Delayed Proximal Flow Diverting Stent Migration in a Ruptured Intracranial Aneurysm: A Case Report

Takong, Wittawat; Kobkitsuksakul, Chai

doi:10.5469/neuroint.2020.00220

Cited by 8 publications

(7 citation statements)

References 10 publications

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“…Nevertheless, both phenomena can culminate in fatal SAH, for example, if the distal end of the FDS dislocates into the aneurysm sac, directing blood flow toward the aneurysm wall, or major ischemic stroke, if the device migrates distally and obstructs a downstream bifurcation ( 53 ). Migration and foreshortening are related to suboptimal wall adaption and the specific low-porosity closed cell design of FDS ( 54 ). Hence, their occurrence is limitable by appropriate sizing and optimal placement.…”

Section: Discussionmentioning

confidence: 99%

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First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating

et al. 2021

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Background: In the last decade, flow diversion (FD) has been established as hemodynamic treatment for cerebral aneurysms arising from proximal and distal cerebral arteries. However, two significant limitations remain—the need for 0.027” microcatheters required for delivery of most flow diverting stents (FDS), and long-term dual anti-platelet therapy (DAPT) in order to prevent FDS-associated thromboembolism, at the cost of increasing the risk for hemorrhage. This study reports the experience of three neurovascular centers with the p64MW-HPC, a FDS with anti-thrombotic coating that is implantable via a 0.021” microcatheter.Materials and methods: Three neurovascular centers contributed to this retrospective analysis of patients that had been treated with the p64MW-HPC between March 2020 and March 2021. Clinical data, aneurysm characteristics, and follow-up results, including procedural and post-procedural complications, were recorded. The hemodynamic effect was assessed using the O'Kelly–Marotta Scale (OKM).Results: Thirty-two patients (22 female, mean age 57.1 years) with 33 aneurysms (27 anterior circulation and six posterior circulation) were successfully treated with the p64MW-HPC. In 30/32 patients (93.75%), aneurysmal perfusion was significantly reduced immediately post implantation. Follow-up imaging was available for 23 aneurysms. Delayed aneurysm perfusion (OKM A3: 8.7%), reduction in aneurysm size (OKM B1-3: 26.1%), or sufficient separation from the parent vessel (OKM C1-3 and D1: 65.2%) was demonstrated at the last available follow-up after a mean of 5.9 months. In two cases, device thrombosis after early discontinuation of DAPT occurred. One delayed rupture caused a caroticocavernous fistula. The complications were treated sufficiently and all patients recovered without permanent significant morbidity.Conclusion: Treatment with the p64MW-HPC is safe and feasible and achieves good early aneurysm occlusion rates in the proximal intracranial circulation, which are comparable to those of well-established FDS. Sudden interruption of DAPT in the early post-interventional phase can cause in-stent thrombosis despite the HPC surface modification. Deliverability via the 0.021” microcatheter facilitates treatment in challenging vascular anatomies.

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Section: Discussionmentioning

confidence: 99%

“…Hence, their occurrence is limitable by appropriate sizing and optimal placement. However, as they also may manifest several months after implantation, regular follow-ups during the 1st year are important ( 54 ).…”

Section: Discussionmentioning

confidence: 99%

First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating

et al. 2021

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“…In most cases, migration of FDD is silent, but there are reports of aneurysm growth and rupture by hemodynamic changes evoked by FDD migration [1,3,5,6]. The rupture of the VADA in this case was thought to be due to the migrated stent, which introduced the bloodstream to the dissected segment, resulting in rupture.…”

Section: Case Reportmentioning

confidence: 79%

“…Finally, there is an inherent factor that makes FDDs more vulnerable to spontaneous migration than other types of stents. FDDs have a specific low-porosity and closed-cell design, which facilitates the transmission of a force exerted at one end of the device to the other end, making migration easier [3].…”

Section: Case Reportmentioning

confidence: 99%

A Case of Migration of Pipeline Embolization Device Causing Rupture during Treatment of an Unruptured Vertebral Artery Dissecting Aneurysm

Kim

Yeo

Lee

2021

Soonchunhyang Med Sci

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Endoluminal reconstruction of an intracranial aneurysm using flow-diverting devices, such as the pipeline embolization device (PED), is a new treatment modality with good clinical outcomes. The device was originally indicated for challenging cases, such as wide-necked large or giant aneurysms, and is gaining popularity as a reliable treatment for nearly all intracranial aneurysms. The overall complication rate of flow-diverting devices use is 17.0%, including occlusion of side-branching or perforating arteries, rerupture of the aneurysm, in-stent thrombosis, and, rarely, stent migration. We report a rare complication of the PED: delayed migration of the PED after successful stent implantation during treatment of an unruptured vertebral artery dissecting aneurysm, which resulted in rupture of the aneurysm. Further, we discuss technical steps that can be taken to prevent this potential complication.

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“…[ 2 ] Proximal FD migration has also been considered a delayed complication, frequently presenting with aneurysm recurrence due to incomplete coverage of the aneurysm neck. [ 2 , 3 , 10 , 15 , 16 ] A chief cause of proximal FD migration is elongation of the device during deployment, which may lead to spontaneous foreshortening. [ 5 , 10 ] Moreover, as causes of both proximal and distal migrations, the significant mismatch (>1 mm) between the inflow and outflow vessels has been considered important.…”

Section: Discussionmentioning

confidence: 99%

Distal migration of the flow-redirection endoluminal device immediately after treatment: A case report and literature review

Nariai¹,

Takigawa²,

Hyodo³

et al. 2022

Surgical Neurology International

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Background: A flow diverter (FD) has been a promising endovascular therapeutic modality for challenging intracranial aneurysms. However, stent migration has been an unusual complication. Until recently, among some types of FDs, the migration of the flow-redirection endoluminal device (FRED; MicroVention Inc., Aliso Viejo, CA, USA) has almost never been reported. Herein, we report a case of acute distal migration of a single FRED secondary to in-stent thrombi with symptomatic ischemic stroke and review the literature on the distal migration of FDs. Case Description: A 35-year-old woman was diagnosed with a left unruptured internal carotid-ophthalmic artery aneurysm. A 3.5 mm diameter and 17 mm long FRED was adequately deployed. The patient awoke from general anesthesia without neurological deficits. However, shortly after the procedure, the patient presented with conjugate deviation toward the left side, right severe hemiparesis, and total aphasia. Although the symptoms gradually improved, angiography was performed. Angiography revealed some in-stent thrombi and distal migration of the FRED, and initially, one of the left M2 inferior trunk branches was occluded by an embolic thrombus. However, the thrombus spontaneously migrated distally without any specific treatment. Finally, despite leaving the migrated stent in situ, the flow almost completely improved, and the patient’s neurologic deficits disappeared. Magnetic resonance imaging following treatment revealed only a small cerebral infarction in the left temporo-occipital area. Conclusion: Distal migration of an FD in an acute setting, including the FRED, may occur even following appropriate placement. In-stent thrombosis can cause distal stent migration and thromboembolic stroke.

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Delayed Proximal Flow Diverting Stent Migration in a Ruptured Intracranial Aneurysm: A Case Report

Cited by 8 publications

References 10 publications

First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating

First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating

A Case of Migration of Pipeline Embolization Device Causing Rupture during Treatment of an Unruptured Vertebral Artery Dissecting Aneurysm

Distal migration of the flow-redirection endoluminal device immediately after treatment: A case report and literature review

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