Endovascular management of acute postprocedural flow diverting stent thrombosis

Abstract

IntroductionPostprocedural thrombosis is a rare complication after flow diverting stent (FD) implantation for aneurysm treatment with few reported cases in the literature. Management strategies and outcomes associated with this complication have not been reported.MethodsA multicenter retrospective series of cases of acute postprocedural FD thrombosis were compiled and prevalence was calculated based on procedural volumes over a 7 year period. Acute postprocedural FD thrombosis was defined as the development of neurologic deficit with angiographic imaging demonstrating acute thrombus within the index FD stent at least 2 hours following completion of the implantation procedure.ResultsA total of 10 cases of postprocedural thrombosis were identified at five participating centers among a total of 768 patients treated (prevalence 1.3%). Thrombosis occurred a median of 5.5 days after implantation (range 0–83 days). 9/10 patients underwent emergent angiography with intent to perform endovascular reperfusion. A variety of different endovascular treatments were used, including aspiration thrombectomy, retrievable stent thrombectomy, balloon angioplasty, and intra-arterial thrombolytic infusion, without any procedural complications. There were no instances of FD migration, stent kinking, or aneurysm rupture. 90% of patients achieved Thrombolysis in Cerebral Infarction 2B or greater revascularization. Favorable clinical outcomes (modified Rankin Scale score of 0–2) at 3 months were achieved in 88% of patients.ConclusionAcute postprocedural thrombosis of an FD is a rare complication that occurs in approximately 1–2% of patients after aneurysm treatment. Patients presenting with acute postprocedural FD thrombosis should be aggressively managed using large vessel occlusion thrombectomy techniques, as good angiographic and clinical outcomes are possible.

Postprocedural Thrombosis following Endovascular Treatment of Intracranial Aneurysm with Flow Diverters or Coiling: A Histologic Study

“…These include the thrombogenic character of materials used to construct FDs, malapposition or movement of FDs, and resistance to antiplatelet agents. 3 Even third-generation FDs with surface modifications with synthetic biocompatible phosphorylcholine seem to have similar outcomes compared with previous generations of FDs. [5][6][7] Noncompliance with dual antiplatelet therapy and resistance to clopidogrel therapy are also known causes of in-stent thrombosis; however, there is controversy regarding the use of platelet function testing prior to FD implantation and converting known nonresponders to other antiplatelet medications such as ticagrelor or prasugrel.…”

“…more commonplace but is sometimes complicated by in situ thrombus formation along coils in the parent artery or within stents and flow diverters (FDs) due to the thrombogenic nature of these devices. [1][2][3] The mechanism of thrombosis is thought to be due to platelet activation because multiple prior studies have shown that complications can be prevented with dual antiplatelet therapy and managed with intra-arterial or intravenous infusion of glycoprotein (Gp) IIb/IIIa inhibitors. When the thrombus is refractory to medical treatment or the distal territory is at risk of infarction, mechanical thrombus removal by endovascular means is performed.…”

The Safety and Efficacy of Flow Diversion versus Conventional Endovascular Treatment for Intracranial Aneurysms: A Meta-analysis of Real-world Cohort Studies from the Past 10 Years

“…37 Failures or complications associated with the FD were also reported, such as remaining filling, postprocedural rupture, postprocedural thrombosis, and ischemic stroke. 38,39 Thus, the feasibility, safety, and efficacy of the FD versus conventional standard treatments are still elusive and controversial. To our knowledge, this is the first meta-analysis that directly compares both techniques, without considering aneurysm size and location, in terms of immediate and long-term angiographic and clinical outcomes.…”