there was no retrograde filling from the posterior communicating arteries. The procedure was performed under conscious sedation. A 6-French Envoy guiding catheter (Cordis Neurovascular, Milpitas, California, USA) was placed at the V2 segment of the right vertebral artery. A Rebar 18 microcatheter (Medtronic, Minneapolis, Minnesota, USA) was navigated over a 0.014-inch microwire (Synchro, Stryker Neurovascular, Kalamazoo, Michigan, USA) into the BA. Unexpectedly, a characteristic “pop” was felt when the microwire advanced at the apex of BA. Vessel perforation was suspected. The microcatheter was advanced over the microwire into the suspected vessel. Microcatheter angiography revealed contrast into parenchyma, confirming thalamoperforating artery perforation (Figure 1B). This ruptured vessel was immediately embolized with 0.15 mL of glue (Glubran 2, GEM Inc, Valenza, Italy) at 15% concentration, and no glue reflux was observed into the BA and bilateral posterior cerebral arteries (Figure 1C).
Figure 1. Case 1. (A) Cerebral angiography showed complete occlusion of basilar artery at the level of the anterior inferior cerebellar arteries. (B) Microcatheter angiography revealed thalamoperforating artery perforation. (C) The ruptured vessel was embolized with 0.15 mL of Glubran 2 (GEM Inc., Italy) at 15% concentration, and no glue reflux was observed into the parent vessel. (D) Vertebral artery angiography revealed complete revascularization in the basilar artery trunk, bilateral posterior cerebral artery and superior cerebellar artery, with no sign of residual distal occlusion and without contrast extravasation. (E) Postprocedure computed tomography showed ultrahigh density in the corpora quadrigemina and bilateral thalamuses. (F) Magnetic resonance imaging showed the presence of infarcts in pons. (G) Cerebral angiography at 18-month post stroke revealed no stenosis in vertebrobasilar artery.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.09.131
Thrombectomy was continued, and the microwire and the microcatheter were advanced without difficulty into the right posterior cerebral artery. A 4 mm 20 mm Solitaire FR stent retriever (Medtronic) was used to perform mechanical thrombectomy with complete extraction of the embolus after 1 pass and obtaining thrombolysis in cerebral infarction grade 3 recanalization (Figure 1D). Postprocedure CT showed ultrahigh density in the corpora quadrigemina and bilateral thalami (Figure 1E). Magnetic resonance imaging showed the presence of infarcts in pons 10 days later (Figure 1F). This patient was functionally independent (mRS ¼ 1) at 3 months. Cerebral angiography at 18 months post stroke revealed no stenosis in the vertebrobasilar artery (Figure 1G). Case 2 A 53-year-old female patient developed a sudden left hemiparesis. At arrival she had an onset of symptoms of 4 hours
Figure 2. Case 2. (A) Cerebral angiography showed complete occlusion of the M1segment of the middle cerebral artery (MCA). (B) Microcatheter angiography revealed a branch of superior trunk of MCA perforation (black arrowhead). (C) The ruptured vessel was
WORLD NEUROSURGERY 121: 19-23, JANUARY 2019
and 45 minutes. The patient had undergone a pulmonary lobectomy and multiple chemotherapies for lung adenocarcinoma within the past 2 years. Neurologic examination revealed a left hemiplegia and a right gaze deviation with a NIHSS score of 15. The brain CT examination confirmed the absence of intracranial hemorrhage. A cerebral angiography demonstrated a right middle cerebral artery (MCA) occlusion (Figure 2A). A 6-French guiding catheter (Cordis) was placed at the right internal carotid artery, and a Rebar 18 microcatheter was navigated into the right MCA over a Synchro soft 200-cm 0.014-inch microwire. The tip of microcatheter was placed into the M2 segment across the occlusion. Meanwhile, the vessel perforated by microwire was noted. The microcatheter was advanced over the microwire into the suspected vessel. Microcatheter angiography revealed contrast into the parenchyma, confirming a branch of superior trunk of MCA perforation (Figure 2B). This ruptured vessel was immediately embolized with 0.18 mL
embolized with 0.18 mL of Glubran 2 at 16.7% concentration. (D) A 24-hour follow-up computed tomography scan demonstrated ultrahigh density in the right frontotemporal region with frontal cortex infarction.
of Glubran 2 at 16.7% concentration. After that, a mechanical thrombectomy was performed using the 4 mm 20 mm Solitaire FR device with extraction of the embolus after 2 passes and obtaining an angiographic TICI 2b result (Figure 2C). A 24-hour follow-up CT demonstrated ultrahigh density in right frontotemporal region with frontal cortex infarction (Figure 1D). The mRS was 2 at 3 months. DISCUSSION MT is now the golden standard for the treatment of AIS with large vessel occlusion because of its high recanalization rates.13 However, MT also carries additional risks related to vascular access, microwire and microcatheter navigation, and stent retriever deployment and withdrawal. Vessel perforation is a seldom and serious complication of endovascular neurointervention, which requires urgent management as patients are at high risk of hemorrhagic stroke and further deterioration. In the Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis trial, this complication occurred in 1.3% of a total of 224 patients who underwent intracranial angioplasty and stenting, resulting in poor outcome (30-day mRS 5) in 2 patients.14 Dorn et al9 reported that the incidence of vessel perforation during Solitaire stent thrombectomy was 4.6% (5/108). First, most MTs were performed under local anesthesia or conscious sedation. It is difficult to acquire a good-quality roadmap for endovascular neurointervention when a patient suffers from severe neurologic deficit or lost consciousness. Theoretically, the incidence of this complication may be higher in endovascular therapy for AIS than that for intracranial atherosclerotic stenosis. The latter are nearly always performed under general anesthesia, which can provide an immobile patient with good image quality. The risk of wire perforation might increase when the microwire is managed in the occluded artery during endovascular treatment. Second, the incidence of perforation during operation is higher in the patients with serious atherosclerotic arteries or rigid emboli. The risk of wire perforation was also relatively high in segments with rich perforating branches. It might be reasonable to pass through the occlusion by manipulating the micro guidewire with a U-shaped tip. This technique could reduce the damage of vessel walls while it might increase the incidence of emboli escape. The clinical outcome of vessel perforation may not be catastrophic if it can be treated promptly. However, the best strategy to address this complication remains uncertain. Obviously, effective occlusion
REFERENCES 1. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11-20.
of the ruptured vessel may be the most crucial measure. Nguyen et al15 reported a case of vessel perforation during MT for acute middle cerebral artery occlusion. The authors’ strategy was to leave the microcatheter in the ruptured vessel to seal the perforated site and then abort the endovascular recanalization therapy. The patient’s neurologic status did not deteriorate after the procedure.15 In another study, intracranial balloon occlusion was attempted in 8 cases and 6 cases were dead in the hospital or at 3 months’ follow-up, unfortunately.16 The present study describes 2 cases in whom glue embolization was used to address these complications. The ruptured vessels were effectively embolized. Stent retriever thrombectomies were then continued, and TICI 2b and 3 recanalizations were achieved. Both patients had a favorable outcome. Vessel perforation may be caused by manipulation of microguidewire, microcatheter, and/or mechanical devices at the time of deployment or retraction. When vessel perforation is suspected, the initial step is never to withdraw the microguidewire or microcatheter from the damaged vessel. Otherwise, it would be difficult to recatheterize the same vessel. The microcatheter should be placed into the proximal portion of the ruptured vessel over the microguidewire. Next, a gentle microcatheter angiography is necessary to confirm vessel perforation. If perforation occurred in a small branch such as a perforating artery, glue embolization is preferable to coil embolization. Detachable coil embolization at the site of bleeding carries a certain risk of tearing the small vessel wall, causing a worse disaster, whereas glue can be easily injected through a microcatheter and withdrawn as soon as glue reflux is observed around the catheter tip. If perforation occurs in the large vessel, coil embolization of the damaged vessel segment may be an alternative to stopping further bleeding. There is no single technique available for the occlusion of all ruptured vessels because each situation is unique. If sacrificing an artery aimed to prevent further bleeding can save lives, this maneuver is appropriate. Rescue glue embolization appears to have encouraging results due to its ease of use and ability to occlude the ruptured vessel for stopping further bleeding.
CONCLUSION We believe that rescue glue embolization of the ruptured vessel should be considered as a treatment strategy of coincidentally vessel perforation during MT for AIS patients. Further studies with more patients will be needed to confirm the reproducibility of this technique.
assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019-1030. 4. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285-2295.
2. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009-1018.
5. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296-2306.
3. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized
6. Dorn F, Prothmann S, Patzig M, Lockau H, Kabbasch C, Nikoubashman O, et al. Stent
retriever thrombectomy in patients who are ineligible for intravenous thrombolysis: a multicenter retrospective observational study. AJNR Am J Neuroradiol. 2016;37:305-310. 7. Akins PT, Amar AP, Pakbaz RS, Fields JD. Complications of endovascular treatment for acute stroke in the SWIFT trial with solitaire and Merci devices. AJNR Am J Neuroradiol. 2014;35:524-528. 8. Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke. 2004; 35:904-911.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.09.131
9. Dorn F, Stehle S, Lockau H, Zimmer C, Liebig T. Endovascular treatment of acute intracerebral artery occlusions with the solitaire stent: singlecentre experience with 108 recanalization procedures. Cerebrovasc Dis. 2012;34:70-77. 10. Baek JM, Yoon W, Kim SK, Jung MY, Park MS, Kim JT, et al. Acute basilar artery occlusion: outcome of mechanical thrombectomy with Solitaire stent within 8 hours of stroke onset. AJNR Am J Neuroradiol. 2014;35:989-993. 11. Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet. 2012;380: 1231-1240.
12. Shi ZS, Liebeskind DS, Loh Y, Saver JL, Starkman S, Vespa PM, et al. Predictors of subarachnoid hemorrhage in acute ischemic stroke with endovascular therapy. Stroke. 2010;41: 2775-2781. 13. Ding D. Endovascular mechanical thrombectomy for acute ischemic stroke: a new standard of care. J Stroke. 2015;17:123-126. 14. Derdeyn CP, Fiorella D, Lynn MJ, Rumboldt Z, Cloft HJ, Gibson D, et al. Mechanisms of stroke after intracranial angioplasty and stenting in the SAMMPRIS trial. Neurosurgery. 2013;72:777-795, 795. 15. Nguyen TN, Lanthier S, Roy D. Iatrogenic arterial perforation during acute stroke interventions. AJNR Am J Neuroradiol. 2008;29:974-975.
WORLD NEUROSURGERY 121: 19-23, JANUARY 2019
16. Mokin M, Fargen KM, Primiani CT, Ren Z, Dumont TM, Brasiliense L, et al. Vessel perforation during stent retriever thrombectomy for acute ischemic stroke: technical details and clinical outcomes. J Neurointerv Surg. 2017;9:922-928.
Received 4 July 2018; accepted 17 September 2018 Citation: World Neurosurg. (2019) 121:19-23. https://doi.org/10.1016/j.wneu.2018.09.131 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.