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A case of vessel perforation during interventional neuroradiological procedure operative findings of the perforated vessel
Surg Neurol 1993;40:241-4
241
A Case of Vessel Perforation During Interventional Neuroradiological Procedure Operative Findings of the Perforated Vessel Tomoaki Terada, M.D., Takashi Okuno, M.D., Seiji Hayashi, M.D., Yoshinari Nakamura, M.D., Kunio Nakai, M.D., Toru Itakura, M.D., and Norihiko Komai, M.D. Department of Neurological Surgery, Wakayama Medical College, Wakayama City, Japan
Terada T, Okuno T, Hayashi S, Nakamura Y, Nakai K, Itakura T, Komai N. A case of vessel perforation during interventional neuroradiological procedure: operative findings of the perforated vessel. Surg Neurol 1993;40:241-4. A case of vessel perforation by a guide wire during an interventional neuroradiological procedure is reported. The patient was a 59-year-old woman with a left frontal basal arteriovenous malformation (AVM) fed by the left anterior cerebral artery. Transarterial embolization of the AVM was attempted. During the procedure, vessel perforation by the guide wire occurred at the left A 1 - A 2 junction and resulted in subarachnoid hemorrhage, which stopped spontaneously. The patient developed progressive obstructive hydrocephalus, and surgical treatment was performed. T h e AVM was totally removed after ventricular drainage, and the arterial perforation site was explored. When clot around the left A 1 - A 2 junction was removed, hemorrhage recurred. This hemorrhage was similar to what has been observed when a small perforating artery was avulsed. The hemorrhage site was coagulated under temporary occlusion of both A1 segments. Surgical intervention was probably not necessary for this type of bleeding if it had stopped spontaneously, because the rebleeding from the small pinhole would be unlikely, and the operation was more hazardous than the usual aneurysmal surgery. KEY WORDS: Arteriovenous malformation; Embolization; Guide wire; Operation; Vessel perforation
With increasing numbers o f interventional neuroradiologic procedures, there are increased reports of complications, such as vessel rupture [1,3,4] and cerebral isch-
Address reprint requests to: Tomoaki Terada, M.D., Department of Neurological Surgery, Wakayama Medical College, 7 Ban-cho 27, Wakayama City 640, Japan. Received March 23, 1992; accepted July 30, 1992.
© 1993 by ElsevierSciencePublishingCo., lnc.
emia [ 2 - 5 ] . Although vessel perforation is one of the most serious complications, its treatment has not yet been established. W e have treated a case of arteriovenous malformation (AVM) in which the feeding artery was perforated by a guide wire during attempted endovascular treatment, and the perforated artery was confirmed by surgery. T h e treatment for the vessel perforation is discussed from the view point of surgical intervention. Case Report A 59-year-old w o m a n was admitted to our hospital for evaluation of recurrent grand real seizures. A computed tomographic (CT) scan with contrast enhancement revealed a calcified, small, round mass in the left frontal basal region. Angiography showed a small A V M mainly fed by the left frontobasal and frontopolar arteries (Figure 1). We chose to embolize the A V M as the first treatment, because the A V M might be cured, judging from its size and the n u m b e r of feeding arteries. W e used a Tracker-18 catheter and standard 0.016-inch guide wire (Target Therapeutics, San Jose, Calif.). The guide wire was easily introduced into the frontobasal artery, but we could not advance the catheter sufficiently to permit embolization. W e changed to an 0.016-inch radifocus guide wire (Terumo, T o k y o , Japan) and tried to introduce it into the feeding artery. Although we noticed the guide wire went posteriorly at the left A 1 - A 2 junction, we judged that it may have entered a small perforating artery that was not opacified by road mapping. A few minutes later, we introduced the microcatheter into the feeding artery. At that time, we noticed that the patient's clinical status deteriorated. She was semicomatose, with a right hemiparesis. Angiography was p e r f o r m e d with the introduced catheter and demonstrated a prolonged circulation time, as well spasm of the feeding artery. N e i t h e r vessel occlusion nor extravasa0090-3019/93/$6.00
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Surg Neurol 1993;40:241-4
Terada et al
Figure 1. Preoperative angiogram of the patient. (A) Lateral view in an early arterial phase of the left internal carotid angiogram; arrowheads demonstrate the main feeding artery to the A VM. (B) Lateral view in a late arterial phase of the left internal carotid angiogram. (C) The oblique view of the left internal carotid angiogram; arrowheads demonstrate the main feeding artery. (D) The anteroposterior view of the left internal carotid angiogram with arrowhead demonstrating the perforation site.
tion was revealed. We felt that a hemorrhagic complication had occurred, and heparin was immediately reversed with protamine sulfate, and 300 mL of mannitol was infused. An emergency CT scan was performed, which showed a subarachnoid hemorrhage located mainly in the interhemispheric fissure and chiasmatic cistern and a small hematoma in the septum pellucidum (Figure 2). H e r level of consciousness improved and was almost normal 30 minutes after subarachnoid hemorrhage. It deteriorated again 2 hours later because of progressive hydrocephalus. Surgery was planned to treat the hydrocephalus, remove the AVM and repair the perforated vessel, which was presumed to be located at the left A 1-A2 junction. Following ventricular drainage, the AVM was removed via subfrontal approach, and the interhemispheric fissure was separated to inspect the perforation site. Thick clot was tightly covering the perforation site. Arterial bleeding suddenly occurred from the left A 1 - A 2 junction as the clot around the artery
was removed (Figure 3). The bleeding was controlled by the temporary occlusion of both A 1 segments. A small pinhole was identified at the left A 1-A 2 junction, and it was treated successfully with bipolar coagulation. The bleeding was quite similar to that observed when a small artery had been avulsed from its parent artery or a major artery has been punctured with a fine needle. H er postoperative course was uneventful except for mild transient paraparesis from vasospasm, which disappeared completely in several days. A follow-up angiogram on the 9th postoperative day showed complete resection of the AVM, and no abnormality was identified at the left A 1-A2 junction except for mild vasospasm. Rebleeding did not occur during a 10-month follow-up period. Discussion Cases of vessel perforations have been documented in a few reports [ 1,3,4]. There are no reports of the operative
Vessel Perforation by Guide Wire
Surg Neurol 1993;40:241-4
243
Figure 2. CT scan after vesselperforation. Massive subarachnoid hemorrhage and a small hematoma in the septum pellucidum is demonstrated. A VM with calcification is seen in the left frontal base.
findings of vessel perforation by a guide wire. The frequency of vessel perforation is reported as 0.9% by a University of California San Francisco (UCSF) group [ 1] and 4.8% by Purdy et al [3]. This complication is serious; however, the treatment of the vessel perforation has not yet been established. If vessel perforation occurs in a
feeding artery that can be sacrificed and/or if it is caused by a catheter, a coil may be placed across the perforation site via the catheter in order to stop the hemorrhage [ 1]. But if perforation of a major cerebral artery is caused only by aguide wire, the treatment is still not established except for the reversal of heparin. It might be possible Figure 3. Operative view of the perforated vessel. Active hemorrhage is demonstrated from the perforated vessel. (A) Photography: (B) illustration.
A
B
244
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T e r a d a et al
1993;40:241-4
Table 1.
Summaryof Vessel Perforation Cases
Case no.
Source
Perforated vessel
Perforating material
Treatment
1 2 3 4 5 6 7 8
Purdy et al [1] Purdy et al [1] Purdy et al [1] Halbach et al [3] Halbach et al [3] Halbach et al [3] Halbach et al [3] Current case
Pericallosal artery ? Callosomarginal artery Anterior choroidal artery Anterior choroidal artery Middle cerebral artery branch Posterior cerebral artery Anterior cerebral artery (A1-A2 corner)
Catheter Catheter Catheter Catheter or guide wire Catheter Catheter Catheter Guide wire
Operation Operation Coil insertion IBCA injection Transient balloon Coil insertion Coil insertion Operation
Prognosis Good Alive Good Good Good Good Good Good
Abbreviations: IBCA, isobutyl cyanoacrylate.
to advance the catheter over the wire to seal the hole and allow deposition o f a coil to seal the site of perforation [1] unless the perforated vessel is a major cerebral artery that cannot be sacrificed. Temporary balloon occlusion across the perforation site might be preferable before and after guide wire removal [1] if the vessel perforation site is recognized. It is important to recognize when and where it occurred. It is still unknown whether rebleeding may occur from a vessel perforation by a guide wire. In our case, the perforated portion was at the left A 1 - A 2 junction, as judged from a retrospective analysis of the video tape recording of the interventional procedure, as well as our operative findings. This bleeding was very similar to that encountered when a small perforating artery is avulsed from a major cerebral artery or when a major vessel is punctured by a fine needle. The operative findings revealed a thick clot covering the perforation site. If this clot had not been removed at surgery, we believe that bleeding would not have recurred. Recurrent hemorrhage is very rare from peripheral arteries that are punctured, once hemostasis is established, unless the vessel is dysplastic or aneurysmal. T h e r e is a case of vessel perforation by a catheter reported by the UCSF group, which was followed for 18 months without rebleeding after hemostasis by transient balloon occlusion [1]. Eight brain AVM cases with vessel perforation by a guide wire or catheter are summarized in Table 1, including our case [1,3]. The c o m m o n findings o f the vessel perforation cases were that it usually occurred at a site o f sharp angulation and that fatal bleeding did not occur in the reported series. As the cause of occurrence at a site o f sharp angulation, we must consider that the guide wire tip near the end o f the catheter adds stiffness to the overall system and can perforate an artery. Gentle
manipulation o f the guide wire at a site of sharp angulation and the development of guide wires that have more flexible tips than that currently on the 0.016 T e r u m o guide wire are necessary. We believe that the contraction o f the muscular wall of an artery will most likely seal a small perforation and prevent a fatal hemorrhage. Vessel rupture by a balloon would would more likely be fatal. We performed an operation to explore and repair the perforated vessel, but the operation was more difficult than the usual aneurysm surgery because of difficulty in the identification of the perforation site and in the method of repairing a small pinhole. Therefore, we conclude that the surgical repair of a perforated vessel by a fine guide wire is probably unnecessary if the subarachnoid hemorrhage is already stopped and the perforated vessel is not dysplastic or an aneurysm. The author thanks Grant B. Hieshima for kindly reviewing this manuscript.
References 1. Halbach VV, Higashida RT, Dowd CF, Barnwell SL, Hieshima GB: Management of vascular perforations that occur during neurointerventional procedures. AJNR 1991;12:319-27. 2. Pelz DM, Fox AJ, Vinuela F, Drake CC, Ferguson GG: Preoperative embolization of brain AVMs with isobutyl-2-cyanoacrylate. AJNR 1988;9:757-64. 3. Purdy PD, Batjer H, Samson D: Management of hemorrhagic complications from preoperative embolization of arteriovenous malformations. J Neurosurg 1991;74:205-11. 4. Purdy PD, Samson D, Batjer HH, Risser RC: Preoperative embolization of cerebral arteriovenous malformations with polyvinyl alcohol particles: experience in 51 adults. AJNR 1990;11:501-10. 5. Samson D, Ditmore QM, Beyer CW Jr: Intravascular use of isobutyl-2-cyanoacrylate: Part 1. Treatment of intracranial arteriovenous malformations. Neurosurgery 1981;8:43-51.
241
A Case of Vessel Perforation During Interventional Neuroradiological Procedure Operative Findings of the Perforated Vessel Tomoaki Terada, M.D., Takashi Okuno, M.D., Seiji Hayashi, M.D., Yoshinari Nakamura, M.D., Kunio Nakai, M.D., Toru Itakura, M.D., and Norihiko Komai, M.D. Department of Neurological Surgery, Wakayama Medical College, Wakayama City, Japan
Terada T, Okuno T, Hayashi S, Nakamura Y, Nakai K, Itakura T, Komai N. A case of vessel perforation during interventional neuroradiological procedure: operative findings of the perforated vessel. Surg Neurol 1993;40:241-4. A case of vessel perforation by a guide wire during an interventional neuroradiological procedure is reported. The patient was a 59-year-old woman with a left frontal basal arteriovenous malformation (AVM) fed by the left anterior cerebral artery. Transarterial embolization of the AVM was attempted. During the procedure, vessel perforation by the guide wire occurred at the left A 1 - A 2 junction and resulted in subarachnoid hemorrhage, which stopped spontaneously. The patient developed progressive obstructive hydrocephalus, and surgical treatment was performed. T h e AVM was totally removed after ventricular drainage, and the arterial perforation site was explored. When clot around the left A 1 - A 2 junction was removed, hemorrhage recurred. This hemorrhage was similar to what has been observed when a small perforating artery was avulsed. The hemorrhage site was coagulated under temporary occlusion of both A1 segments. Surgical intervention was probably not necessary for this type of bleeding if it had stopped spontaneously, because the rebleeding from the small pinhole would be unlikely, and the operation was more hazardous than the usual aneurysmal surgery. KEY WORDS: Arteriovenous malformation; Embolization; Guide wire; Operation; Vessel perforation
With increasing numbers o f interventional neuroradiologic procedures, there are increased reports of complications, such as vessel rupture [1,3,4] and cerebral isch-
Address reprint requests to: Tomoaki Terada, M.D., Department of Neurological Surgery, Wakayama Medical College, 7 Ban-cho 27, Wakayama City 640, Japan. Received March 23, 1992; accepted July 30, 1992.
© 1993 by ElsevierSciencePublishingCo., lnc.
emia [ 2 - 5 ] . Although vessel perforation is one of the most serious complications, its treatment has not yet been established. W e have treated a case of arteriovenous malformation (AVM) in which the feeding artery was perforated by a guide wire during attempted endovascular treatment, and the perforated artery was confirmed by surgery. T h e treatment for the vessel perforation is discussed from the view point of surgical intervention. Case Report A 59-year-old w o m a n was admitted to our hospital for evaluation of recurrent grand real seizures. A computed tomographic (CT) scan with contrast enhancement revealed a calcified, small, round mass in the left frontal basal region. Angiography showed a small A V M mainly fed by the left frontobasal and frontopolar arteries (Figure 1). We chose to embolize the A V M as the first treatment, because the A V M might be cured, judging from its size and the n u m b e r of feeding arteries. W e used a Tracker-18 catheter and standard 0.016-inch guide wire (Target Therapeutics, San Jose, Calif.). The guide wire was easily introduced into the frontobasal artery, but we could not advance the catheter sufficiently to permit embolization. W e changed to an 0.016-inch radifocus guide wire (Terumo, T o k y o , Japan) and tried to introduce it into the feeding artery. Although we noticed the guide wire went posteriorly at the left A 1 - A 2 junction, we judged that it may have entered a small perforating artery that was not opacified by road mapping. A few minutes later, we introduced the microcatheter into the feeding artery. At that time, we noticed that the patient's clinical status deteriorated. She was semicomatose, with a right hemiparesis. Angiography was p e r f o r m e d with the introduced catheter and demonstrated a prolonged circulation time, as well spasm of the feeding artery. N e i t h e r vessel occlusion nor extravasa0090-3019/93/$6.00
242
Surg Neurol 1993;40:241-4
Terada et al
Figure 1. Preoperative angiogram of the patient. (A) Lateral view in an early arterial phase of the left internal carotid angiogram; arrowheads demonstrate the main feeding artery to the A VM. (B) Lateral view in a late arterial phase of the left internal carotid angiogram. (C) The oblique view of the left internal carotid angiogram; arrowheads demonstrate the main feeding artery. (D) The anteroposterior view of the left internal carotid angiogram with arrowhead demonstrating the perforation site.
tion was revealed. We felt that a hemorrhagic complication had occurred, and heparin was immediately reversed with protamine sulfate, and 300 mL of mannitol was infused. An emergency CT scan was performed, which showed a subarachnoid hemorrhage located mainly in the interhemispheric fissure and chiasmatic cistern and a small hematoma in the septum pellucidum (Figure 2). H e r level of consciousness improved and was almost normal 30 minutes after subarachnoid hemorrhage. It deteriorated again 2 hours later because of progressive hydrocephalus. Surgery was planned to treat the hydrocephalus, remove the AVM and repair the perforated vessel, which was presumed to be located at the left A 1-A2 junction. Following ventricular drainage, the AVM was removed via subfrontal approach, and the interhemispheric fissure was separated to inspect the perforation site. Thick clot was tightly covering the perforation site. Arterial bleeding suddenly occurred from the left A 1 - A 2 junction as the clot around the artery
was removed (Figure 3). The bleeding was controlled by the temporary occlusion of both A 1 segments. A small pinhole was identified at the left A 1-A 2 junction, and it was treated successfully with bipolar coagulation. The bleeding was quite similar to that observed when a small artery had been avulsed from its parent artery or a major artery has been punctured with a fine needle. H er postoperative course was uneventful except for mild transient paraparesis from vasospasm, which disappeared completely in several days. A follow-up angiogram on the 9th postoperative day showed complete resection of the AVM, and no abnormality was identified at the left A 1-A2 junction except for mild vasospasm. Rebleeding did not occur during a 10-month follow-up period. Discussion Cases of vessel perforations have been documented in a few reports [ 1,3,4]. There are no reports of the operative
Vessel Perforation by Guide Wire
Surg Neurol 1993;40:241-4
243
Figure 2. CT scan after vesselperforation. Massive subarachnoid hemorrhage and a small hematoma in the septum pellucidum is demonstrated. A VM with calcification is seen in the left frontal base.
findings of vessel perforation by a guide wire. The frequency of vessel perforation is reported as 0.9% by a University of California San Francisco (UCSF) group [ 1] and 4.8% by Purdy et al [3]. This complication is serious; however, the treatment of the vessel perforation has not yet been established. If vessel perforation occurs in a
feeding artery that can be sacrificed and/or if it is caused by a catheter, a coil may be placed across the perforation site via the catheter in order to stop the hemorrhage [ 1]. But if perforation of a major cerebral artery is caused only by aguide wire, the treatment is still not established except for the reversal of heparin. It might be possible Figure 3. Operative view of the perforated vessel. Active hemorrhage is demonstrated from the perforated vessel. (A) Photography: (B) illustration.
A
B
244
Surg N e u r o l
T e r a d a et al
1993;40:241-4
Table 1.
Summaryof Vessel Perforation Cases
Case no.
Source
Perforated vessel
Perforating material
Treatment
1 2 3 4 5 6 7 8
Purdy et al [1] Purdy et al [1] Purdy et al [1] Halbach et al [3] Halbach et al [3] Halbach et al [3] Halbach et al [3] Current case
Pericallosal artery ? Callosomarginal artery Anterior choroidal artery Anterior choroidal artery Middle cerebral artery branch Posterior cerebral artery Anterior cerebral artery (A1-A2 corner)
Catheter Catheter Catheter Catheter or guide wire Catheter Catheter Catheter Guide wire
Operation Operation Coil insertion IBCA injection Transient balloon Coil insertion Coil insertion Operation
Prognosis Good Alive Good Good Good Good Good Good
Abbreviations: IBCA, isobutyl cyanoacrylate.
to advance the catheter over the wire to seal the hole and allow deposition o f a coil to seal the site of perforation [1] unless the perforated vessel is a major cerebral artery that cannot be sacrificed. Temporary balloon occlusion across the perforation site might be preferable before and after guide wire removal [1] if the vessel perforation site is recognized. It is important to recognize when and where it occurred. It is still unknown whether rebleeding may occur from a vessel perforation by a guide wire. In our case, the perforated portion was at the left A 1 - A 2 junction, as judged from a retrospective analysis of the video tape recording of the interventional procedure, as well as our operative findings. This bleeding was very similar to that encountered when a small perforating artery is avulsed from a major cerebral artery or when a major vessel is punctured by a fine needle. The operative findings revealed a thick clot covering the perforation site. If this clot had not been removed at surgery, we believe that bleeding would not have recurred. Recurrent hemorrhage is very rare from peripheral arteries that are punctured, once hemostasis is established, unless the vessel is dysplastic or aneurysmal. T h e r e is a case of vessel perforation by a catheter reported by the UCSF group, which was followed for 18 months without rebleeding after hemostasis by transient balloon occlusion [1]. Eight brain AVM cases with vessel perforation by a guide wire or catheter are summarized in Table 1, including our case [1,3]. The c o m m o n findings o f the vessel perforation cases were that it usually occurred at a site o f sharp angulation and that fatal bleeding did not occur in the reported series. As the cause of occurrence at a site o f sharp angulation, we must consider that the guide wire tip near the end o f the catheter adds stiffness to the overall system and can perforate an artery. Gentle
manipulation o f the guide wire at a site of sharp angulation and the development of guide wires that have more flexible tips than that currently on the 0.016 T e r u m o guide wire are necessary. We believe that the contraction o f the muscular wall of an artery will most likely seal a small perforation and prevent a fatal hemorrhage. Vessel rupture by a balloon would would more likely be fatal. We performed an operation to explore and repair the perforated vessel, but the operation was more difficult than the usual aneurysm surgery because of difficulty in the identification of the perforation site and in the method of repairing a small pinhole. Therefore, we conclude that the surgical repair of a perforated vessel by a fine guide wire is probably unnecessary if the subarachnoid hemorrhage is already stopped and the perforated vessel is not dysplastic or an aneurysm. The author thanks Grant B. Hieshima for kindly reviewing this manuscript.
References 1. Halbach VV, Higashida RT, Dowd CF, Barnwell SL, Hieshima GB: Management of vascular perforations that occur during neurointerventional procedures. AJNR 1991;12:319-27. 2. Pelz DM, Fox AJ, Vinuela F, Drake CC, Ferguson GG: Preoperative embolization of brain AVMs with isobutyl-2-cyanoacrylate. AJNR 1988;9:757-64. 3. Purdy PD, Batjer H, Samson D: Management of hemorrhagic complications from preoperative embolization of arteriovenous malformations. J Neurosurg 1991;74:205-11. 4. Purdy PD, Samson D, Batjer HH, Risser RC: Preoperative embolization of cerebral arteriovenous malformations with polyvinyl alcohol particles: experience in 51 adults. AJNR 1990;11:501-10. 5. Samson D, Ditmore QM, Beyer CW Jr: Intravascular use of isobutyl-2-cyanoacrylate: Part 1. Treatment of intracranial arteriovenous malformations. Neurosurgery 1981;8:43-51.