Clin Neuroradiol DOI 10.1007/s00062-013-0272-4
Correspondence
Trapping of Endovascular Microguidewire: A Rare and Serious Complication During Therapeutic Microcatheterization for Cerebrovascular Disease Y. D. Cho · C. H. Kim · H.-S. Kang · M. H. Han · S. H. Kim
Received: 7 July 2013 / Accepted: 25 November 2013 © Springer-Verlag Berlin Heidelberg 2013
Introduction
Case Presentation
Since the International Subarachnoid Aneurysm Trial, endovascular coil embolization has been widely used for treatment of intracranial aneurysms [1, 2]. A multifaceted strategy is often needed for complex aneurysms, utilizing various protection techniques in combination. Technical advancements in the devices offering protection and improved coiling methods have subsequently made it possible to treat a large percentage of oddly configured lesions [2]. However, device exchange via a larger-sized microcatheter is sometimes essential for passage of protection devices into distal branches; and in the process, a long microguidewire may be required. Microguidewire use is mandatory in intracranial over-the-wire-type stenting. Presented here are several instances where trapping of a long microguidewire occurred as a rare and serious complication of microcatheterization.
Three instances of microguidewire trapping accrued at two institutions. Details of these events, where neither advancement nor easy retrieval of the microwires was feasible, were well documented. Related demographic and clinical data are shown in Table 1. This study was approved by the institutional review boards of the respective facilities.
H.-S. Kang, MD, PhD () · M. H. Han, MD, PhD Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 28 Yongon-dong, Jongno-gu, 110-744 Seoul, Korea e-mail: [email protected] Y. D. Cho, MD · C. H. Kim, MD · M. H. Han, MD, PhD Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea S. H. Kim, MD Department of Neurosurgery, Bundang CHA Hospital, College of Medicine, CHA University, Sungnam, Korea
Patient 1 A 71-year-old woman was admitted for endovascular treatment of a small but wide-necked aneurysm at the right middle cerebral artery (MCA) bifurcation. Our plan was to first apply a microcatheter protective technique, reserving stent protection as a fall-back strategy. Under general anesthesia, a 6F guiding catheter was thus advanced to the cervical segment of right internal carotid artery, followed by passage of an Excelsior SL-10 microcatheter (Boston Scientific, Natick, MA) into the superior division of MCA. At this point, a microcatheter of larger caliber (Prowler Select Plus, Codman, Miami Lakes, FL) was to replace the Excelsior SL-10, relying on a long microguidewire (Transend 300 Floppy, Boston Scientific) to effect the exchange. Unfortunately, the microwire became trapped during the exchange process and was impossible to readily advance or retrieve. Attempts at forcible withdrawal retracted the entire right cerebral artery, without releasing the wire. Furthermore, the M1 trunk was not visualized on angiography, and all tension on the microwire was released. This maneuver restored main MCA flow, but the superior division of MCA was still not visualized. We assumed that hyperacute vasospasm had intervened due to arterial perforation by the microguidewire.
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Table 1 Summary of the patients’ data Number Age Sex Disease Procedure Trapped Microwire Procedural ICH or SAH Follow-up result GOS (years) microwire retrieval comment after retrieval 1 71 F Aneurysm Coiling Transend Yes Untreated Yes Frontal infarction 4 300 floppy aneurysm Weakness grade IV 2 58 F Aneurysm Coiling Transend No Residual No Complete occlusion 5 300 floppy aneurysm of aneurysm 3 54 M VA stenosis Stenting Transend Yes Stenting with Yes Diplopia 4 d/t dissection 300 floppy angioplasty F female, M male, VA vertebral artery, d/t due to, ICH intracerebral hemorrhage, SAH subarachnoid hemorrhage, GOS Glasgow outcome scale
Intra-arterial nimodipine (1 mg) was slowly infused while waiting for the vasospasm to abate. However, the microguidewire remained trapped, even after microcatheter advancement nearly to the wire tip. Almost 2 h elapsed before the wire was eventually removed. A modicum of apparent tissue compacted at the wire tip was inadvertently lost, without histologic verification. The superior division, thereafter, was visualized on angiography, but its caliber was reduced, and its proximal portion had become too tortuous to detail. Although intra-arterial nimodipine (1 mg) was again infused, the arterial narrowing did not change. Immediate post-procedural computed tomography (CT) showed diffuse subarachnoid hemorrhage (SAH) with intracerebral hemorrhage (ICH), and follow-up CT showed frontal infarction attributable to the injured frontal branch. The patient suffered minor neurologic sequelae, with left-sided grade IV (Glasgow outcome scale 4) weakness. Follow-up conventional angiography, performed at 1 month, and a magnetic resonance angiogram at 6 months showed sustained narrowing of the superior division, with the untreated aneurysm unchanged in size and configuration (Fig. 1). Patient 2 A 58-year-old woman with a wide-necked aneurysm of left superior cerebellar artery was treated by coil embolization, with intended stent protection. Initially, a guiding catheter was introduced into the dominant right vertebral artery (VA). Due to inherent tortuosity of proximal VA, placement of a guiding catheter is generally at its orifice. The coil frame was first successfully formed, inserting filling coils next via 1.7F dual microcatheters. Stent deployment was then elected to cover a gradual protrusion of the coiled mass at the aneurysm neck. One microcatheter used for coil delivery was to be exchanged for another of larger caliber (Prowler Select Plus) to deliver the stent. The long microguidewire (Transend 300 Floppy) engaged for this exchange again became trapped. On pull-back, it could not be released, and flow through the right VA was arrested. Left vertebral angiography (subsequent to an additional femoral puncture) showed that distal flow was maintained, without extravasation of contrast. However, the tip of the trapped wire was external to vascular lumen.
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Fearing extravasation from labored wire retrieval (as with patient 1), the trapped wire was left intact, cutting it below skin level at the right groin exit. Immediate post-procedural CT showed no intracranial hemorrhage, and the patient was discharged 3 days later, fully recovered. However, right thigh pain (aggravated by walking) prompted a subsequent visit. Plain radiographs indicated that the wire implant had fractured at two points, although the distal segment was unaffected. A proximal fragment had migrated into thigh muscle and was easily removed through a small incision. On follow-up digital subtraction angiography (DSA) at 6 months, occlusion of the aneurysm and stable positioning of the distal wire were both evident (Fig. 2). Patient 3 A 54-year-old man was admitted for infarction of the right medulla, following asymptomatic distal VA dissection. The dissected segment was severely narrowed on DSA, so intracranial stenting was required. Under local anesthesia, a 6F guiding catheter was advanced to the cervical segment of right VA. A 1.7F microcatheter was then passed into right posterior cerebral artery, under the guidance of a long microguidewire (Transend 300 Floppy). The wire unexpectedly became trapped during balloon exchange, with its tip lodged near a thalamoperforator artery. Given these circumstances, balloon angioplasty received priority, and an intracranial stent was deployed. The narrowed VA lumen was thus preserved, maintaining sufficient flow. Efforts to retrieve the wire could then begin, although the patient complained of severe headache with each attempt. Eventual withdrawal of the trapped wire was marked by a sudden bursting headache. Immediate post-procedural CT showed focal SAH with ICH of midbrain, and follow-up magnetic resonance imaging confirmed right thalamic infarction in the distribution of the injured perforator. The patient did suffer permanent right oculomotor nerve palsy. Summary of Three Cases In two patients, the microguidewire trapping occurred in the process of microcatheter exchange during coil embolization for unruptured aneurysms. The other instance took place
Trapping of Endovascular Microguidewire: A Rare and Serious Complication During Therapeutic
3
Fig. 1 a Aneurysm at middle cerebral artery (MCA) bifurcation by conventional angiography. b Microcatheter placement in vascular lumen, confirmed by super-selective angiography of MCA superior division using 1.7F microcatheter. c Microguidewire trapped during microcatheter exchange, resisting advancement or withdrawal. d Nonvisualization of M1 trunk while struggling to retrieve microwire. e M1 flow restoration (with arterial kink and non-visualization of superior division) following intra-arterial nimodipine infusion and relief of mi-
crowire tension. f Flow restoration to superior division (now smaller in caliber and kinked) after retrieval of microwire. g Tissue-like material compacted at microwire tip. h Post-procedural computed tomography (CT): diffuse subarachnoid hemorrhage. i Follow-up angiography (1 month): configuration of aneurysm unchanged and sustained arterial narrowing of superior division. j Follow-up CT: right frontal infarction in distribution of superior division
during stenting for intracranial arterial stenosis. A specific type of all trapped microwire was Transend 300 Floppy. In two patients, forceful retrieval of entrapped wires resulted in new ICH and SAH. Permanent sequelae remained in both patients. However, the third patient recovered without further insult, when the wire was simply left in place.
mechanism of such trapping is unclear, we contend that perforator or small-branch arterial injury likely occurred, based on hemorrhages (ICH and SAH) sustained by two patients once the wires were freed. Of note, the trapped microwire tips were extravascular in every instance. Another possible suspicion is that the tip of the microwire got subintima and got trapped in the intima of the vessel, and the tissue found attached to the tip is the intima of the vessel. Small-branch arterial injury/perforation by microguidewires is rare but is a well-known procedural complication [3, 4]. To avoid this hazard, operators must be skilled handlers and exert great care. Control of a long microwire during microcatheter exchange is not easy (as illustrated) and is the stage of an exchange where branch perforation is apt
Discussion Trapping of microguidewires during intracranial endovascular procedures seldom occurs. To our knowledge, this is first report where trapped microwires proved resistant to both advancement and withdrawal. Although the precise
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Y. D. Cho et al.
Fig. 2 a Aneurysm of superior cerebellar artery by conventional angiography. b Dual-microcatheter insertion of coils into sac of aneurysm. c Long microguidewire advanced into distal posterior cerebellar artery for microcatheter exchange. d Microwire trapping during microcatheter exchange. e Vertebral arterial kink and flow arrest with tug on microwire. f Trapped microwire tip positioned external to vascular
lumen confirmed by left vertebral angiography-bilateral distal PCA flow maintained via left vertebral artery; aneurysm occluded with neck remnant. g, h Retention of trapped microwire in vascular lumen. i Post-procedural CT: intracranial hemorrhage absent. j Follow-up angiography (6 months): occluded aneurysm and stable microwire position
to occur. However, most instances of branch perforation do not involve wire trapping. There are two potential explanations for wire entrapment in this scenario. The first is hyperacute vasospasm (followed by leakage or arterial injury) and the second is the microwire itself. Vasospasm was suspected here, as the affected branch or perforator was not visualized on angiography before wire retrieval. In addition, arterial narrowing (patient 1) was observed after retrieval of the wire. Nevertheless, vasospasm alone does not account for the entire sequence of events. Distal branch perforation has been rare in our experience, and usually, the wires are easily retrieved (albeit with SAH). We, therefore, focused on the nature of the microwire. In our patients, all trapped microguidewires were the Transcend 300 Floppy. This element features a soft platinum coil tip for
improved tip-shape retention and superb radiopacity, differing from the Transcend EX 205 cm (Fig. 3). Although we are unsure of its contribution to trapping specifically or to the related events in general, material resembling tissue was found in the screw-shaped tip after retrieval. This presumptive tissue (likely arterial, but with no histologic confirmation) suggests that microwire tip may be responsible for the trapping phenomenon. In short, we believe that this long microguidewire, with its soft platinum coil tip, may injure small arteries or perforators, causing hyperacute vasospasm and wire entrapment. Should wire trapping occur, it may be necessary to attempt retrieval after one or more of the following actions: (1) intra-arterial nimodipine infusion, (2) microcatheter advancement near the entrapment site, and (3) prolonged wait. In our patients, none of these methods proved effective. Other preliminary interventions to prevent
13
Trapping of Endovascular Microguidewire: A Rare and Serious Complication During Therapeutic
5
These incidents occurred while navigating distal vasculature and likely were related to small-branch/perforator arterial injury inflicted by the microguidewire. Serious consequences from forceful removal may be avoided by simply implanting the trapped microwire. Conflict of Interest We declare that we have no conflict of interest.
References
Fig. 3 Microscopic imaging: Transend EX.014 and Transend 300 Floppy microguidewire tips
(or limit) extravasation deserve consideration, such as immediate anticoagulant reversal, lowering of blood pressure, and temporary (or permanent) closure of the arterial rent via balloon. Excessive struggle to retrieve the trapped wire may only worsen the injury. If retrieval is unsuccessful after reasonable efforts, wire implantation may be a safe alternative. Conclusion
1. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J et al. International Subarachnoid Trial (ISAT) Collaborative Group. International Subarachnoid Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360:1267–74. 2. Lee SJ, Cho YD, Kang HS, Kim JE, Han MH. Coil embolization using the self-expandable closed-cell stent for intracranial saccular aneurysm: a single-center experience of 289 consecutive aneurysms. Clin Radiol. 2012;68:256–63. 3. Halbach VV, Higashida RT, Dowd CF, Barnwell SL, Hieshima GB. Management of vascular perforations that occur during neurointerventional procedures. AJNR Am J Neuroradiol. 1991;12:319–27. 4. Lee SJ, Shin HS, Lee SH, Koh JS. Coincidental occurrence of acute in-stent thrombosis and iatrogenic vessel perforation during a Wingspan stent placement: management with a stent in-stent technique. Neurointervention. 2012;7:40–4.
Presented here are three instances of microguidewire trapping as a rare complication of endovascular therapeutics.
13
Correspondence
Trapping of Endovascular Microguidewire: A Rare and Serious Complication During Therapeutic Microcatheterization for Cerebrovascular Disease Y. D. Cho · C. H. Kim · H.-S. Kang · M. H. Han · S. H. Kim
Received: 7 July 2013 / Accepted: 25 November 2013 © Springer-Verlag Berlin Heidelberg 2013
Introduction
Case Presentation
Since the International Subarachnoid Aneurysm Trial, endovascular coil embolization has been widely used for treatment of intracranial aneurysms [1, 2]. A multifaceted strategy is often needed for complex aneurysms, utilizing various protection techniques in combination. Technical advancements in the devices offering protection and improved coiling methods have subsequently made it possible to treat a large percentage of oddly configured lesions [2]. However, device exchange via a larger-sized microcatheter is sometimes essential for passage of protection devices into distal branches; and in the process, a long microguidewire may be required. Microguidewire use is mandatory in intracranial over-the-wire-type stenting. Presented here are several instances where trapping of a long microguidewire occurred as a rare and serious complication of microcatheterization.
Three instances of microguidewire trapping accrued at two institutions. Details of these events, where neither advancement nor easy retrieval of the microwires was feasible, were well documented. Related demographic and clinical data are shown in Table 1. This study was approved by the institutional review boards of the respective facilities.
H.-S. Kang, MD, PhD () · M. H. Han, MD, PhD Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 28 Yongon-dong, Jongno-gu, 110-744 Seoul, Korea e-mail: [email protected] Y. D. Cho, MD · C. H. Kim, MD · M. H. Han, MD, PhD Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea S. H. Kim, MD Department of Neurosurgery, Bundang CHA Hospital, College of Medicine, CHA University, Sungnam, Korea
Patient 1 A 71-year-old woman was admitted for endovascular treatment of a small but wide-necked aneurysm at the right middle cerebral artery (MCA) bifurcation. Our plan was to first apply a microcatheter protective technique, reserving stent protection as a fall-back strategy. Under general anesthesia, a 6F guiding catheter was thus advanced to the cervical segment of right internal carotid artery, followed by passage of an Excelsior SL-10 microcatheter (Boston Scientific, Natick, MA) into the superior division of MCA. At this point, a microcatheter of larger caliber (Prowler Select Plus, Codman, Miami Lakes, FL) was to replace the Excelsior SL-10, relying on a long microguidewire (Transend 300 Floppy, Boston Scientific) to effect the exchange. Unfortunately, the microwire became trapped during the exchange process and was impossible to readily advance or retrieve. Attempts at forcible withdrawal retracted the entire right cerebral artery, without releasing the wire. Furthermore, the M1 trunk was not visualized on angiography, and all tension on the microwire was released. This maneuver restored main MCA flow, but the superior division of MCA was still not visualized. We assumed that hyperacute vasospasm had intervened due to arterial perforation by the microguidewire.
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Y. D. Cho et al.
Table 1 Summary of the patients’ data Number Age Sex Disease Procedure Trapped Microwire Procedural ICH or SAH Follow-up result GOS (years) microwire retrieval comment after retrieval 1 71 F Aneurysm Coiling Transend Yes Untreated Yes Frontal infarction 4 300 floppy aneurysm Weakness grade IV 2 58 F Aneurysm Coiling Transend No Residual No Complete occlusion 5 300 floppy aneurysm of aneurysm 3 54 M VA stenosis Stenting Transend Yes Stenting with Yes Diplopia 4 d/t dissection 300 floppy angioplasty F female, M male, VA vertebral artery, d/t due to, ICH intracerebral hemorrhage, SAH subarachnoid hemorrhage, GOS Glasgow outcome scale
Intra-arterial nimodipine (1 mg) was slowly infused while waiting for the vasospasm to abate. However, the microguidewire remained trapped, even after microcatheter advancement nearly to the wire tip. Almost 2 h elapsed before the wire was eventually removed. A modicum of apparent tissue compacted at the wire tip was inadvertently lost, without histologic verification. The superior division, thereafter, was visualized on angiography, but its caliber was reduced, and its proximal portion had become too tortuous to detail. Although intra-arterial nimodipine (1 mg) was again infused, the arterial narrowing did not change. Immediate post-procedural computed tomography (CT) showed diffuse subarachnoid hemorrhage (SAH) with intracerebral hemorrhage (ICH), and follow-up CT showed frontal infarction attributable to the injured frontal branch. The patient suffered minor neurologic sequelae, with left-sided grade IV (Glasgow outcome scale 4) weakness. Follow-up conventional angiography, performed at 1 month, and a magnetic resonance angiogram at 6 months showed sustained narrowing of the superior division, with the untreated aneurysm unchanged in size and configuration (Fig. 1). Patient 2 A 58-year-old woman with a wide-necked aneurysm of left superior cerebellar artery was treated by coil embolization, with intended stent protection. Initially, a guiding catheter was introduced into the dominant right vertebral artery (VA). Due to inherent tortuosity of proximal VA, placement of a guiding catheter is generally at its orifice. The coil frame was first successfully formed, inserting filling coils next via 1.7F dual microcatheters. Stent deployment was then elected to cover a gradual protrusion of the coiled mass at the aneurysm neck. One microcatheter used for coil delivery was to be exchanged for another of larger caliber (Prowler Select Plus) to deliver the stent. The long microguidewire (Transend 300 Floppy) engaged for this exchange again became trapped. On pull-back, it could not be released, and flow through the right VA was arrested. Left vertebral angiography (subsequent to an additional femoral puncture) showed that distal flow was maintained, without extravasation of contrast. However, the tip of the trapped wire was external to vascular lumen.
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Fearing extravasation from labored wire retrieval (as with patient 1), the trapped wire was left intact, cutting it below skin level at the right groin exit. Immediate post-procedural CT showed no intracranial hemorrhage, and the patient was discharged 3 days later, fully recovered. However, right thigh pain (aggravated by walking) prompted a subsequent visit. Plain radiographs indicated that the wire implant had fractured at two points, although the distal segment was unaffected. A proximal fragment had migrated into thigh muscle and was easily removed through a small incision. On follow-up digital subtraction angiography (DSA) at 6 months, occlusion of the aneurysm and stable positioning of the distal wire were both evident (Fig. 2). Patient 3 A 54-year-old man was admitted for infarction of the right medulla, following asymptomatic distal VA dissection. The dissected segment was severely narrowed on DSA, so intracranial stenting was required. Under local anesthesia, a 6F guiding catheter was advanced to the cervical segment of right VA. A 1.7F microcatheter was then passed into right posterior cerebral artery, under the guidance of a long microguidewire (Transend 300 Floppy). The wire unexpectedly became trapped during balloon exchange, with its tip lodged near a thalamoperforator artery. Given these circumstances, balloon angioplasty received priority, and an intracranial stent was deployed. The narrowed VA lumen was thus preserved, maintaining sufficient flow. Efforts to retrieve the wire could then begin, although the patient complained of severe headache with each attempt. Eventual withdrawal of the trapped wire was marked by a sudden bursting headache. Immediate post-procedural CT showed focal SAH with ICH of midbrain, and follow-up magnetic resonance imaging confirmed right thalamic infarction in the distribution of the injured perforator. The patient did suffer permanent right oculomotor nerve palsy. Summary of Three Cases In two patients, the microguidewire trapping occurred in the process of microcatheter exchange during coil embolization for unruptured aneurysms. The other instance took place
Trapping of Endovascular Microguidewire: A Rare and Serious Complication During Therapeutic
3
Fig. 1 a Aneurysm at middle cerebral artery (MCA) bifurcation by conventional angiography. b Microcatheter placement in vascular lumen, confirmed by super-selective angiography of MCA superior division using 1.7F microcatheter. c Microguidewire trapped during microcatheter exchange, resisting advancement or withdrawal. d Nonvisualization of M1 trunk while struggling to retrieve microwire. e M1 flow restoration (with arterial kink and non-visualization of superior division) following intra-arterial nimodipine infusion and relief of mi-
crowire tension. f Flow restoration to superior division (now smaller in caliber and kinked) after retrieval of microwire. g Tissue-like material compacted at microwire tip. h Post-procedural computed tomography (CT): diffuse subarachnoid hemorrhage. i Follow-up angiography (1 month): configuration of aneurysm unchanged and sustained arterial narrowing of superior division. j Follow-up CT: right frontal infarction in distribution of superior division
during stenting for intracranial arterial stenosis. A specific type of all trapped microwire was Transend 300 Floppy. In two patients, forceful retrieval of entrapped wires resulted in new ICH and SAH. Permanent sequelae remained in both patients. However, the third patient recovered without further insult, when the wire was simply left in place.
mechanism of such trapping is unclear, we contend that perforator or small-branch arterial injury likely occurred, based on hemorrhages (ICH and SAH) sustained by two patients once the wires were freed. Of note, the trapped microwire tips were extravascular in every instance. Another possible suspicion is that the tip of the microwire got subintima and got trapped in the intima of the vessel, and the tissue found attached to the tip is the intima of the vessel. Small-branch arterial injury/perforation by microguidewires is rare but is a well-known procedural complication [3, 4]. To avoid this hazard, operators must be skilled handlers and exert great care. Control of a long microwire during microcatheter exchange is not easy (as illustrated) and is the stage of an exchange where branch perforation is apt
Discussion Trapping of microguidewires during intracranial endovascular procedures seldom occurs. To our knowledge, this is first report where trapped microwires proved resistant to both advancement and withdrawal. Although the precise
13
4
Y. D. Cho et al.
Fig. 2 a Aneurysm of superior cerebellar artery by conventional angiography. b Dual-microcatheter insertion of coils into sac of aneurysm. c Long microguidewire advanced into distal posterior cerebellar artery for microcatheter exchange. d Microwire trapping during microcatheter exchange. e Vertebral arterial kink and flow arrest with tug on microwire. f Trapped microwire tip positioned external to vascular
lumen confirmed by left vertebral angiography-bilateral distal PCA flow maintained via left vertebral artery; aneurysm occluded with neck remnant. g, h Retention of trapped microwire in vascular lumen. i Post-procedural CT: intracranial hemorrhage absent. j Follow-up angiography (6 months): occluded aneurysm and stable microwire position
to occur. However, most instances of branch perforation do not involve wire trapping. There are two potential explanations for wire entrapment in this scenario. The first is hyperacute vasospasm (followed by leakage or arterial injury) and the second is the microwire itself. Vasospasm was suspected here, as the affected branch or perforator was not visualized on angiography before wire retrieval. In addition, arterial narrowing (patient 1) was observed after retrieval of the wire. Nevertheless, vasospasm alone does not account for the entire sequence of events. Distal branch perforation has been rare in our experience, and usually, the wires are easily retrieved (albeit with SAH). We, therefore, focused on the nature of the microwire. In our patients, all trapped microguidewires were the Transcend 300 Floppy. This element features a soft platinum coil tip for
improved tip-shape retention and superb radiopacity, differing from the Transcend EX 205 cm (Fig. 3). Although we are unsure of its contribution to trapping specifically or to the related events in general, material resembling tissue was found in the screw-shaped tip after retrieval. This presumptive tissue (likely arterial, but with no histologic confirmation) suggests that microwire tip may be responsible for the trapping phenomenon. In short, we believe that this long microguidewire, with its soft platinum coil tip, may injure small arteries or perforators, causing hyperacute vasospasm and wire entrapment. Should wire trapping occur, it may be necessary to attempt retrieval after one or more of the following actions: (1) intra-arterial nimodipine infusion, (2) microcatheter advancement near the entrapment site, and (3) prolonged wait. In our patients, none of these methods proved effective. Other preliminary interventions to prevent
13
Trapping of Endovascular Microguidewire: A Rare and Serious Complication During Therapeutic
5
These incidents occurred while navigating distal vasculature and likely were related to small-branch/perforator arterial injury inflicted by the microguidewire. Serious consequences from forceful removal may be avoided by simply implanting the trapped microwire. Conflict of Interest We declare that we have no conflict of interest.
References
Fig. 3 Microscopic imaging: Transend EX.014 and Transend 300 Floppy microguidewire tips
(or limit) extravasation deserve consideration, such as immediate anticoagulant reversal, lowering of blood pressure, and temporary (or permanent) closure of the arterial rent via balloon. Excessive struggle to retrieve the trapped wire may only worsen the injury. If retrieval is unsuccessful after reasonable efforts, wire implantation may be a safe alternative. Conclusion
1. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J et al. International Subarachnoid Trial (ISAT) Collaborative Group. International Subarachnoid Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360:1267–74. 2. Lee SJ, Cho YD, Kang HS, Kim JE, Han MH. Coil embolization using the self-expandable closed-cell stent for intracranial saccular aneurysm: a single-center experience of 289 consecutive aneurysms. Clin Radiol. 2012;68:256–63. 3. Halbach VV, Higashida RT, Dowd CF, Barnwell SL, Hieshima GB. Management of vascular perforations that occur during neurointerventional procedures. AJNR Am J Neuroradiol. 1991;12:319–27. 4. Lee SJ, Shin HS, Lee SH, Koh JS. Coincidental occurrence of acute in-stent thrombosis and iatrogenic vessel perforation during a Wingspan stent placement: management with a stent in-stent technique. Neurointervention. 2012;7:40–4.
Presented here are three instances of microguidewire trapping as a rare complication of endovascular therapeutics.
13
