Rescue N-butyl-2 cyanoacrylate embolectomy using a Solitaire FR device after venous glue migration during arteriovenous malformation embolization: technical note

Abstract

One of the procedural risks in arteriovenous malformation (AVM) embolization is possible migration of the embolic agent into the venous drainage with an incomplete nidus occlusion, which may lead to severe hemorrhagic complications. This report presents the case of a 29-year-old man who presented with a deep intraparenchymal hematoma on the left side secondary to the spontaneous rupture of a claustral AVM. Upon resorption of the hematoma, the patient underwent an initial therapeutic session of N-butyl-2 cyanoacrylate endovascular embolization, with the purpose of reducing the AVM volume and flow before performing Gamma Knife radiosurgery. After glue injection into one of the arterial feeders, the control angiography showed a partial migration of the glue cast into the straight sinus, with most of the nidus still visible. Because of the bleeding risk due to possible venous hypertension, it was decided to try to retrieve the glue from the vein by using a stent retriever via jugular access. This maneuver allowed a nearly complete removal of the glue cast, thereby restoring normal venous flow drainage. The patient showed no clinical worsening after the procedure. To the authors’ knowledge, this is the first report of the use of the Solitaire FR device as a rescue glue retriever. This method should be considered by physicians in cases of unintended glue migration into the venous circulation during AVM embolization.

Removal of distal fragments of liquid embolic agents during arteriovenous malformation embolization using the TIGERTRIEVER 13: a technical report

“…Their efficiency in the successful removal of thrombi in stroke has been demonstrated in the meta-analysis of multiple randomized controlled trials 12. We also initially reported on the efficacy of stentrievers for the removal of coils13 and there have been a few case reports7–11 describing the use of stent retrievers in removing refluxed Onyx in parent arteries, such as the M1 segment of the MCA and basilar artery (table 2). However, the ability to obtain access to distal vessels is limited due to the size of the microcatheters that can be used and the potential risk of hemorrhage related to straightening of the vessels with subsequent bleeding from transmedullary arteries when the stentrievers are removed.…”

“…There are only a few case reports describing removal of refluxed Onyx from large vessels, such as the M1 segment of the middle cerebral artery (MCA) and the basilar artery,7–11 using standard thrombectomy tools. The TIGERTRIEVER 13 (Rapid Medical, Yoqneam, Israel) is a new stent retriever with a specific design developed for mechanical thrombectomy in small vessels.…”

PHIL Migration to Internal Carotid Artery and Middle Cerebral Artery: Late Mechanical Retrieval with Solitaire AB Stent

“…In this case, the Merci retriever device was used with partial removal of the plug. In the same year, Fahed et al 8 reported the use of Solitaire FR for retrieving N-butyl-2 cyanoacrylate from the venous system. Moreover, Li et al reported the use of Solitaire AB to retrieve Onyx from the basilar artery.…”

Retrieval of a migrated N-butyl-2 cyanoacrylate cast using a snare-kit system during dural AVF embolization: A case report

“…However, caution should be taken during the use of such stent-retrieval devices in the venous circulation because veins are known to have more fragile walls than arteries. 6 The use of the Solitaire FR device was unsuitable for the case described here because of the small size of the device relative to the large sinus lumen. To our knowledge, there are no other reported techniques for retrieval of a migrated NBCA cast in the scientific English literature.…”