Stentectomy of detached Solitaire – Novel techniques

Vipul GuptaMedanta, The Medicity

New Delhi, India

Case report – Stentectomy case 1

• Case 1: Seventy one year old male presented within 2 hours with global aphasia and right sided weakness (NIHSS – 22). Multimodal CT imaging revealed a NCCT ASPECTS of 10, occlusion of left internal carotid artery (ICA) from the origin and distal left M1 middle cerebral artery (MCA) and A2 anterior cerebral artery (ACA). Intravenous thrombolysis was not offered due to recent history of stroke. TICI 3 reperfusion was established in the MCA territory after a single pass with SOLITAIRE 4 x 40 mm stent. Following that, during second pass for the A2 ACA thrombus stent detachment occurred. The proximal radio-opaque marker of the detached stent was noted abutting the wall at the proximal genu of the cavernous ICA. There was no flow in the ACA territory. Snare retrieval with Amplatz goose neck microsnare (4 mm) failed. Therefore, stent based retrieval was performed with a SOLITAIRE 4 x 40 mm stent (Figure 1). TICI 3 reperfusion was established in the ACA territory and the 3 months mRS was 1.

A – Left A1 ACA and M1 MCA occlusion

B – left A1 ACA occlusion; TICI 3 reperfusion in left MCA territory

C – native image showing deployed stent in left A2 – A3 ACA

• 71 male; Global aphasia and right sided weakness (NIHSS – 22) – 2 hours• NCCT ASPECTS of 10; Intravenous thrombolysis was not offered due to

recent history of stroke.

D: distal (white arrow) and proximal (black arrow) markers of the detached stent

E - distal end of the detached stent(BOLD white arrow), distal end of the second stent (black arrow), proximal end of detached stent (white arrow), Distal marker of the microcatheter (BOLD black arrow)

Post stentectomy DSA - TICI 3 reperfusion

Technique: A ‘deploy and engage’ technique was used to capture the proximal end of detached stent. The ‘deployment’ step involves partial deployment (distal radio-opaque markers have expanded and are opposed to wall of the ICA) of an appropriately sized solitaire device proximal to or within the detached stent. The ‘engagement’ step involves advancing the ‘microcatheter - partly deployed stent complex’ in an attempt to engage the proximal part of the detached stent. The proximal stent is then re-sheathed to capture the proximal legs/ struts of the detached stent. Following that, microcatheter, device and detached stent are retrieved (Figure 2).

3 month mRS - 1

Line art demonstrating the technique of Stentectomy by Deploy and engage technique

Stentectomy case 2

Case 2: A 50 year old female presented at 3.5 hours with global aphasia and right sided weakness (NIHSS 21). Multimodal imaging revealed left M1 MCA occlusion and a small core. Intravenous thrombolysis was deferred due to a recent history of myocardial infarction. Stent detachment occurred during the third pass with SOLITAIRE 4 x 40 mm. Both snare and stent based retrieval failed. A ‘loop and snare’ technique was employed and the stent was retrieved successfully. TICI 2a reperfusion was established.

A- occluded proximal left M1 MCA

B- detached stent – distal and proximal markers (white arrow); left M1 MCA is occluded

C- distal end of the detached stent (white double arrow heads); proximal marker of detached stent (white single arrow head); proximal and distal marker of the microcatheter (single white arrow); microwire (black arrow)

• 50 female; 3.5 hours; Global aphasia and right sided weakness (NIHSS 21). NCCT ASPECTS – 8

D – snaring of the microwire Road map showing distal and proximal markers of the removed stent

E- detached stent (white arrow); Microcatheter (BOLD white arrow); Snare (SOLID white arrow)

F- TICI 2 A reperfusion

‘Loop and snare’ technique: A small caliber microcatheter with a curved tip (Steam shaped) is advanced through the detached stent. Following that, the microwire is navigated through the struts and back into the parent artery to form a loop. The microcatheter is then navigated over the microwire into the parent artery. A 4 mm snare is then advanced into the parent artery and the microwire is snared. Following that, the microcatheter and the snare are pulled back together with an attempt to retrieve the stent.

Line art demonstrating the stentectomy technique – Loop and Snare

Key learning points

• Why removal of detached stent (stentectomy) ? – avoids use of lytic/ dual antiplatelet

• Stentectomy technique : Snare – however unsuccesful in many cases Deploy and engage Loop and snare

• Can be used to remove displaced stents during stent assisted coiling

Acutely ruptured blister aneurysm –Prasugrel loading followed FD placement

Case series

DSA – Blister aneurysm of left ICA

Antiplatelet protocol:

Ecosprin 150 mgPrasugrel 50 mg

2 hrs prior to stent deployment

Heparin 3000 IU at start of procedure1000 IU to 2000 IU prior to stent deploymentACT 300 (x 2 upper limit of normal)

A 63-year-old female patient presented with Fisher grade 2 subarachnoid hemorrhage.

Fig. 1 A & B – 3D reconstructed images show a fusiform aneurysm of supraclinoid ICA at the level of PCOM with a prominent ventral bulge (arrow, A). Another very small aneurysmal bulge seen from A1 segment of right ACA (arrowheads, A, B). Small aneurysm also seen in right ICA paraclinoidal segment pointing medially (arrow, B). C- DSA in working projection. D- Pipeline reconstruction device. E- native image showing good opposition of the flow diverter to the arterial wall. F- Post stenting DSA shows persistent filling of the aneurysm.

D E F

B CA B

Fig. 2 Follow-up angiogram. A- DSA shows complete occlusion of the fusiform aneurysm. Minimal filling of left ACA seen. B- Native image of DSA shows intimal growth over the stent. C & D – 3D reconstructed images shows complete occlusion of the ICA aneurysms with minimal opacification of ACA.

B

C D

A

17 patients: SS, ODS, SS+Coil 1 rebleed (died)Good outcome on f/u – 82%Mortality – 18%

Blister Aneurysm

Our experience with FD vs non FD

Complete occlusion – 89% vs 71% i.f.o FD

Repeat treatment – none vs 11.7% i.f.o FD

Rebleed resulting in death – none vs 5.8% i.f.o FD

Submitted for publication

Learning points

• In our series loading with Prasugrel and Ecosprin was safe and effective for flow diverter placement in acutely ruptured blister aneurysms

• Timing is critical, we loaded two hours before the procedure

• • FD was safe and effective in these aneurysms and

compared favorably with our previously reported results with stent(single/overlapping) and coiling

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