Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.
Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.
Neurosurgery. 2019 Jul 1;85(suppl_1):S70-S71. doi: 10.1093/neuros/nyz043.
Iatrogenic dissection of the internal carotid artery (ICA) during endovascular approaches is challenging. This video illustrates a case of iatrogenic ICA dissection at the skull base during mechanical thrombectomy for M1 occlusion. This case was further complicated by post-thrombectomy M1 restenosis that did not improve with submaximal angioplasty. ICA dissection occurred while navigating the guide catheter into the distal cervical ICA over a 0.38 inch Glidewire (MicroVention-Terumo, Aliso Viejo, California). The dissection flap was crossed with a SofiaPlus intermediate catheter (MicroVention-Terumo), Velocity microcatheter (Penumbra, Alameda, California), and double-ended 0.18 inch wire. The M1 occlusion was crossed and treated with Solumbra technique by pulling a Solitaire stent-retriever (Medtronic, Dublin, Ireland) through a SofiaPlus aspiration catheter (MicroVention). Post-recanalization M1 stenosis was noted, which was believed to be due to underlying intracranial atherosclerotic disease because of the appearance of platelet aggregation instead of a typical vasospasm response to a stent-retriever. A noncompliant Gateway 2 × 12 mm balloon catheter (Stryker Neurovascular, Kalamazoo, Michigan) was used to cross the lesion and perform submaximal angioplasty. Next, the dissection was treated by advancing a NeuronMAX guide catheter (Penumbra) over the SofiaPlus into the vertical petrous carotid artery beyond the dissection flap and unsheathing a Wallstent (Stryker Neurovascular) across the flap. Because of progressive M1 restenosis, a Wingspan stent (Stryker Neurovascular) was deployed. Final runs demonstrated Thrombolysis in Cerebral Infarction 2C recanalization. Pre-stenting thrombectomy was chosen because the duration of symptoms was >48 h; thus, determining the risk of reperfusion hemorrhage by evaluating intracranial shunting before stenting was prudent. Reperfusion hemorrhage would complicate the antiplatelet agent therapy necessary for stent placement. Consent was obtained from the patient prior to performing the procedure. Institutional review board approval is not required for the report of a single case.
在血管内治疗途径中，医源性颈内动脉（ICA）夹层是一项挑战。这段视频展示了一例机械血栓切除术中基底节区医源性 ICA 夹层的病例，M1 闭塞。该病例在血栓切除术后 M1 再狭窄，最大程度的血管成形术也没有改善，情况更加复杂。在将导引导管导航至远端颈内动脉时，0.38 英寸的 Glidewire（MicroVention-Terumo，加利福尼亚州 Aliso Viejo）发生了夹层。夹层瓣用 SofiaPlus 中间导管（MicroVention-Terumo）、Velocity 微导管（Penumbra，加利福尼亚州阿拉米达）和双头 0.18 英寸的导丝交叉。M1 闭塞通过 Solumbra 技术穿过 SofiaPlus 抽吸导管（MicroVention）拉动 Solitaire 支架回收器（Medtronic，都柏林，爱尔兰）进行治疗。再通后发现 M1 狭窄，由于出现血小板聚集，而不是典型的支架回收器引起的血管痉挛反应，因此认为这是由于颅内动脉粥样硬化病变引起的。使用非顺应性 Gateway 2×12 毫米球囊导管（Stryker Neurovascular，密歇根州卡拉马祖）穿过病变部位并进行最大程度的血管成形术。接下来，通过将 NeuronMAX 导引导管（Penumbra）推进 SofiaPlus 至夹层瓣外的垂直岩骨颈内动脉，将 Wallstent（Stryker Neurovascular）穿过瓣鞘，治疗夹层。由于 M1 再狭窄进展，部署了 Wingspan 支架（Stryker Neurovascular）。最后一次运行显示 Thrombolysis in Cerebral Infarction 2C 再通。选择支架前血栓切除术是因为症状持续时间>48 小时；因此，在支架置入前通过评估颅内分流来确定再灌注出血的风险是谨慎的。再灌注出血会使支架置入所需的抗血小板药物治疗复杂化。在进行该手术之前，已获得患者的同意。对于单个病例的报告，不需要机构审查委员会的批准。
