Solitaire® stent for endovascular coil retrieval

Unexpected coil mass migration during transvenous embolization of a dural arteriovenous fistula resolved with guidewire-assisted snaring technique

Endovascular embolization is a standard treatment for dural arteriovenous fistulas (dAVFs). Although it is considered relatively safe, intraoperative and postoperative complications can occur. Herein, a rare case of unexpected coil mass migration requiring a retrieval procedure during sinus occlusion for a transverse-sigmoid sinus dAVF (TSdAVF) is described. An 83-year-old man presented with worsening decline in cognitive function. Magnetic resonance angiography showed a TSdAVF. Since his symptoms seemed to be a result of the TSdAVF, transvenous embolization preserving the normal cranial venous circulation was planned. During sinus occlusion, including embolization of the shunted pouch of the TSdAVF, unexpected migration of the coil mass to the confluence of the superior sagittal sinus and the transverse sinus occurred. The migrated coil mass impeded venous circulation in the superior sagittal sinus. Since the presence of the coil mass at the confluence could have had catastrophic sequelae, the coil mass was retrieved using a guidewire-assisted snaring technique. Sinus occlusion was subsequently completed with repositioning of the coil mass at the target site. The TSdAVF resolved, with no recurrence confirmed for 1 year. Clinicians should be aware that coil mass migration can unexpectedly occur during sinus occlusion performed for treatment of a TSdAVF. The guidewire-assisted snaring technique might be effective in resolving this intraoperative complication.

Strategy of stretched Coils: Insights from a single center experience

OBJECTIVE

A stretched coil, characterized by excessive elongation within the parent artery during a coil embolization procedure, poses a significant risk of forming a thrombus. This study reports on cases of stretched coils spanning 16 years and discusses effective assessment methods and treatment strategies.

METHOD

Retrospective analysis of the institutional database comprising 14 cases where stretched coils were observed during coil embolization procedures was conducted, starting from January 2007.

RESULTS

Among the 14 cases, four involved coil embolization for subarachnoid hemorrhage due to ruptured aneurysm, while the remaining cases were unruptured aneurysms. Starting in 2017, vaso-computed tomography (vaso-CT) was employed in nine cases to evaluate the proximal end of the stretched coils. Reimplantation was performed in 3 cases. Among them, two cases were relieved by pushing the coil delivery wire or microwire, while one case underwent balloon-assisted reimplantation. The stretched coils were removed in three cases by pulling. A rescue gooseneck microsnare technique was applied in one case. The stent was fixed in five cases. In two cases, no additional procedures were performed. Thrombosis is a potential complication that occurred in three cases of stretched coils.

CONCLUSION

Many studies have addressed coil stretching and introduced various rescue methods, but relying solely on angiography for diagnosis or applying an inappropriate rescue technique can lead to ischemic stroke. This study emphasized the importance of vaso-CT as a tool for accurately identifying the proximal end of a stretched coil. Additionally, we aimed to facilitate the selection of an appropriate rescue technique.

Retrieval of Migrated Coils From Distal Cerebral Vasculature Using Stent Retriever: A Case Series

The incidence of coil dislocation during an endovascular embolization of intracranial aneurysm is low but it can lead to serious thrombo-embolic complications. Therefore, coil displacement/migration often requires either retrieval or fixation of the errant coil with a stent. There are no standard recommended methods of coil retrieval. We present a series of three cases in which off-label application of a stent retriever allowed successful retrieval of herniated coils.

Parent artery stenting as a rescue management for stretched coils during cerebral aneurysms embolization: Report of three cases and review of literature

BACKGROUND

Displacement of a stretched coil into the parent artery during intracranial aneurysm coiling is a challenging situation where the risk of acute intravascular thrombosis might be a life-threatening condition. The usual way of management is coil snaring, yet in some cases, it might not be feasible to retrieve the coil. Parent artery rescue stenting had already been described as a way of management in acutely thrombosed parent arteries during aneurysm coiling.

CASE REPORTS

We present three cases with an inadvertent displacement of the unraveled coils into the parent artery for which rescue stenting was carried out to crush the coil against the vessel wall aiming to eliminate its thrombogenic effect. Our preliminary experience is that rescue stenting of the parent artery for stretched coil could be a convenient effective option particularly in case of failed/risky snaring with no notable immediate or long-term complications.

REVIEW AND DISCUSSION

We review the reported cases of stretched coils with or without further unraveling and fracture and discuss the possible consequences, salvage methods, and clinical outcomes. Neurointerventionists should be aware of this complication and get acquainted with bailout strategies.

Emergency surgical removal of a migrated coil during embolization of a giant internal carotid artery aneurysm: illustrative case

BACKGROUND

Coil migration during endovascular treatment for an intracranial aneurysm is rare. When it occurs intraoperatively, it often mandates prompt endovascular retrieval or, as a salvage maneuver, microsurgical extraction if it fails endovascularly.

OBSERVATIONS

The authors presented a case of immediate coil migration during embolization of a giant intracranial cavernous segment of the internal carotid aneurysm. The patient immediately underwent emergency surgical extraction after unsuccessful endovascular retrieval attempts. The migrated coil was successfully removed through the M1 segment of the middle cerebral artery. The patient had full recovery without new neurological deficits. Four years after the incident, she was living independently. Previous case reports of emergency surgical removal of immediate coil migration were provided.

LESSONS

Surgical extraction of migrated coil after unfeasible endovascular retrieval served as an alternative salvage procedure. Hybrid neurological angiography in the operating suite may prevent unnecessary transfer and provide better real-time visualization of the migrated coil.

Endovascular retrieval of a dislocated pushable coil in the common hepatic artery using a cerebral stent retriever

BACKGROUND

This is case of removing a dislocated pushable coil from the common hepatic artery (CHA) as a possible complication of using pushable coils in the embolization of an upper gastrointestinal bleeding (UGIB) from the gastroduodenal artery (GDA) by using a pRESET stent retriever (Phenox, Bochum, Germany) which is utilized mainly for treatment of endovascular stroke.

CASE PRESENTATION

An 88-year-old female patient was referred to our hospital to get an emergency embolization of the GDA causing an UGIB with a relevant drop of the hemoglobin level. During the routine embolization of the GDA using pushable coils, a complete dislocation of the last coil into the CHA took place leading to a relevant slowing down of the arterial blood flow to the liver. A decision was thereby made to remove the dislocated coil to avoid further possible complications which was successfully achieved.

CONCLUSIONS

Various stent retrievers have been proven to be effective in removing dislocated coils during intracerebral coiling of different pathologies. This case report is to our knowledge the first case report proving the high efficacy and safety of using yet another stent retriever, namely a pRESET stent retriever in removing a fully dislocated coil in the abdominal vessels, namely in this case the CHA.

Mechanical Embolectomy of Distally Migrated Onyx After Surgical Resection of Glomus Vagale Tumor: Technical Report and Review of Literature

BACKGROUND

Endovascular embolization is an important tool in the management of multiple pathologies as a preoperative adjunct in the care of arteriovenous malformations or vascular tumors.

CASE DESCRIPTION

We report a case of delayed distal Onyx migration after surgical resection of a glomus vagale tumor, which had been preoperatively embolized. In this report, the patient underwent successful embolectomy of the migrated Onyx fragment using manual aspiration.

CONCLUSIONS

This case represents the first in the literature to describe this potential delayed complication, as well as its management strategy.

Endovascular Retrieval of Dislodged Neurovascular Devices with a Stentriever: Case Series and Technical Review

PURPOSE

Endovascular treatment of neurovascular disorders is now well established as effective and safe; however, the nature of the intracranial vasculature poses unique challenges. The unintentional dislodgement or fracture of a device and its migration within cerebral vessels is a complication with serious potential morbidity that must be managed urgently. In this series, the authors describe 7 cases of a stentriever being used to remove foreign objects from within the cerebral vasculature.

METHODS

A retrospective search of all interventional neurovascular procedures performed in 2017 at a tertiary metropolitan hospital was performed to identify cases of dislodged devices.

RESULTS

Five dislodged endovascular coils, 1 microcatheter, and 1 fractured stentriever were technically successfully retrieved. In 6 of the cases, the foreign object was successfully removed with a stentriever alone, whereas 1 case used a J-tip wire and a "J-tip flick" to manipulate the coil and facilitate retrieval. Stentrievers, particularly when used alone, confer the advantages of speed, cost, as well as being tailor-made for cerebral vessels. They also allow continuous blood flow when deployed, a critical advantage when considering cerebral perfusion. Critical techniques include the gradual deployment of the stentriever alongside the foreign object to allow its entanglement and partial resheathing, so that the foreign object can become pinned within the microcatheter. Stentrievers do remain limited by vessel caliber and are less able to entangle larger, stiffer devices.

CONCLUSION

The migration of foreign devices during neurointerventional procedures is a serious complication requiring urgent treatment. This case series highlights the efficacy and advantages of using a stentriever and suggests its consideration as a first-line technique in recovering dislodged foreign bodies in the cerebral vasculature.

Snare technique for endovascular retrieval of coil extending to the atrium after embolization of a dural arteriovenous fistula

BACKGROUND

No data exist regarding retrieval of displaced or stretched coil extending to the right atrium after endovascular embolization of cerebrovascular diseases. We describe a snare technique for retrieval of a displaced coil extending to the right atrium after embolization of dural arteriovenous fistula (DAVF).

METHODS

A 35-year-old female with a DAVF underwent transjugular coil embolization that failed with displaced coil extending to the right atrium at an outside hospital. After admission to our hospital, Onyx embolization of the DAVF was performed through left facial vein-inner canthus vein-superior ophthalmic vein to the cavernous sinus. Post-embolization angiography showed complete occlusion of the DAVF. Then we attempted to snare the tip of the displaced coil that extended to the right atrium through femoral vein-inferior vena cava approach. However, current snare techniques failed to retrieve the extended coil after several attempts. Then one week later, we used a modified dual microcatheter and microwire technique to retrieve the displaced coil. One suite of microcatheter and microwire was used to produce a handmade snare device (HMD). The other suite of microcatheter and microwire was used to assist the HMD to snare the displaced coil.

RESULTS

Through transjugular vein approach, we used our modified dual microcatheter and microwire snare technique (handmade snare device system) to retrieve the extended coil. After several attempts, the extended coil in the atrium was successfully retrieved. Post-procedure angiography and cardiac examinations did not show any signs of abnormality.

CONCLUSIONS

For displaced coil extending to the right atrium after transvenous embolization, our method of modified dual microcatheter technique with HMD snare device system is an effective method to retrieve the extending coil.

Magnetic wires: A novel design for neuroendovascular coil retrieval

The present study aimed to evaluate the operation, application and safety of a novel prototype device designed for the retrieval of a migrated coils, an intraprocedural complication of endovascular aneurysm treatment, compared with the widely used Solitaire AB stent retriever. The prototype retrieval device, referred to as magnetic wires, consisted of two microwires that were joined by a small magnetic ring near to the tips. To retrieve a coil, the wires are advanced through the dislodged coil one at a time and then capture the target coil in a chopstick-like manner, as their tips are attracted to the magnet. In vitro tests were performed five times for each retrieval device using a pulsing flow circulator to compare retrieval effectiveness. In vivo efficacy testing was performed in 5 male piglets. The left and right carotid arteries were used to assess the magnetic wires and the Solitaire retriever, respectively. While the two devices successfully retrieved coils in vitro at a rate of 100%, the magnetic wires did so in a shorter time. In vivo, the magnetic wires successfully captured the migrated coils in 3/5 cases (60%), whereas the Solitaire AB stent retriever was successful 4/5 cases (80%). Endothelial injury was observed following magnetic wires retrieval in 1/5 cases (20%) and following use of the Solitaire AB stent retriever in 3/5 cases (60%). These results demonstrate the feasibility and safety of this novel prototype coil retrieval device, which with further development has the potential to be an optimal device for the retrieval of dislodged coils.

Endovascular Coil Retrieval Using Dual Synchronous Solitaire Revascularization Devices

BACKGROUND AND IMPORTANCE

Coil migration is a potential complication of endovascular aneurysm treatment. Dislodged coils into the parent artery require retrieval to prevent thromboembolic complications. A variety of techniques for coil retrieval have been described, including the use of single stentrievers and aspiration catheters.

CLINICAL PRESENTATION

The use of 2 stentrievers, as opposed to a single device, was thought to be advantageous in coil removal by the additional point of friction due to the extensive length of coil stretching and earlier failure of a single device.

CONCLUSION

In this report, 2 synchronous Solitaire FR Revascularization Devices (Covidien/Medtronic, Dublin, Ireland) were deployed, 1 distal and 1 proximal, to retrieve an inadvertently deployed coil.

Endovascular Retrieval of Migrated Coil within the Distal Middle Cerebral Artery Using Stentriever Device

BACKGROUND

Displacement of endovascular coils during endovascular embolization of an intracranial aneurysm is a potentially life-threatening complication. Several methods for coil retrieval have been described, including the use of microsnares and microforceps retrieval devices. With the recent surge of stentriever implementation in the treatment of ischemic stroke, some operators are now using such devices in the retrieval of migrated coils. We present a case of a balloon-assisted coil embolization of a communicating segment internal carotid artery aneurysm, complicated by coil migration far distally into the middle cerebral artery, which was retrieved successfully with a stentriever. To the best of our knowledge, this is the furthest migration of a coil to be successfully retrieved with a stentriever. We review conservative and invasive management of displaced coils and the technical advantages of stentrievers over retrieval devices.

METHODS

The patient's medical records were retrospectively reviewed, including clinical and radiographic information. This study received institutional review board approval.

RESULTS

The patient was treated with balloon-assisted coil embolization of the internal carotid artery aneurysm. The migrated coil was retrieved successfully using a novel application of a stentriever.

CONCLUSIONS

In certain situations, a stentriever does not mandate complete ensnaring of the target to be retrieved and thus need not always be deployed distal to a migrated coil mass to be successful. Due to the mechanical advantage of strut-engagement, stentrievers can afford to be positioned in relatively suboptimal positions, and this is especially useful in cases involving tortuous and small distal vessels (<2 mm diameter).

Retrieval of a migrated coil with a handmade microwire-snare device

BACKGROUND

Intraprocedural coil migration during endovascular treatment of intracranial aneurysms is associated with potential vessel occlusion and thromboembolic complications. There is no standard management strategy for coil migration. Here, we describe our experience with using a handmade microwire-snare device (HMD) to retrieve a migrated coil.

METHODS

The HMD consists of a 0.017-inch microcatheter, a 0.014-inch microwire, and a 4-0 silk thread. The ring of the microwire-snare device can open, close, and twist in a figure eight pattern for coil entwinement. In addition, the ring can be shaped as needed to navigate tortuous vessels or capture the migrated coil.

RESULTS

The HMD was successfully used to retrieve two migrated coils. In the first case, the coil was displaced in the M2 branch of the middle cerebral artery. In the second case, the coil loop prolapsed into the parent artery. In both cases, control cerebral angiograms performed after retrieval confirmed the patency of the vessels and a lack of thromboembolic complications. At the 3-month follow-up, magnetic resonance angiography demonstrated stable patency of the affected vessels.

CONCLUSIONS

The HMD is a cost-effective, easy-to-use, safe, and universally available device for retrieving migrated coil(s) during intracranial aneurysm embolization procedures.

Retrieval of Distally Migrated Coils with Detachable Intracranial Stent during Coil Embolization of Cerebral Aneurysm

Migration of coils during endovascular procedures is a rare, but well-known complication. We are reporting two cases of successfully retrieving migrated coil using detachable intracranial stent. In both of our cases there was distal migration of coil during the intracranial aneurysm coiling procedure. The Solitaire® AB stent (Covidien, Irvine, CA, USA) was used to retrieve those coils. The stent was passed distal to the migrated coil using standard technique. It was then partially deployed and gradually withdrawn along with the entangled coil. Coil retrieval using the fully retrievable intracranial stent is a very simple, safe and easily available alternative for retrieval of distally migrated coil.

Endovascular retrieval of a dislocated coil in the peroneal artery with a stent retriever

We present a patient who underwent successful removal of a fully detached platinum coil from the peroneal artery using a Solitaire^™ stent retriever (Covidien, Irvine, CA) that is usually used in endovascular stroke treatment.

A direct aspiration first pass technique for retrieval of a detached coil

A 64-year-old man was referred to our hospital for treatment of a cerebral aneurysm that was incidentally found. The aneurysm was 7 mm in size and located on the left anterior communicating artery. Using a balloon assisted technique, we performed coil embolization. During the second coil insertion, the first coil was dislodged into the anterior communicating artery. We attempted coil retrieval using a snare, which was unsuccessful. We applied a direct aspiration first pass technique (ADAPT) and advanced a Penumbra 4MAX immediately proximal to the dislodged coil; the dislodged coil was then successfully retrieved. ADAPT is a simple procedure for retrieval of a detached coil, and it can be used as an alternative to the snare technique.

A direct aspiration first pass technique for retrieval of a detached coil

A 64-year-old man was referred to our hospital for treatment of a cerebral aneurysm that was incidentally found. The aneurysm was 7 mm in size and located on the left anterior communicating artery. Using a balloon assisted technique, we performed coil embolization. During the second coil insertion, the first coil was dislodged into the anterior communicating artery. We attempted coil retrieval using a snare, which was unsuccessful. We applied a direct aspiration first pass technique (ADAPT) and advanced a Penumbra 4MAX immediately proximal to the dislodged coil; the dislodged coil was then successfully retrieved. ADAPT is a simple procedure for retrieval of a detached coil, and it can be used as an alternative to the snare technique.

Clinical and Angiographic Outcomes of Aneurysms Treated with Two Self-expanding Stent-assisted Coiling Systems: A Comparison of Solitaire AB and Enterprise VRD Stents

OBJECTIVE

The purpose of this study was to compare clinical findings and outcomes of Enterprise and Solitaire stent-assisted coiling (SAC).

MATERIALS AND METHODS

Between January 2012 and March 2014, 86 patients (mean age, 60.3 years) harboring 89 aneurysms were treated with Enterprise (n = 57) or Solitaire (n = 32) SAC. The patients' demographics, angiographic results, and clinical outcomes were reviewed retrospectively.

RESULTS

There were no cases of stent navigation, deployment failure, arterial dissection, or intraoperative aneurysmal rupture. Angiographic follow-up imaging was available for 86 (96.6%) aneurysms (Enterprise group, n = 55; Solitaire group, n = 31). Immediate postoperative and follow-up angiographic results showed no flow or only minimal flow into the neck in 83% (Enterprise group, 77.2%; Solitaire group, 93.8%) and 95.3% (Enterprise group, 92.7%; Solitaire group, 100%) of SAC-treated aneurysms, respectively. Both stent groups showed good immediate postoperative and follow-up clinical outcomes. Excepting 2 cases, all patients achieved modified Rankin Scale scores of 0. Coil loop or tail protrusion into the parent artery was observed in 17 (29.8%) and 7 (21.9%) cases in the Enterprise and Solitaire groups, respectively. No statistically significant difference in terms of angiographic results or clinical outcomes was observed between the groups.

CONCLUSION

Excellent and comparable clinical and angiographic outcomes for wide-neck intracranial aneurysms were achieved using both stents. Because of its higher radial strength and better vessel wall apposition, we cautiously propose that the Solitaire stent may be more effective for SAC of aneurysms harboring a large or severe tortuous parent artery.

Retrieval of migrated coils with stent retrievers: an animal study

BACKGROUND AND PURPOSE

Coil migration is a potentially serious complication of endovascular aneurysm treatment. The aim of the study was to systematically investigate the effectiveness of coil retrieval with a stent retriever in an animal model.

MATERIALS AND METHODS

A total of 148 coils of various types and sizes were placed into arteries of varying diameters in a porcine in vivo model. Coil retrieval was performed by placing a Trevo ProVue stent retriever over the coil and trying to trap a part of the platinum coil within the stent mesh by advancing the microcatheter over the stent or simply by retrieving the stent without trying to trap the coil by advancing the microcatheter.

RESULTS

Coil retrieval was successful in 101 of 102 cases (99%), in which trapping of the coil within the stent retriever by advancing the microcathter was applied. When we only pulled back the stent without trapping the coil, retrieval was successful in only 5 of 46 cases (11%). Coil type, coil structure (2D versus 3D), actual coil shape in the affected vessel, investigator experience, aspiration, coil localization, and vessel diameter had no significant influence on retrieval outcome. There was no case of vessel perforation.

CONCLUSIONS

Retrieval of migrated platinum coils with a stent retriever is an effective treatment option for migrated coils when the correct technique is applied.

Retrieval of unintended migrated detached coil: case report

Owing to the rapid development of intervention techniques and devices, endovascular coil embolization of cerebral arteries has become standardized. It is particularly preferred when a patient presents with an unruptured intracranial aneurysm of the posterior communicating artery (PcomA). However, the risk of thrombogenic complications of the coil migration may also result in a large cerebral infarction. When coil migration occurs during embolization, a procedure for removal of the embolic coil should be performed immediately. We experienced a clinically rare case of migration of a framing coil to the distal middle cerebral artery aneurysm during endovascular embolization of an unruptured PcomA aneurysm. The migrated coil was barely retrieved using snare techniques.

Manual Aspiration Technique to Retrieve a Prematurely Detached Coil during Cerebral Aneurysm Embolization

Coil herniation, premature deployment, and fracture are procedure associated complications of endovascular aneurysm embolization that optimally necessitate coil retrieval when feasible. Several published techniques describe different strategies for managing coil complications including various snare retrieval devices, alligator retrieval devices, stent fixation, and open surgical resection of coils when distal blood flow is compromised. We report a novel technique employed to retrieve a prematurely detached coil during an aneurysm embolization using a syringe fixed to the microcatheter to carefully aspirate a loose coil with direct fluoroscopic visualization. This technique can only be utilized in the circumstance where the proximal end of the coil remains in the microcatheter. Conventional techniques of coil retrieval and stenting are discussed and compared to the rational for using the manual aspiration technique.

Intraprocedural retrieval of migrated coils during endovascular aneurysm treatment with the Trevo Stentriever device

Coil migration during endovascular treatment of intracranial aneurysms occurs in 2-6% of cases. As endovascular coiling of aneurysms has become increasingly popular and as endovascular technology continues to rapidly evolve, the prevalence of intraprocedural coil migration will invariably rise. Since coil masses are highly thrombogenic, migration out of the aneurysm sac into the parent artery may result in large territory infarcts which subsequently manifest as significant neurological morbidity. Therefore safe and timely retrieval of migrated coils is essential to avoiding poor angiographic and clinical outcomes. A 66-year-old woman with an unruptured 5 × 3mm, wide-necked posterior communicating artery aneurysm was referred for endovascular treatment. During coiling with the dual catheter technique, both initially deployed coils dislodged from the aneurysm sac and migrated distally into the middle cerebral artery. After failed retrieval with an Alligator device (Chestnut Medical Technologies, Menlo Park, CA, USA), we used two Trevo devices (Concentric Medical, Mountain View, CA, USA) in succession to successfully retrieve the migrated coils. The aneurysm was then occluded with stent-assisted coil embolization. There were no post-procedural angiographic or clinical complications. The patient was subsequently discharged home without neurological deficit. This case illustrates the first use of the Trevo device for retrieval of migrated coils during endovascular treatment of an intracranial aneurysm to our knowledge. Due to the lack of guidelines defining the standard management of intraprocedural coil migration, current strategies are based on retrospective review of published reports and expert opinion. We present a unique and effective method for endovascular retrieval of displaced coils using a Trevo Stentriever device.

Management strategies for intraprocedural coil migration during endovascular treatment of intracranial aneurysms

Migration of a coil during endovascular treatment of intracranial aneurysm occurs in 2-6% of cases. The consequences of coil migration vary significantly from minor flow alterations of the parent artery which are asymptomatic to thromboembolic occlusion of major intracranial vessels resulting in large territory infarcts. We performed a comprehensive literature review and identified 37 reported cases of migrated coil retrieval consisting of 10 case reports and six case series. Most of the aneurysms presented with rupture (65%) and were located in the anterior circulation (70%). The endovascular treatment approaches were coil embolization alone (57%), stent-assisted coiling (26%) and balloon remodeling (17%). Endovascular retrieval was performed with microwires, the Alligator Retrieval device, Merci devices, snares and stentrievers. There was a single report of microsurgical extraction following failed endovascular removal and three cases of coil fracture in which the coil fragments were secured to the vessel walls with stents.