Retrieval of herniated coil during stent-assisted coiling

Author: SUJIJANTARAT Nanthiya

Find out how Dr. Nanthiya Sujijantarat (Departments of Neurosurgery and of Radiology & Biomedical Imaging, Yale University, New Haven CT, USA) treated a 45-year-old male patient suffering a ruptured, giant, partially thrombosed R ICA termination aneurysm.

• Case

  CASE PRESENTATION

  • 45-year-old male patient presents with a ruptured, giant, partially thrombosed R ICA termination aneurysm.

   

  

   

  • ASA 325 mg PO and Plavix 600 mg PO the night before Neuro-IR.
  • ASA 325 mg PO and Plavix 75 mg the morning of Neuro-IR.
  • Dual puncture technique – R radial 6F sheath and R femoral 6F sheath.

   

  

   

   

  POD#3

   

  

   

  3 ½ - MONTHS LATER

   

  

   

   

  RE-COILING OF ANEURYSM

  • A first coil was inserted and detached. However, attempts to place a 2nd coil resulted in kickback of the microcatheter tip outside the aneurysm and into the stent.
  • The microcatheter could not be tracked back inside the aneurysm over the partially deployed coil and attempts to remove the coil resulted in stretching of the coil tail (proximally) – almost as if the coil was tethered between the tines of the stent.

   

  • The microcatheter tip is now in the cavernous ICA. Removal of the microcatheter resulted in further stretching and detachment of the coil.

   

  

   

  • The force of injection carries the herniated coil tail (still stuck in the aneurysm) against the stent.

   

  

   

  • If you look closely, you can see the stretched coil going into the tip of the guide catheter in both AP and lateral views.

   

  

   

  COIL RETRIEVAL

  • Attempts to retrieve the coil mass using a snare and “baby” stent retriever were not successful.
  • We re-attempted using a large diameter stent retriever delivered through an 027 microcatheter.

   

  1. Stent retriever deployed proximal to coil mass.
  2. Partially re-sheath and use momentum to push collapsed stent retriever into the coil mass.
  3. Re-sheath stent retriever catching coils within the closing opening of the stent retriever.
  4. Withdraw stent retriever, microcatheter, and coil mass in unison.

   

  

   

  FINAL RESULT & FOLLOW-UP

   

  

   

  TEACHING POINTS

  • During stent-assisted coiling, great care must be taken not to lose access to the aneurysm during deployment of a coil. This can lead to all kinds of unanticipated problems.
  • Use a large stent-retriever to try and grab as much of the herniated coil as possible. We found the following steps useful in this case after some trial and error.

   

  1. Stent retriever deployed proximal to coil mass.
  2. Partially re-sheath and use momentum to push collapsed stent retriever into the coil mass.
  3. Re-sheath stent retriever catching coils within the closing opening of the stent retriever.
  4. Withdraw stent retriever, microcatheter, and coil mass in unison.