Retained and fractured microcatheter: a cause of transient ischaemic attacks: endovascular management using carotid stents

The use of Microsurgical Exploration of the External Carotid Artery for Removal of a Retained Microcatheter After Middle Meningeal Artery Embolization Using Live Fluoroscopy: A Technical Note

BACKGROUND

Fragmentation, disconnection, or entrapment of an in-use microcatheter during neuro-endovascular procedures is a known risk. Often a benign entity, retained catheters are not infrequently observed, but severe complications including thrombus, thromboembolic events, pseudoaneurysm, and limb ischemia have been described, necessitating retrieval. This technical case report demonstrates the safe use of an external carotid artery (ECA) approach for ligation and removal of a retained microcatheter after middle meningeal artery (MMA) embolization. This article also demonstrates the use of live intraoperative fluoroscopy as a surgical adjunct to ensure that the catheter is fully removed without any injury, shearing, or breakage during removal.

METHODS

A 66-year-old male patient presented with bilateral subdural hematomas to an outside hospital. He subsequently underwent evacuation of the hematomas followed by a right-sided MMA embolization, complicated by Onyx (Medtronic, Minneapolis, MN) entrapment of the microcatheter in the MMA. The patient was asymptomatic, but there was significant concern about continuing antiplatelet/anticoagulation therapy in the presence of the subdural hematoma. We proceeded with an open surgical approach for catheter retrieval. As the catheter was withdrawn, intraoperative fluoroscopy demonstrated complete removal without any retained fragments.

RESULTS

The patient recovered without event and was discharged on postoperative day 1. On follow-up the patient continued to do well without any complications from the fragment that remained in the external carotid circulation.

CONCLUSIONS

This case and accompanying video demonstrates the effective use of open ECA surgical approach to retrieve the retained microcatheter after an MMA embolization. This approach allowed for safe and effective removal of the microcatheter while significantly reducing complication risks.

Retrieval of a Fractured Marathon Microcatheter Entrapped in Onyx Using a Novel Stentriever-Assisted Technique

BACKGROUND AND IMPORTANCE

Endovascular embolization using Onyx has been a major advancement in the treatment of cerebrovascular malformations. Microcatheter entrapment in Onyx is a procedural complication which can pose a thromboembolic risk to patients. There have been 4 retrieval techniques for intact microcatheters entrapped in Onyx previously described in the literature, which are summarized in this report. We present the first case using a novel stentriever-assisted technique to successfully and safely retrieve a fractured microcatheter entrapped in Onyx.

CLINICAL PRESENTATION

An adult patient with a Cognard IIa + b dural arteriovenous fistula (dAVF) underwent Onyx embolization. The microcatheter became entrapped and fractured while initially attempting removal. A stentriever was used off label to capture the fractured microcatheter and then a larger caliber microcatheter was railroaded over it. Retrieval of the fractured microcatheter by the stentriever was then facilitated by counter traction on the Onyx cast using the larger microcatheter.

CONCLUSION

This novel stentriever-assisted technique is a safe and effective rescue maneuver for retrieving a fractured microcatheter trapped in Onyx during embolization of dAVF. There is a need for further research and development of novel devices for retrieval of entrapped microcatheters.

Bailouts During Neurointervention; Novel Techniques in Tackling Coil Migration and Premature Intravascular Detachment of Microcatheter Tip

BACKGROUND

Intracranial vascular malformations are increasingly being treated via the endovascular route. Though generally safe, a multitude of intraprocedural complications that potentially lead to disastrous clinical outcomes may arise. It is crucial for the operators to be well versed with the various techniques that are available to overcome any procedure-specific complications.

METHODS

We present 2 cases in which we encountered premature intravascular detachment of the microcatheter tip and coil migration while treating a dural arteriovenous fistula and aneurysm, respectively. We used a stentriever to remove the detached microcatheter tip and suction using the reperfusion catheter to remove the migrated coil, both techniques that have not been reported in the literature thus far.

RESULTS

Detached microcatheter tip and migrated coil were successfully retrieved using a stentriever and aspiration catheter.

CONCLUSIONS

These novel techniques could potentially reduce mortality and morbidity associated with neurointervention.