Neurointervention.  2014 Feb;9(1):26-31. 10.5469/neuroint.2014.9.1.26.

Mechanical Thrombectomy Using the Solitaire FR system for Occlusion of the Top of the Basilar Artery: Intentional Detachment of the Device after Partial Retrieval

• Siu KL
• Lee DG
• Shim JH
• Suh DC
• Lee DH

• KMID: 1910771
• DOI: http://doi.org/10.5469/neuroint.2014.9.1.26

Abstract

Acute, distal, basilar artery occlusion is a challenging neurovascular emergency. There have been several reports regarding the successful application of the Solitaire FR device for treating this lesion. However, due to the lack of a suitable, balloon-tipped, guiding catheter for the vertebral artery, during this procedure we frequently experience the occurrence of clot fragmentation and distal migration. There may be some technical solutions to solve this problem. The purpose of this report is to present a technical variation of using the Solitaire FR, and which is referred to as the 'intentional device detachment technique.' As a clot tends to re-embolize during its passage through the tortuous cranio-cervical junction level of the vertebral artery or its passage through the tip of the guiding catheter, due to the lack of proximal flow arrest, we thought that not removing the stent segment of the device which is capturing the clot could avoid this problem. We were able to successfully apply this technique in two cases. We believe that this technique can be a possible technical option for using the Solitaire FR device when a patient has little concern regarding the subsequent use of antiplatelets.

Keyword

Stroke/therapy; Basilar artery; Mechanical thrombolysis; Stent retriever

MeSH Terms

Basilar Artery*
Catheters
Emergencies
Humans
Mechanical Thrombolysis
Stents
Thrombectomy*
Vertebral Artery

Figure

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  Fig. 1 A 67-year-old male presented with gradually worsening brainstem symptoms. DWI showed patch, high-signal lesions in the left superior cerebellar artery territory (not shown).A. Right vertebral angiogram showed acute, complete, distal basilar artery occlusion. B. Antegrade flow is seen immediately following placement of the Solitaire FR in the left posterior cerebral artery. C. On the subsequent several passages of the device, the shape of the filling defect changed slightly. Eventually, the clot migrated distally, showing irregular filling defects in the left posterior cerebral artery lumen. D. At this time, we obtained a control angiogram during the device pull-back. The proximal half of the filling defect was still enclosed by the device mesh, however, the distal half of the clot was uncovered by the device. E. We managed to pull back more proximally, however, the distal uncovered segment of the clot had migrated into the right posterior cerebral artery lumen. We decided to detach the device in order to avoid further distal migration of the clot during full retrieval. The detached stent part was then in the right distal vertebral artery lumen below the origin of the ipsilateral posterior inferior cerebellar artery.

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  Fig. 2 A 64-year-old male presented with altered mental status. The initial DWI showed multifocal cerebellar hemispheric and brainstem infarcts (not shown).A. Right vertebral angiogram showed complete occlusion of the basilar top. B. The artery was open as soon as the device was placed. The control angiogram taken while the device was pulled back, shows a well-marginated filling defect. C. The device was intentionally detached. The clot was still caught by the device while the artery was fully open and without distal clot migration.

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