Abstract

BackgroundAs mechanical thrombectomy is commonly performed, preparation for various complications is necessary. However, few reports have described microguidewires (MGWs) becoming entrapped.

Case DescriptionAn 83-year-old man with a history of cancer in the pancreatic head developed a disturbance of consciousness and left hemiplegia. Mechanical thrombectomy was performed for occlusion of the right posterior cerebral artery. The occluded lesion was passed using an MGW with a straight tip. The MGW became impossible to move after advancing into the perforator distal to the occluding thrombus. The MGW was removed using a goose-neck snare under general anesthesia. A small amount of subarachnoid hemorrhage occurred after wire removal but did not affect the clinical course.

ConclusionMGW entrapment is a rare complication in neuroendovascular therapy, particularly in mechanical thrombectomy. Removal of an entrapped MGW is associated with a risk of hemorrhagic complications. If the thrombus is hard and a J-shaped wire cannot be passed, the risk of MGW entrapment is high.

Keywords: Mechanical thrombectomy, Posterior cerebral artery occlusion, Subarachnoid hemorrhage, Wire entrapment

INTRODUCTION

The indications for mechanical thrombectomy to treat acute ischemic stroke have expanded, and ever more distally occluded blood vessels are being approached, but various complications have also been encountered.[ 8 ] We report a case in which a microguidewire (MGW) became entrapped during mechanical thrombectomy for occlusion of the posterior cerebral artery (PCA).

CASE DESCRIPTION

An 83-year-old man with a medical history of cancer of the pancreatic head and carcinomatous peritonitis was admitted to our hospital with a diagnosis of febrile neutropenia. On hospital day 8, he presented with disturbance of consciousness and left hemiplegia. National Institutes of Health Stroke Scale score was 17. Magnetic resonance imaging of the head revealed a suspected occlusion in the distal basilar artery [ Figure 1 ]. Atrial fibrillation was not observed, so embolic stroke due to Trousseau syndrome was suspected. Diagnostic angiography revealed a right PCA occlusion and thrombus protruding into the basilar artery [ Figure 2 ], so a mechanical thrombectomy was performed. A 6-Fr guiding sheath (ASAHI FUBUKI XF; Asahi Intecc, Aichi, Japan) was advanced to the left vertebral artery, and an aspiration catheter (ACE 68; Penumbra, Alameda, CA, USA) was advanced to the basilar artery. Using an MGW (Synchro Select Standard; Striker, Fremont, CA, USA), we first attempted to pass the occluding lesion with a J-shaped wire tip, but crossing proved impossible. The tip of the MGW was changed to a straighter shape, allowing successful passage past the occluded lesion. We intended to advance the MGW distal to the PCA, but when we recognized that the MGW had entered a perforator of the P1 segment of the PCA and attempted to retract the wire, the microwire stopped moving completely. Even when the microcatheter and aspiration catheter were advanced as close as possible to the microwire, removal was impossible. Fusion images from non-contrast-enhanced computed tomography and three-dimensional cerebral angiography revealed that the MGW had been advanced into the perforating artery [ Figure 3 ]. General anesthesia was induced, heparin antagonism was administered, and the MGW was captured and retrieved using a goose-neck snare under hypotension control. Nothing was found attached to the tip of the MGW. Vertebral artery angiography immediately after MGW removal revealed that the right PCA remained occluded with no extravasation. Postoperative computed tomography revealed a slight subarachnoid hemorrhage in the interpeduncular fossa, but this hemorrhage did not affect the clinical course. The PCA occlusion resulted in complete cerebral infarction of the brainstem and occipital lobe [ Figure 4 ], leading to severe neurological symptoms.

Figure 1:

(a and b) Preoperative magnetic resonance imaging. Diffusion-weighted imaging demonstrates acute cerebral infarction of bilateral posterior lobes and the right thalamus. (c) Preoperative magnetic resonance angiography demonstrates occlusion of the right posterior cerebral artery.

Figure 2:

(a) Preoperative angiography. (b) The microguidewire (MGW) is advanced into the perforating artery. (c) The MGW is found to be completely entrapped when attempting to pull back from the origin of the perforating artery. (d) The MGW is captured using a goose-neck snare (arrowhead). (e) Postoperative angiography.

Figure 3:

Fusion images of intraoperative non-contrast-enhanced computed tomography when the microguidewire (MGW) was entrapped and three-dimensional cerebral angiography. (a) The axial image demonstrates the MGW entrapped in the posterior cerebral artery. (b-d) Coronal images showing the origin of the perforator (arrow) at the tip of the MGW (arrowhead).

Figure 4:

Postoperative computed tomography demonstrates slight subarachnoid hemorrhage at the interpeduncular fossa.

DISCUSSION

We report a case in which the MGW became entrapped during mechanical thrombectomy for PCA occlusion. In recent years, reports supporting mechanical thrombectomy for medium-vessel occlusion have been published, and indications for this procedure are expanding.[ 5 ] On the other hand, thrombectomy for medium-vessel occlusion has a high complication rate, with vessel perforation in particular showing twice the frequency of that in large-vessel occlusion.[ 8 ] Entrapment of an MGW is a rare complication, occurring in 0.1–0.2% of percutaneous coronary interventions, but has been reported even more rarely in neuroendovascular therapy.[ 1 ] To date, only eight cases of MGW entrapment during neuroendovascular therapy have been reported, and none of those occurred during mechanical thrombectomy.[ 2 - 4 , 6 , 7 ]

We investigated the causes of MGW entrapment based on past reports [ Table 1 ].[ 2 - 4 , 6 , 7 ] Cho et al. reported three cases, with two during treatment for aneurysms and the remaining during treatment for arterial stenosis.[ 2 ] In all three cases, entrapment occurred during microcatheter exchange using an MGW. The hyperacute vasospasm associated with arterial perforation and dissection, or the characteristics of the MGW, were considered the most likely causes. Entrapment may be more likely to occur for MGWs in which the tip has a spring structure not covered by a jacket. Darsaut et al. reported a case during coil embolization for an unruptured basilar artery aneurysm.[ 3 ] When a horizontal microballoon was guided to the basilar artery from the internal carotid artery through the posterior communicating artery, the MGW advanced into the posterior choroidal artery and became difficult to reposition. In those reports, everted vascular intima was caught by the tip of the MGW under retraction.[ 2 , 3 ] MGW entrapment may thus occur when the diameter of the MGW matches that of the small vessel into which the MGW has advanced. During mechanical thrombectomy, detecting the vascular course distal to the occlusion is difficult, and the MGW is likely to become instead entrapped by unintentional advancement into a perforating branch. To avoid MGW entrapment, magnetic resonance angiography images from before the occlusion of the target vessels should be used as a reference when available. In addition, for hard thrombi that are difficult to pass using a J-shaped MGW, switching to thrombus retrieval by suction alone is preferable to forcing the MGW past the thrombus lesion. In the present case, the thrombus may have been hard due to Trousseau syndrome, and manipulation of the MGW inside the thrombus did not work. Clinicians need to recognize that under such circumstances, the risk of MGW entrapment is high.

Table 1:

Summary of microguidewire entrapment cases.

Various options are available for bailout. First, a vasodilating agent should be considered. In the present case, a vasodilator was injected intra-arterially in consideration of the possibility of vasospasm, but the drug would not have reached the target vessel through the occluded site. The second method is MGW retrieval using a goose-neck snare. However, retrieval of the MGW carries a risk of causing subarachnoid hemorrhage. In reports of wire removal cases, including the present case, subarachnoid hemorrhage has inevitably developed [ Table 1 ]. Some cases have progressed to serious complications, so MGW retrieval should be considered carefully.[ 2 , 3 ] In the present case, general anesthesia was administrated, hypotension was managed, heparin antagonism was administered, and a snare catheter was used to capture the wire near the tip and achieve removal while minimizing vascular deviation. A third option is to leave the MGW in the body. In cases where the wire was placed in the body, some reports have described the delayed treatment of the wire due to discomfort in the thigh, and careful follow-up is required in addition to the onset of thrombosis.[ 2 , 7 ] In this case, bleeding was minimal because the proximal site was occluded, but preparation for hemorrhagic complications is mandatory when removing an entrapped MGW.

CONCLUSION

We encountered a rare complication in which the MGW became entrapped. Because serious hemorrhagic complications may occur during wire removal, the appropriate bailout must be carefully considered. In cases of hard thrombus, such as in patients with Trousseau syndrome, when the movement of the MGW past the lesion proves difficult, careful consideration must be given to whether to attempt lesion crossing.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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