Early surgical removal of migrated coil/stent after failed embolization of intracranial aneurysm

Abstract

OBJECT Distal coil or stent migration is a rare, but potentially morbid complication of intracranial aneurysm embolization. At present, there is no established standard of surgical evacuation of displaced material—in particular, there is no consensus on the optimum time for such intervention. The authors report their positive experiences with an ultra-early surgical evacuation of 2 migrated coils and a flow-diverter stent. METHODS Uncontrolled coil or stent migration occurred in 3 (0.75%) of approximately 400 patients treated between 1999 and 2012 in the authors' institution. In all 3 cases, the materials moved from their intended position to the middle cerebral artery (MCA). Surgical evacuation was started immediately (within half an hour) after a futile attempt of removing them via intraarterial route, under the same anesthesia and with no active reversal of heparinization. RESULTS No excessive bleeding was observed. Displaced coils were extracted through an incision of a branch of MCA—the anterior temporal artery, the stent was removed through a direct incision of MCA. Recombinant tissue plasminogen activator (rtPA) was injected to the stem of the internal carotid artery toward the end of the procedure, with no discernible adverse effects. Two patients were discharged with no deficit (Glasgow Outcome Scale [GOS] Score 5); the other patient was conscious with mild hemiparesis (GOS Score 4) at discharge. CONCLUSIONS The experiences of these 3 cases suggest that immediate removal of a migrated stent/coil is feasible and may be effective. Indirect access to the MCA through its branch helps to shorten the time of temporary clipping of the artery to a minimum. Maintaining active heparinization and direct intraarterial injection of rtPA are helpful in promoting blood flow in the MCA.

Coil migration during or after endovascular coiling of cerebral aneurysms

“…Data regarding intraprocedurally or postprocedurally coil migration following endovascular coiling of cerebral aneurysms are limited to case reports and a few small case series 7. Our study showed that coil migration is a rare phenomenon with an incidence of 0.3%, which is lower than that reported in the literature (0.5–6%) 4 7–14. This discrepancy in rates is, in part, related to use of the term 'coil migration' interchangeably in the literature for a range of malpositioning, partial coil stretching, partial prolapse, and displacement of coils from the aneurysmal cavity 7 12.…”

“…There is no consensus about the best salvage mechanism or retrieval device for migrated coils. Various methods of retrieval have been described, including stent retrievers, Snaring, Alligator, and Merci devices, aspiration, wire recanalization techniques, and surgical extraction 7 12 14 25–30. Endovascular retrieval methods should be initially considered rather than open surgery given the delay, complexity, and high morbidity of the open surgical approach.…”

Nickel-Related Adverse Reactions in the Treatment of Cerebral Aneurysms: A Literature Review

“…serve as a last resort for medically-refractory patients, and had been performed in other scenarios such as migrated flow-diverters. 25,26…”

Endovascular stentectomy using the snare over stent-retriever (SOS) technique: An experimental feasibility study

“…Loss [ 1 ], dislocation [ 2 ], twisting, incomplete unfolding [ 3 ], as well as misplacement [ 4 ] of stents are complications encountered in interventional neuroradiology. Options to deal with these problems are limited and include surgical removal (either challenging in the neurovasculature or even impossible depending on the location) [ 2 ] [ 3 ], or placement of a second stent to fix the problem [ 4 ].…”

“…Loss [ 1 ], dislocation [ 2 ], twisting, incomplete unfolding [ 3 ], as well as misplacement [ 4 ] of stents are complications encountered in interventional neuroradiology. Options to deal with these problems are limited and include surgical removal (either challenging in the neurovasculature or even impossible depending on the location) [ 2 ] [ 3 ], or placement of a second stent to fix the problem [ 4 ]. In many cases, however, the stent is left as it is and the patient is being continuosly treated with anti-platelet medication [ 5 ] carrying the risk of vessel stenosis, occlusion, and cerebral infarctions [ 6 , 7 ].…”