Iatrogenic VA dissection rescued with flow-diverter stenting - floss technique-

Patient presentation

• A 28-year-old male with seizures and an occipital Grade 3 AVM was going to have a staged embolization prior to surgery.
• Under conscious sedation, through a right femoral artery (FA) and left vertebral artery (VA) a 071 guide catheter was inserted, inadvertently the VA was dissected causing occlusion of the VA and posterior inferior cerebellar artery (PICA).

Floss technique flow-diverter placement 

• Dissection occlusion of the left VA

• Bilateral VA injection angiography delineating the length of the affected left VA.
• Left PICA missing

• Left FA access was obtained. Dual antiplatelet boluses were administered (aspirin 650mg and clopidrogel 600mg) orally.
• After obtaining access on the left FA, a 5 Fr diagnostic catheter was advanced into the right VA. Under road map, a 0.017-inch microcatheter was advanced into the right VA, basilar artery, and left VA and through the left VA dissection segment.
• Simultaneously, a 0.27-inch microcatheter was advanced through the left VA catheter. Using a 4mm snare the 0.027 microcatheter was advanced from the left into the right VA (floss technique).
• Accessing the right VA to bring the 0.027-inch microcatheter distal to the dissection segment confirmed adequate positioning of the microcatheter in the true lumen of the artery, and not in the false lumen of the dissection.

• Bilateral femoral artery access

• Accessing the right VA with a 017 microcatheter into the left VA

• Right VA microcatheter snare
• Capturing left VA 027 microcatheter from the pseudo lumen up into the true lumen

• Once the 027 is in the true lumen of the VA, the dissection is reduced with 2 flow diverter stents.

• Adequate rescue and revascularization of the left VA

• Iatrogenic VA injury (dissection, perforation, occlusion) is preventable by careful manipulation of the leading wire and catheter. Large wires (0.035-inch, 0.038-inch) should not be advanced into the V4 segment of the VA.
• The majority of VA or internal carotid artery dissections are treated medically with antiplatelet or anticoagulation unless there is flow limitation or vessel occlusion.
• Endovascular repair of VA dissection/occlusion consists of apposing the dissection flap against the vessel wall, it can be achieved with balloon angioplasty or stent reconstruction. It is extremely important to confirm positioning in the true lumen of the vessel before any further repair.