Neurointervention.  2024 Nov;19(3):180-184. 10.5469/neuroint.2024.00409.

Inadvertent Detachment of Stent Retrievers: Report of 2 Cases

• Ok T
• Yoon PH
• Seo KD

• KMID: 2560223
• DOI: http://doi.org/10.5469/neuroint.2024.00409

Abstract

Mechanical thrombectomy using a stent retriever is a widely-used technique for recanalizing occluded cerebral arteries in acute ischemic stroke. Although rare, inadvertent stent detachment has primarily been reported with earlier stent retriever designs. We present 2 cases of inadvertent stent detachment with the pRESET stent. In the first case, an elderly patient presented with right middle cerebral artery occlusion and experienced stent detachment during the second retrieval. Despite this, successful recanalization was achieved through balloon angioplasty. In the second case, an elderly patient experienced stent detachment after the third retrieval, and recanalization of the M1 segment was unsuccessful due to the inability to pass the microcatheter. The first patient had a modified Rankin scale (mRS) score of 3, while the second had a poor prognosis with an mRS score of 5. These cases highlight that inadvertent stent detachment can impact outcomes, and balloon angioplasty may serve as a useful salvage therapy.

Keyword

Thrombectomy; Stents; Accidents; Balloon angioplasty

Figure

• 

  Fig. 1. (A) A right internal carotid artery (ICA) angiogram demonstrates occlusion in the inferior division of the right middle cerebral artery (MCA) (arrow). (B) Stent deployment is completed, with arrows indicating the distal and proximal markers of the stent. (C) A right ICA angiogram reveals occlusion in the proximal M1 segment of the MCA following stent detachment with arrows indicating the distal and proximal markers of the stent. (D) Native fluoroscopic image showing the detached stent (arrows mark the distal and proximal marker). (E) An aspiration catheter (Esperance; Wallaby Medical) is advanced through the stent, and suction thrombectomy is performed (arrow indicates the distal portion of the aspiration catheter and arrowheads indicate the distal and proximal markers of the stent). (F) A right ICA angiogram shows improved distal flow in the MCA following intra-arterial tirofiban injection. (G) Native fluoroscopic image showing an inflated balloon (arrows, 3×15 mm Gateway; Boston Scientific). (H) The final right ICA angiogram demonstrates good flow restoration in the MCA with arrows indicating the distal and proximal markers of the stent.

• 

  Fig. 2. (A) A right internal carotid artery (ICA) angiogram in the anterior-posterior (AP) view shows occlusion in the distal M1 segment of the middle cerebral artery (MCA). The precise location of the occlusion is obscured due to its overlap with the MCA trunk (arrow). (B) A right ICA angiogram in the lateral view confirms occlusion in the distal M1 segment of the MCA (arrow). (C) In the AP view, stent deployment is completed (arrowheads mark the distal and proximal stent markers, while the arrow indicates the site of occlusion). (D) Lateral view post-deployment. Arrow indicates the site of occlusion. (E) AP view. The final angiogram shows occlusion in the distal M1 segment of the MCA following stent detachment with arrows indicating the distal and proximal markers of the stent. (F) Lateral view of the final angiogram with arrow indicating the distal marker of stent. (G) AP native fluoroscopic image showing the detached stent (arrows mark the distal and proximal marker). (H) Lateral native fluoroscopic image (arrows mark the distal and proximal marker).

Reference

1. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, DAWN Trial Investigators, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018; 378:11–21.

2. Yoshimura S, Sakai N, Yamagami H, Uchida K, Beppu M, Toyoda K, et al. Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med. 2022; 386:1303–1313.

3. Nogueira RG, Doheim MF, Al-Bayati AR, Lee JS, Haussen DC, Mohammaden M, et al. Distal medium vessel occlusion strokes: understanding the present and paving the way for a better future. J Stroke. 2024; 26:190–202.

4. Delgado Almandoz JE, Kayan Y, Young ML, Fease JL, Scholz JM, Milner AM, et al. Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques. J Neurointerv Surg. 2016; 8:1123–1128.

5. Pilgram-Pastor SM, Piechowiak EI, Dobrocky T, Kaesmacher J, Den Hollander J, Gralla J, et al. Stroke thrombectomy complication management. J Neurointerv Surg. 2021; 13:912–917.

6. Masoud H, Nguyen TN, Martin CO, Holloway WE, Ambekar S, Yavagal DR, et al. Inadvertent stent retriever detachment: a multicenter case series and review of device experience FDA reports. Interv Neurol. 2016; 4:75–82.

7. Kurre W, Aguilar-Pérez M, Schmid E, Sperber W, Bäzner H, Henkes H. Clinical experience with the pREset stent retriever for the treatment of acute ischemic stroke--a review of 271 consecutive cases. Neuroradiology. 2014; 56:397–403.

8. Kim ST, Jin SC, Jeong HW, Seo JH, Ha SY, Pyun HW. Unexpected detachment of solitaire stents during mechanical thrombectomy. J Korean Neurosurg Soc. 2014; 56:463–468.

9. Parthasarathy R, Gupta V, Goel G, Mahajan A. Solitaire stentectomy: ‘deploy and engage’ and ‘loop and snare’ techniques. BMJ Case Rep. 2016; 2016:bcr2016012547.

10. Kang DH, Park J, Hwang YH, Kim YS. Inadvertent self-detachment of solitaire AB stent during the mechanical thrombectomy for recanalization of acute ischemic stroke: lessons learned from the removal of stent via surgical embolectomy. J Korean Neurosurg Soc. 2013; 53:360–363.

11. Mazya M, Egido JA, Ford GA, Lees KR, Mikulik R, Toni D, SITS Investigators, et al. Predicting the risk of symptomatic intracerebral hemorrhage in ischemic stroke treated with intravenous alteplase: safe Implementation of Treatments in Stroke (SITS) symptomatic intracerebral hemorrhage risk score. Stroke. 2012; 43:1524–1531.

12. Piasecki P, Wierzbicki M, Tulik P, Potocka K, Stępień A, Staszewski J, et al. Inadvertent detachment of stent retrievers during mechanical thrombectomy-a clinical and biomechanical perspective. Life (Basel). 2021; 11:658.

13. Kwon HJ, Chueh JY, Puri AS, Koh HS. Early detachment of the Solitaire stent during thrombectomy retrieval: an in vitro investigation. J Neurointerv Surg. 2015; 7:114–117.