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Incidental superior cerebellar artery aneurysm in a 70-year-old woman. A,B) 2D angiography (A) and 3DRA (B) show the large left superior cerebellar artery aneurysm with donut-shaped lumen. C) Circular deposition of coils in the donut-shaped lumen. D) Almost complete occlusion after coiling.
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The cerebral protection device (CPD) itself may cause complications, including locking between the CPD and other devices, that may result in catastrophic outcomes requiring surgical removal of these locked devices. We describe a case of locking between a CPD and the stent-delivering catheter during carotid artery stenting, which was safely rescued...
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Key Clinical Message
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Citations
... However, EPD is related to periprocedural complications during CAS. Entrapment of EPD in stents is a very rare complication, and most cases are resolved by surgical removal [10][11][12]. Page et al. [12] reported a case of a retained EPD during CAS necessitating open surgical removal. In this case, numerous attempts were made to retrieve the Spider Fx EPD with an angioplasty balloon, diagnostic catheter, or dilator sheath. ...
Background
Distal embolic protection devices have been widely used to reduce the incidence of embolic events during carotid artery stenting. Entrapment of an embolic protection device is an extremely rare complication, and most cases are resolved by surgical removal.
Case presentation
A 67-year-old male underwent carotid artery stenting with an embolic protection device. During the procedure, the embolic protection filter became entrapped within the stent. The complication was resolved endovascularly without sequelae.
Conclusion
The most important step in stenting is to be careful until the procedure is completed. However, if complications occur during the operation, in-depth knowledge of the catheters, wires, and devices will help the operator resolve the problem using endovascular techniques.
... The most common causes of difficult retrieval of CPD are strongly calcified plaques, residual in-stent stenosis, carotid tortuosity and re-CAS due to stent fracture [9][10][11][12]. Neurological complications may occur due to vasospasm, filter thrombosis, cerebral embolism or carotid artery dissection [13,14] The first choice in the retrieval of entangled CPD is endovascular technique, effective in most cases [15,16]. In case of failure, conversion to open surgery is necessary [17][18][19]. ...
... According to many authors, there is a huge risk of occlusion of the filter caused by thrombosis and occlusion of filter pores by embolization and hyperplasia. However, these observations concern acute, intraoperative occlusion [5,16]. We did not find results regarding late carotid filter patency in the literature. ...
... Cerebral-protection devices (CPDs) are an effective tool for reducing the risk of embolic complications during carotid artery angioplasty and stenting (CAS) [1,2]. However, the CPD itself may cause complications that may result in serious outcomes requiring rescue maneuvers and/or surgical removal of the device with iatrogenic sequelae [3][4][5][6][7]. ...
Introduction:
Cerebral-protection devices (CPDs) are a well-established system for reduction of embolic risk in carotid artery angioplasty and stenting (CAS). Although rare, adverse events with CPDs are unpredictable and can be associated with serious outcomes and iatrogenic sequelae.
Presentation of case:
We describe the unique case of dislocation of a FilterWire EX™ filter loop during right CAS. On trying to recapture the CPD filter at the end of the procedure, the filter loop suddenly detached from the guidewire and dislocated to the proximal middle cerebral artery. Attempted retrieval of the loop failed and the patient developed a transient neurological deficit caused by an acute ischemic infarction in the lenticular nucleus. No further retrieval attempt was pursued. No further dislocation of the loop or clinical event have been reported during the 16-year follow up.
Discussion:
This case reported a favorable outcome of conservative management for entrapped material from a CPD after iatrogenic damage from failed retrieval. No similar reports are available in the literature, and conservative management is generally not a recommended approach because of the potential complications. However, rescue retrieval attempts are as well a potential source of serious events, and no clear guidelines exist on the management of mechanical complications from CPD.
Conclusion:
Entrapment of CPD components constitutes an adverse event with no unique solution for risk-free management. The potential risks associated with the use of protection devices are still to be fully explored, and improving the standard of care and patient safety needs to be a top priority.
... This was avoided by gently withdrawing the locked EPD Solitaire stent complex by first advancing the introducer sheath and collapsing the membranous portion of the EPD within the stented segment. 10 The subsequent removal of the locked complex was successful and without any clinical sequelae. ...
Inadvertent occlusion of an internal carotid artery (ICA) during stenting may be a catastrophic situation requiring a bailout operation to prevent permanent neurologic sequelae. The underlying mechanisms of ICA occlusion may include filter-related flow arrest, arterial dissection, vasospasm, and the accordion effect, and timely differential diagnosis is crucial for appropriate management. We present herein a case of stenting-related accordion effect that led to complete ICA occlusion, wherein temporary placement of a retrievable intracranial stent for rescue was successful in achieving flow restoration, but further complicated by engagement with the filter. The differential diagnosis, preventive measures, and management of the accordion effect are discussed.
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... This was avoided by gently withdrawing the locked EPD Solitaire stent complex by first advancing the introducer sheath and collapsing the membranous portion of the EPD within the stented segment. 10 The subsequent removal of the locked complex was successful and without any clinical sequelae. ...
Intracranial stent designed for the treatment of wide-neck aneurysm Braided design allows the fine nitinol wires to slide smoothly onto each other to reach perfect vessel conformability, as well as provide coil support
Objective:
To carry out surgery safely for vessels in which stents were placed, it is essential to have knowledge of what would happen if the stents were clamped or cut. Using all stents that are permitted in Japan, we recorded with surgical microscope in detail the behavior of the stents when they were clamped or cut, and discussed the morphological changes along with image findings.
Methods:
We classified carotid artery and intracranial stents as Group 1A, 1B, 2A, 2B according to the structure of stent eye; laser cut-type or bladed-type. Each stent was clamped using a YASARGIL aneurysm clip, Bulldoc forceps and vascular forceps. Degree of closure and presence or absence of stent deformation after declamp were recorded using a surgical microscope. Furthermore, we carried out morphological evaluations using high-resolution cone-beam CT. Lastly each stent was cut and the behavior was also recorded and differences between stents were examined.
Results:
Complete clamp was confirmed both visually and based on image evaluations with the Bulldoc forceps and vascular forceps in the Groups of carotid artery stents, with the YASARGIL aneurysm clip in the Groups of intracranial stents. In the Groups of bladed-type stents, we found that the stents elongated during clamp and the component wire scattered at the time of stent cutting. Furthermore, they can be easily separated by holding with forceps.
Conclusions:
Knowing the properties of each stent is essential to conduct safe surgery in response to problems. Special care must be taken when clamping and cutting bladed-type stents.
Background
Despite the development of neuroendovascular treatment, device-related complications requiring surgical procedures remain. We report a case requiring surgical retrieval of a filter protection device in carotid artery stenting (CAS) with an open-cell stent, due to stent deformation, and review past reports on CAS in which surgical retrieval of devices was required.
Case Description
An 82-year-old man underwent CAS for symptomatic right internal carotid artery stenosis with severe calcification and tortuosity. Immediately after placement of the open-cell stent, stent deformation was detected and the filter protection device could not be retrieved. All noninvasive device retrieval attempts failed, and the device was ultimately retrieved surgically. After surgery, right cerebral infarction progressed increased, but no permanent deficit was observed.
Conclusions
As the treatment of cerebrovascular disease shifts from surgical to endovascular approaches, surgeons must be familiar with devices and techniques to manage complications of neuroendovascular treatment.
Background:
Crossing a nascently deployed carotid artery stent (CAS) is required to perform angioplasty and filter recapture. If the traversing balloon or filter recapture catheters are eccentric or tangentially angled to the vertical axis of the CAS they can ensnare on the ledge of the proximal CAS step-off, potentially causing life-threatening complications secondary to deformation, displacement, or mechanical occlusion of the stent. We report a novel "balloon bridge" technique that facilitates safe entry and passage across the CAS with both a balloon catheter and an LBGC.
Methods:
We used the balloon bridge technique for two patients with >90% carotid artery stenosis and steep carotid artery angles of origin who underwent routine CAS, balloon angioplasty, and distal embolic protection. During filter recapture, the balloon was inflated across the junction of the distal LBGC tip and proximal CAS, centering the LBGC within the vessel lumen and CAS. During balloon deflation, the LBGC was sequentially advanced successfully navigating the LBGC across the proximal stent construct without resistance or complication.
Results:
The balloon bridge technique was completed without complications. We believe that the mechanism of action is secondary to balloon facilitated LBGC alignment with the true axis of the stent.
Conclusions:
Traversing a CAS with a LBGC or balloon catheter can be tedious and fraught with the potential of neurologic peril should mechanical deformation and occlusion occur. The balloon bridge technique is safe and highly effective for navigating a catheter that is eccentric or tangentially angled to the long axis of a CAS.
