Pull-on-pipe maneuver for rescuing a prolapsed flow diverter

CASE PRESENTATION

• Case timeline

• Neuroimaging

• Diagnostic angio

TREATMENT

• In the process of retrieving the flow diverter wire with the microcatheter, the PED was inadvertently pushed into the aneurysm. The resulting partial prolapse moved the proximal edge of the PED dangerously close into the aneurysm lumen. (See Figure 2B,E) Pulling on the microcatheter over the microwire only partly reduced the degree of prolapse.
• The POP maneuver was then performed to restore the PED into its desired configuration:
• After removal of the wire, a second PED (5.0 x 30mm) was partially deployed in the mid aspect of the first PED.
• After apposition of the deployed portion of the second PED inside the first PED, we pulled on the second PED to restore the positioning of the first PED.
• The second pipeline stent was then completely deployed proximally on the petrous ICA. (See Figure 2C,F)

OUTCOMES

• No more diplopia

DISCUSSION

• Srinivasan VM, Carlson AP, Mokin M, et al. Prolapse of the Pipeline embolization device in aneurysms: incidence, management, and outcomes. Neurosurg Focus. Chalouhi N, Tjoumakaris SI, Gonzalez LF, et al. Spontaneous Delayed Migration/Shortening of the Pipeline Embolization Device: Report of 5 Cases. Am J Neuroradiol.

SALVAGE STRATEGIES

• Be careful of balloon angioplasty and distal wire recapture

CAUTION!

• Among 14 case reports of prolapsed flow diverters:
  • 3 occurred during balloon angioplasty to improve apposition
  • 2 during distal wire capture

WHY REPOSITION?

• Among 14 case reports of prolapsed flow diverters, no intervention was done for 5
• Of these 5, 2 died from aneurysm rupture
• Coincidentally these two also presented in a delayed fashion (7 and 3 days post-procedure

POINTS FOR DISCUSSION

• What other maneuvers could have been done to reposition?
• Pipe sizing concerns?