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Inadvertent Self-Detachment of Solitaire AB Stent during the Mechanical Thrombectomy for Recanalization of Acute Ischemic Stroke: Lessons Learned from the Removal of Stent via Surgical Embolectomy.

Kang DH, Park J, Hwang YH, Kim YS - J Korean Neurosurg Soc (2013)

Bottom Line: The following diffusion weighted image MRI revealed no significant increase in infarction size, therefore, we performed surgical removal of the stent to rescue the patient and to elucidate the reason why the self-detachment occurred.Postoperative angiography demonstrated complete recanalization of the internal carotid artery.The patient's neurological deficits gradually improved, and the modified Rankin scale score was 2 at three months after surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Cardiocerebrovascular Center, Kyungpook National University Hospital, Daegu, Korea. ; Department of Radiology, Cardiocerebrovascular Center, Kyungpook National University Hospital, Daegu, Korea.

ABSTRACT
We recently experienced self-detachment of the Solitaire stent during mechanical thrombectomy of acute ischemic stroke. Then, we tried to remove the detached stent and to recanalize the occlusion, but failed with endovascular means. The following diffusion weighted image MRI revealed no significant increase in infarction size, therefore, we performed surgical removal of the stent to rescue the patient and to elucidate the reason why the self-detachment occurred. Based upon the operative findings, the stent grabbed the main thrombi but inadvertently detached at a severely tortuous, acutely angled, and circumferentially calcified segment of the internal carotid artery. Postoperative angiography demonstrated complete recanalization of the internal carotid artery. The patient's neurological deficits gradually improved, and the modified Rankin scale score was 2 at three months after surgery. In the retrospective case review, bone window images of the baseline computed tomography (CT) scan corresponded to the operative findings. According to this finding, we hypothesized that bone window images of a baseline CT scan can play a role in terms of anticipating difficult stent retrieval before the procedure.

No MeSH data available.


Related in: MedlinePlus

Surgical finding of the acutely angled and circumferentially calcified distal ICA (A) before arteriotomy is showing. Surgically removed Solitaire AB stent is containing the main thrombi at the distal part of the stent strut (B). A-P and lateral angiography immediately after surgery is showing full recanalization of the occlusion (C and D). Bone window image of a baseline CT scan shows severely and circumferentially calcified supraclinoid segment of the ICA (arrow), which corresponds to the surgical finding (E). ICA: internal carotid artery.
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Figure 3: Surgical finding of the acutely angled and circumferentially calcified distal ICA (A) before arteriotomy is showing. Surgically removed Solitaire AB stent is containing the main thrombi at the distal part of the stent strut (B). A-P and lateral angiography immediately after surgery is showing full recanalization of the occlusion (C and D). Bone window image of a baseline CT scan shows severely and circumferentially calcified supraclinoid segment of the ICA (arrow), which corresponds to the surgical finding (E). ICA: internal carotid artery.

Mentions: The patient underwent an extended superciliary approach as canvassed in a previous report by the present authors6). We first created a supraorbital craniotomy, and dissection of the proximal sylvian fissure revealed an intracranial ICA that was diffusely atherosclerotic and occluded with the Solitaire stent harboring the embolus (Fig. 3A). A part of superior wall of the ICA that was not atherosclerotic and contained the distal part of the stent was chosen for arteriotomy. A 5-mm longitudinal incision was required to remove the stent and associated embolus. The neurovascular surgeon first pulled the stent carefully but failed to remove, which was probably caused by some strut of the stent engaging a part of calcified lumen, then reinforced the pulling force resulted in successful removal of the stent finally. The stent grabbed the main thrombi at distal part of the stent and both proximal and distal markers of the stent were preserved (Fig. 3B). The arteriotomy site was repaired by a clip assisted micro-suture technique. Persistent arterial blood flow below the clip was ascertained with a microvascular Doppler. Postoperative angiography demonstrated complete recanalization of the ICA (Fig. 3C, D). The patient's neurological deficits improved, and the modified Rankin scale score was 2 at three months after surgery.


Inadvertent Self-Detachment of Solitaire AB Stent during the Mechanical Thrombectomy for Recanalization of Acute Ischemic Stroke: Lessons Learned from the Removal of Stent via Surgical Embolectomy.

Kang DH, Park J, Hwang YH, Kim YS - J Korean Neurosurg Soc (2013)

Surgical finding of the acutely angled and circumferentially calcified distal ICA (A) before arteriotomy is showing. Surgically removed Solitaire AB stent is containing the main thrombi at the distal part of the stent strut (B). A-P and lateral angiography immediately after surgery is showing full recanalization of the occlusion (C and D). Bone window image of a baseline CT scan shows severely and circumferentially calcified supraclinoid segment of the ICA (arrow), which corresponds to the surgical finding (E). ICA: internal carotid artery.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3756129&req=5

Figure 3: Surgical finding of the acutely angled and circumferentially calcified distal ICA (A) before arteriotomy is showing. Surgically removed Solitaire AB stent is containing the main thrombi at the distal part of the stent strut (B). A-P and lateral angiography immediately after surgery is showing full recanalization of the occlusion (C and D). Bone window image of a baseline CT scan shows severely and circumferentially calcified supraclinoid segment of the ICA (arrow), which corresponds to the surgical finding (E). ICA: internal carotid artery.
Mentions: The patient underwent an extended superciliary approach as canvassed in a previous report by the present authors6). We first created a supraorbital craniotomy, and dissection of the proximal sylvian fissure revealed an intracranial ICA that was diffusely atherosclerotic and occluded with the Solitaire stent harboring the embolus (Fig. 3A). A part of superior wall of the ICA that was not atherosclerotic and contained the distal part of the stent was chosen for arteriotomy. A 5-mm longitudinal incision was required to remove the stent and associated embolus. The neurovascular surgeon first pulled the stent carefully but failed to remove, which was probably caused by some strut of the stent engaging a part of calcified lumen, then reinforced the pulling force resulted in successful removal of the stent finally. The stent grabbed the main thrombi at distal part of the stent and both proximal and distal markers of the stent were preserved (Fig. 3B). The arteriotomy site was repaired by a clip assisted micro-suture technique. Persistent arterial blood flow below the clip was ascertained with a microvascular Doppler. Postoperative angiography demonstrated complete recanalization of the ICA (Fig. 3C, D). The patient's neurological deficits improved, and the modified Rankin scale score was 2 at three months after surgery.

Bottom Line: The following diffusion weighted image MRI revealed no significant increase in infarction size, therefore, we performed surgical removal of the stent to rescue the patient and to elucidate the reason why the self-detachment occurred.Postoperative angiography demonstrated complete recanalization of the internal carotid artery.The patient's neurological deficits gradually improved, and the modified Rankin scale score was 2 at three months after surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Cardiocerebrovascular Center, Kyungpook National University Hospital, Daegu, Korea. ; Department of Radiology, Cardiocerebrovascular Center, Kyungpook National University Hospital, Daegu, Korea.

ABSTRACT
We recently experienced self-detachment of the Solitaire stent during mechanical thrombectomy of acute ischemic stroke. Then, we tried to remove the detached stent and to recanalize the occlusion, but failed with endovascular means. The following diffusion weighted image MRI revealed no significant increase in infarction size, therefore, we performed surgical removal of the stent to rescue the patient and to elucidate the reason why the self-detachment occurred. Based upon the operative findings, the stent grabbed the main thrombi but inadvertently detached at a severely tortuous, acutely angled, and circumferentially calcified segment of the internal carotid artery. Postoperative angiography demonstrated complete recanalization of the internal carotid artery. The patient's neurological deficits gradually improved, and the modified Rankin scale score was 2 at three months after surgery. In the retrospective case review, bone window images of the baseline computed tomography (CT) scan corresponded to the operative findings. According to this finding, we hypothesized that bone window images of a baseline CT scan can play a role in terms of anticipating difficult stent retrieval before the procedure.

No MeSH data available.


Related in: MedlinePlus