A Novel Endovascular Technique for Retrieving Intracranial Vascular Foreign Body
Year: 2024
Type: article
Study design: Case Report
Abstract: Sir, Recent advancements in endovascular technology have led to a significant rise in the utilization of endovascular procedures, resulting in a corresponding increase in the probability of foreign body (FB) embolization. Nevertheless, although the endovascular approach is minimally invasive, it is not completely free of its inherent, albeit minimal, complications.[1] We report a rare case of a 55-year-old man with hypertension who experienced chest discomfort and exertional dyspnea, and was advised to undergo a coronary angiogram. During the procedure, the patient reported transient left hemibody paresthesias and left upper limb immobility, necessitating an immediate termination. Upon scrutiny, the angiography catheter tip was missing. On-table fluoroscopy confirmed its embolization into the cerebral vasculature. The patient was promptly transferred to our tertiary vascular center for a potential FB retrieval. A digital subtraction angiogram of the cerebral vasculature revealed a foreign body at the right middle cerebral artery M1 division just distal to the mid-portion [Figure 1]. Endovascular retrieval of the FB was initiated under general anesthesia, with arterial access obtained through the right transfemoral route at the groin. A 7F-Destination long sheath (Terumo Corporation, Japan) was positioned with its distal end, reaching the level of the second cervical vertebra. Subsequently, a 6.3F DAC (distal access catheter—Stryker Neurovascular, USA) was guided through the long sheath and placed at the cavernous internal carotid artery level. Using a Rebar 18 microcatheter (Medtronic, USA) and a Synchro 0.014 wire (Stryker Neurovascular, USA), the Rebar was successfully positioned at the superior division of the M2 segment. Next, a Solitaire 6 × 70 mm (Medtronic, USA) stent retriever was deployed through the FB [refer to Figure 2]. A final angiogram confirmed normal cerebral vasculature without any adverse findings [refer to Figure 3]. Following an uneventful postoperative stay, the patient was discharged two days later.Figure 1: A digital subtraction angiogram demonstrating the broken tip of a 5F coronary angiographic catheter at the right middle cerebral artery (MCA) M1 division just distal to the mid-portionFigure 2: (a) Digital subtraction angiogram showing the stent retriever that has engaged the intravascular foreign body. (b) Schematic representation of the capture of the foreign body by the stent retrieverFigure 3: (a) The final check angiogram demonstrating normal cerebral circulation. (b) The retrieved intravascular foreign bodyIn the majority of available literature, the retrieval of intravascular FB is consistently associated with a 100% survival rate. In contrast, untreated cases exhibit mortality and serious complication rates ranging from 60% to 71%.[2] The primary causes of FB embolization include improper device deployment, incorrect device selection, device fracture, loss of control, and other technical errors, often stemming from erroneous handling.[1] The most commonly affected sites for intravascular FB lodging are the right atrium (35.8%), superior vena cava (11.3%), and right ventricle (11.3%). In approximately 6% to 10% of instances, open surgical retrieval may be required.[3] The most commonly encountered types of intravascular foreign bodies (FB) include broken central lines and guidewires, fragments of angiographic catheters and sheaths, inferior vena cava filters, embolization coils or occluding devices, endovascular stents, intravascular ultrasound catheters, temporary pacing wires, pacemaker wires, fragments from cardiac valves, and atrial septal defect closure devices.[1,3,4] In our patient, we employed a novel technique utilizing a stent retriever to capture the foreign body (FB). Given the shape and location of the FB, more conventional methods like loop snare grasp and loop snare grasp-guide wire techniques proved unsuitable. The Dormia basket and filter techniques are better suited for larger vessels or peripheral locations, while the retrieval forceps technique poses relatively high risks such as iatrogenic vessel damage and potential perforation.[4] The direction and position of the FB lumen made the angioplasty balloon catheter technique challenging, as it would involve balloon dilation within a bend while ensuring safe FB retrieval. The aspiration catheter technique would have been beneficial if the FB lumen aligned with the vascular and aspiration catheter lumen.[3] The stent-retriever device is well suited for navigating the cerebral vasculature due to its flexibility, providing adequate traction and control on the FB without further complicating the retrieval process. There is no doubt that the ideal approach is the primary prevention of intravascular foreign bodies. Achieving this goal requires appropriate device selection, early detection of FB embolization, and a multidisciplinary team working together to determine the correct treatment strategy with the aim of achieving optimal outcomes while minimizing complications. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Neurology India
Institution: Medicover Hospitals
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4403585176