J Cerebrovasc Endovasc Neurosurg.  2016 Sep;18(3):296-301. 10.7461/jcen.2016.18.3.296.

Pseudoaneurysm Formation after Repetitive Suction Thrombectomy Using a Penumbra Suction Catheter

• Jeong EO
• Kwon HJ
• Choi SW
• Koh HS

• KMID: 2355658
• DOI: http://doi.org/10.7461/jcen.2016.18.3.296

Abstract

With the recent advent of suction catheters, the use of manual aspiration thrombectomy (MAT) for patients with acute ischemic stroke with large vessel occlusion has increased. Although contrast leakage and subarachnoid hemorrhage have been reported during MAT procedures, pseudoaneurysm formation due to vessel injury by suction catheters has not been. We discuss the case of a 60-year-old woman who presented to our emergency room with dysarthria and left-sided weakness. She underwent suction thrombectomy 5 times for acute middle cerebral artery occlusion and significant contrast leakage occurred during the procedure. On follow-up angiogram on post-operative day 15, we noticed a pseudoaneurysm, which was treated with detachable coil embolization. Surgeons who perform suction thrombectomy should keep in mind the possibility of vessel injury that results in the formation of a pseudoaneurysm, especially at the branching site or tortuous segments.

Keyword

Pseudoaneurysm; Suction; Thrombectomy

MeSH Terms

Aneurysm, False*
Catheters*
Dysarthria
Embolization, Therapeutic
Emergency Service, Hospital
Female
Follow-Up Studies
Humans
Infarction, Middle Cerebral Artery
Middle Aged
Stroke
Subarachnoid Hemorrhage
Suction*
Surgeons
Thrombectomy*

Figure

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  Fig. 1 Digital subtraction angiography (DSA) roadmap images during thrombectomy. (A) Roadmap shows right middle cerebral artery, mid M1 segment occlusion, and the suction catheter tip (Penumbra 5MAX, Penumbra Inc., Alameda, CA, USA) for the first manual aspiration thrombectomy (MAT) (arrow). (B) For the second MAT, the roadmap shows more distal M1 occlusion than seen in the angiogram performed after the first MAT and the suction catheter tip (arrow). (C) Roadmap shows right distal M1 segment occlusion after the third MAT and suction catheter tip for the fourth MAT (arrow). (D) Roadmap shows one M2 branch occlusion by migrated thrombus and suction catheter (Penumbra 4MAX) tip for the fifth MAT (arrow).

• 

  Fig. 2 Digital subtraction angiography (DSA) and three-dimensional reconstruction images, computed tomography (CT) after thrombectomy. (A) DSA shows contrast leakage (arrow) at distal M1 near the fourth MAT point. (B) CT shows diffuse SAH on the right Sylvian fissure and multiple sulci accompanying ventriculomegaly (C) DSA performed on postoperative day (POD) 12 shows multiple vasospasms at M2 and M3 segments (arrows) and no evidence of an aneurysm sac. (D) DSA performed on POD 15 shows an aneurysm sac near the extravasation site (arrow). (E) Three-dimensional reconstruction image of pseudoaneurysm at the origin site of small temporal branch of the right M1 segment (arrow).

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  Fig. 3 Angiograms obtained during embolization and the follow-up period. (A) Digital subtraction angiography (DSA) roadmap image shows a single microcatheter selected into the pseudoaneurysm sac (arrow). (B) Non-subtracted angiography shows no contrast filling in the pseudoaneurysm after detachable coil embolization (arrow). (C) DSA performed on postoperative (POD) day 17 shows complete occlusion of the pseudoaneurysm (arrow). (D) Magnetic resonance angiography performed on POD 125 shows no evidence of a remnant sac (arrow).

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