- Email: [email protected]
The POP (Pull on Pipe) Maneuver: A Technical Note for Rescuing a Prolapsed Pipeline Device
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The POP (Pull on Pipe) Maneuver: A Technical Note for Rescuing a Prolapsed Pipeline Device Jose Danilo Bengzon Diestro, MD,*,1 Carmen Parra-Farinas, MD,* Mohamed Akli Zetchi, MD,*,† Julian Spears, MD,*,† and Thomas R. Marotta, MD* Background: Flow diverters have revolutionized the treatment of large aneurysms. However, prolapse of the device into the aneurysm is a known complication that may have fatal consequences. Case: We present a case of a 21-year-old male with a giant aneurysm located in the cavernous segment of the right internal carotid artery. After Pipeline Embolization Device (PED) deployment, while retrieving the PED wire, the proximal end of the stent shortened, resulting in prolapse of the device into the aneurysm. We utilized the Pull on Pipe (POP) maneuver, characterized by the deployment of a second PED inside the lumen of the prolapsed device and gentle traction to restore the initial flow diverter into its proper position. The maneuver also allows for the immediate deployment of the second PED to improve proximal purchase and overall construct stability. Conclusion: The POP maneuver is a novel strategy for salvaging herniated flow diverters and establishing a more stable PED construct. Key Words: Endovascular—aneurysm—flow diversion—pipeline—prolapse © 2020 Elsevier Inc. All rights reserved.
Background The surgical treatment of large cavernous internal carotid artery aneurysms (>10 mm)1 is not straightforward. The use of coiling with or without stent assistance, only achieves a 67% complete occlusion at 3 months and 18% of these patients eventually need retreatment.2 An alternative treatment option shown to result in superior 3-month occlusion rates (93%) is parent artery occlusion.2 This latter procedure however requires the patient to pass an angiographic occlusion test first.3 The introduction of the Pipeline Embolization Device (PED) has revolutionized the treatment of these aneurysms. The PED provides a flow diverting construct that can bypass aneurysms resulting in occlusion even without the use of coils.4 Pooled analysis for the use of PED for all types of aneurysms shows an impressive 85.5% 1-year occlusion rate with a 3.0% retreatment rate.5 The device can
also be deployed over perforators and major arterial branches without shutting down flow into these vessels.6 Despite the ability of the PED to overcome features of “uncoilable” aneurysms such as wide necks and involvement of vital arterial branches, the use of the device is not without some peculiar difficulties. The overall complication rate of PED treatment found in a systematic review was 17.0%. Device migration and poor positioning accounted for 5.8%.7 Other complications included: in stent stenosis, branch occlusion, ischemic events, wire perforation, poor stent opening, and intracerebral hemorrhage. The propensity of the device to elongate with oversizing and to shorten with undersizing can affect the PED’s flow diverting effect and result in improper placement.8 Complete prolapse of 1 end of the device into the aneurysm can result in incomplete neck coverage or even worse, flow diversion into the
From the *Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada; and †Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada. Received November 13, 2019; revision received December 15, 2019; accepted January 1, 2020. Funding: This study did not receive any financial support. Address correspondence to Jose Danilo B. Diestro MD, Medical Imaging Room CC3-141, Department of Medical Imaging, St. Michael’s Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8. E-mail: [email protected]. 1 Institution where the work was performed: St. Michael’s Hospital, University of Toronto. 1052-3057/$ - see front matter © 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104647
Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2020: 104647
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aneurysmal sac. Thus, maneuvers to manage this complication are important parts of a neurointerventionist’s skill set. We present a case of a partially prolapsed PED during the treatment of a large cavernous internal carotid artery aneurysm. The stent was carefully repositioned using a novel technique, the “pull on pipe” (POP) maneuver.
Case Presentation The patient was a 21-year-old, right-handed, male, student who was previously well until June 2015 when he had sudden loss of consciousness followed by jerking movements of all his limbs while standing outside his home. Because of the facial injuries that he sustained after his seizure a cranial computed tomography scan was done and this revealed a cavernous sinus internal carotid artery aneurysm. He was started on levetiracetam. He had no pre-existing conditions such as infections, intracranial neoplasms, or metabolic derangements that could have provoked a seizure. Conservative management that consisted of annual clinic visits with serial imaging, was initially pursued. In the interim, he had 1-2 episodes of seizures yearly characterized a general feeling of unease followed by generalized tonic clonic movements lasting for 3 minutes. The breakthrough seizures usually occurred during missed doses of his antiepileptic drug. He was initially lost to follow-up from our clinic. Four years later after his initial presentation, he developed diplopia on rightward gaze. When we saw him in clinic, he already had limited abduction of the right, right eye ptosis, and miosis. These findings were consistent with a right cranial nerve 6 palsy with an accompanying Horner’s syndrome. We localized the findings in the right cavernous sinus, the site of his previous aneurysm. We suspected that further growth of the aneurysm resulted in irritation of the sympathetic nerves surrounding the cavernous segment of
the internal carotid artery and the adjacent cranial nerve 6. Our localization was confirmed by repeat neurovascular imaging that showed significant growth of the aneurysm from a previous 17 mm to 31 mm in greatest dimension (See Fig 1, A,B). Because he felt that levetiracetam was causing daytime somnolence, he was shifted to valproic acid. He has not had seizure episode this past year. He has no other comorbid conditions. He has no family history of aneurysms. His mother was diagnosed with epilepsy and maintained on antiepileptic drugs throughout her childhood until her seizures abated in adulthood. He occasionally drinks alcohol and uses marijuana. He previously smoked cigarettes but has already quit. On account of his ocular symptoms and significant increase in size of the aneurysm, treatment with flow diversion was planned.
Technical Note A 6 French Shuttle (Cook Medical) was navigated into the right common carotid artery over a 5 French Berenstein Tip Select Catheter (Penumbra) and a Glidewire Advantage guidewire (Terumo). Afterwards, a Navien 072 catheter (Covidien) was exchanged over the Advantage wire and brought into the right internal carotid artery (ICA). A 26 £ 28 £ 30 mm aneurysm was visualized in the cavernous segment of the right ICA (See Fig 1, C). An Excelsior SL-10 microcatheter (Stryker) was navigated over a Traxcess-14 mircowire (Microvention) into the M2 segment of the right middle cerebral artery (MCA). A Phenom 27 (Medtronic) microcatheter was exchanged over the microwire into the M1 segment of the right MCA. Subsequently a 5.0 £ 35 mm PED (Medtronic) was deployed from the cavernous ICA (distal to the neck of the aneurysm) to the petrous ICA (See Fig 2, A,D). In the process of retrieving the flow diverter wire with the microcatheter, the PED was inadvertently pushed into the aneurysm. The resulting partial prolapse moved the
Figure 1. Preoperative and postoperative images of a right cavernous segment internal carotid artery aneurysm (arrow). (A) Sagittal CT showing initial imaging in May 2015. (B) Sagittal CT done in June 2019 showing progression in the size of the aneurysm. (C) Three-dimensional reconstruction of digital subtraction angiogram done July 2019 showing the large aneurysm and its relationship to the cavernous segment of the internal carotid artery. (D) Sagittal CT taken 4 months post-op showing a dramatic decrease in the filling portion of the aneurysm and the PED above the aneurysm remnant. Abbreviations: PED, Pipeline Embolization Device.
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Figure 2. Lateral views of digital subtraction angiogram (DSA) with a superimposed graphical representation of the PEDs and x-rays documenting the treatment of the right cavernous segment internal carotid artery aneurysm. (A,D) Initial stent (red) deployment (B,E) PED prolapse into the aneurysm (C,F) Proper placement of the 2 PEDs (red and blue) after the POP maneuver; yellow arrow indicates the direction of pull of the second PED (blue). Abbreviations: PED, Pipeline Embolization Device.
proximal edge of the PED dangerously close into the aneurysm lumen (See Fig 2, B,E). Pulling on the microcatheter over the microwire only partly reduced the degree of prolapse. The POP maneuver was then performed to restore the PED into its desired configuration: 1. After removal of the wire, a second PED (5.0 £ 30 mm) was partially deployed in the mid aspect of the first PED. 2. After apposition of the deployed portion of the second PED inside the first PED, we pulled on the second PED to restore the positioning of the first PED. 3. The second pipeline stent was then completely deployed proximally on the petrous ICA (See Fig 2, C,F).
Outcome and Follow-Up The patient had transient severe right eye pain spanning the first postoperative month that was alleviated with an initial course of dexamethasone and pain medications. Neuroimaging repeated 4 months post-op showed marked regression of the residual filling of the aneurysm (See Fig 1, D). Four months after his surgery, diplopia was only present on the most extreme gaze. Clinical exam no longer showed any problems with ocular motility. From a modified Rankin Score (mRS) of 2 because his eye symptoms significantly affected with daily activities his score mRS is now down to 1. The entire case is summarized in a timeline (See Supplemental File 1).
Discussion The delivery wire was carefully removed from the system through the microcatheter. Final cerebral angiograms and cone beam CT demonstrated adequate positioning and wall apposition of both PEDs and beginning aneurysmal flow stasis.
The incidence of PED prolapse based on 2 institutional case series is between 1.2% (3/413)8 to 3.2% (5/155).9 Several case reports10-15 and case series8,9 have documented the phenomenon and several salvage techniques (See Table 1). Two cases11,15 that dealt with proximal end prolapse
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Retrograde access with a microwire via the posterior communicating artery into the aneurysm was accomplished. The distal end of the microwire was caught with a snare going into the aneurysm proximally. A microcatheter coming proximally was then tracked past the aneurysm and the internal carotid artery and was used to deploy 2 more flow diverters and obtain optimal proximal purchase. Similar to the described technique above but utilized the anterior communicating artery instead of the posLeft internal carotid Between 2 telescoping terior communicating artery. artery (Cavernous flow diverters/intraprocedural, segment)/30 mm during postdeployment angioplasty Left internal carotid Distal/intraprocedural, A balloon was anchored in the middle cerebral artery and the microcatheter was gently pulled to align the artery (supraclinoid during postdeployment prolapsed end of the flow diverter to the distal internal carotid artery. This allowed for the deployment of segment)/26 mm angioplasty a second flow diverter to improve distal purchase. Left internal carotid Proximal/intraprocedural, A balloon was inflated under the floating proximal end of the flow diverter to align to the proximal internal artery (supraclinoid after deployment carotid artery and allow insertion of a microwire. Next, the balloon was maneuvered into the flow segment) 14 mm diverter and inflated. The balloon was gently pulled to align the construct better for the deployment of 2 more flow diverters into the proximal arterial landing zone. Proximal/intraprocedural, after deployment
MartinezGaldamez14/60
Crowley13/70
Kan15/58
Left internal carotid artery (Cavernous segment)/27.5 mm
Prolpased end/timing
Technique
Hauck11/64
The timely repositioning of prolapsed flow diverters is important in the prevention of complications. We believe that the POP maneuver is a simple but effective way of addressing prolapsed PEDs. It allows for repositioning of the initially deployed stent and elongation of the entire flow diversion construct for a more stable and proximal landing zone. Future research focused on salvage maneuvers done for improperly positioned flow diverters based
Aneurysm location/ largest aneurysm diameter
Conclusion and Recommendation
Author/ patient’s age (y)
regained access to the distal end of the PED with a microwire through the anterior communicating artery and posterior communicating artery. The use of a balloon was utilized in 2 cases13,14 to properly align the prolapsed side of the flow diverter with the aneurysm outlet. One patient with a giant ICA aneurysm terminus aneurysm underwent an external carotid artery-MCA bypass and manual extraction of the prolapsed PED.12 Our POP technique of partially deploying another telescoping stent and using the friction between the 2 stents as an anchor to reposition the original stent by pulling on the second stent has not been described elsewhere. The maneuver repositions the original PED and allows for the deployment of a second device to further improve the stability of the entire flow diverter construct. Unlike the aforementioned cases however, microcatheter access in the prolapsed PED was never lost in our case. A limitation of our maneuver is that it requires proximal access into the prolapsed PED. Similar to the other described maneuvers for proximal PED prolapse, inability to find this access into the prolapsed side precludes salvage maneuvers. The POP maneuver can also be used with the retrograde snare maneuver described in Table 1. The timing of prolapse varied among the reported cases, with some8,11-15 documented during the procedure while others8-10 are seen on repeat imaging done as part of routine monitoring or due to recurrence of symptoms. Similar to our patient, another case also had prolapse of a proximal end of the PED occur during distal wire capture.8 Three cases had intraoperative prolapse occurring during balloon angioplasty in an attempt to improve stent apposition.12,13,15 Emphasis should be placed in careful manipulation of the stent after deployment as the structure still has a tendency to change position. The threat of further migration of the partially prolapsed PED in our case prompted us to remedy the situation even before total herniation of the proximal end of the PED into the aneurysmal sac. Two cases of delayed presentation of PED prolapse, one involving the proximal segment (7 days post-op)10 and the other involving the distal segment (3 days post-op)9 both resulted in aneurysmal rupture and mortality. For 1 of these cases, the bailout procedure of placing another PED was delayed for a week.10 It was during this wait time when the aneurysmal rupture occurred. These cases emphasize that this complication should be addressed in an urgent manner.
Table 1. Salvage maneuvers for prolapsed flow diverters
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on large PED databases would be helpful for all neurointerventionalists.
Authors’ Contribution J.D.B.D., C.P.F., M.A.Z., J.S., and T.R.M. were responsible for conception, design, and aquisition of data. J.D.B.D., C.P.F., M.A.Z., J.S., and T.R.M. were responsible for drafting the article and revising it for critically important content. J.D.B.D., C.P.F., M.A.Z., J.S., and T.R.M. had final approval of the final manuscript. J.D.B.D., C.P.F., M.A.Z., J.S., and T.R.M. have agreed to be accountable for the article and to ensure that all questions regarding the accuracy or integrity of the article are investigated.
Informed Consent
6.
7.
8.
9.
Written informed consent was obtained from the patient.
Declaration of Competing Interest
10.
The authors have no conflicts of interest for this article.
Supplementary materials Supplementary material associated with this article can be found in the online version at doi:10.1016/j.jstrokecere brovasdis.2020.104647.
References 1. Becske T, Kallmes DF, Saatci I, et al. Pipeline for Uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology 2013;267:858-868. https://doi.org/ 10.1148/radiol.13120099. 2. Turfe ZA, Brinjikji W, Murad MH, et al. Endovascular coiling versus parent artery occlusion for treatment of cavernous carotid aneurysms: a meta-analysis. J Neurointerv Surg 2015;7:250-255. https://doi.org/10.1136/neurintsurg-2014-011102. 3. Bechan RS, Majoie CB, Sprengers ME, et al. Therapeutic internal carotid artery occlusion for large and giant aneurysms: a single center cohort of 146 patients. Am J Neuroradiol 2016;37:125-129. https://doi.org/10.3174/ajnr.A4487. 4. Kallmes DF, Ding YH, Dai D, et al. A new endoluminal, flow-disrupting device for treatment of saccular aneurysms. Stroke 2007;38:2346-2352. https://doi.org/ 10.1161/STROKEAHA.106.479576. 5. Kallmes DF, Brinjikji W, Cekirge S, et al. Safety and efficacy of the Pipeline embolization device for treatment of
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intracranial aneurysms: a pooled analysis of 3 large studies. J Neurosurg 2017;127:775-780. https://doi.org/ 10.3171/2016.8.JNS16467. Fiorella D, Lylyk P, Szikora I, et al. Curative cerebrovascular reconstruction with the Pipeline embolization device: the emergence of definitive endovascular therapy for intracranial aneurysms. J Neurointerv Surg 2009;1:56-65. https://doi.org/10.1136/jnis.2009.000083. Zhou G, Su M, Yin Y-L, et al. Complications associated with the use of flow-diverting devices for cerebral aneurysms: a systematic review and meta-analysis. Neurosurg Focus 2017;42:E17. https://doi.org/ 10.3171/2017.3.FOCUS16450. Srinivasan VM, Carlson AP, Mokin M, et al. Prolapse of the Pipeline embolization device in aneurysms: incidence, management, and outcomes. Neurosurg Focus 2017;42: E16. https://doi.org/10.3171/2017.3.FOCUS1738. Chalouhi N, Tjoumakaris SI, Gonzalez LF, et al. Spontaneous delayed migration/shortening of the pipeline embolization device: report of 5 cases. Am J Neuroradiol 2013;34:2326-2330. https://doi.org/10.3174/ajnr.A3632. Navarro R, Cano EJ, Brasiliense LBC, et al. Fatal outcome after delayed pipeline embolization device migration for the treatment of a giant superior cerebellar artery aneurysm: technical note for complication avoidance. Open J Mod Neurosurg 2014;04:163-168. https://doi.org/ 10.4236/ojmn.2014.44028. Hauck EF, Natarajan SK, Langer DJ, et al. Retrograde trans-posterior communicating artery snare-assisted rescue of lost access to a foreshortened pipeline embolization device: complication management. Oper Neurosurg 2010;67:ons495-ons502. https://doi.org/10.1227/NEU.0b013e3181f8530d. Bowers CA, Taussky P, Park MS, et al. Rescue microsurgery with bypass and stent removal following Pipeline treatment of a giant internal carotid artery terminus aneurysm. Acta Neurochir (Wien) 2015;157:2071-2075. https://doi.org/10.1007/s00701-015-2593-3. Crowley RW, Abla AA, Ducruet AF, et al. Novel application of a balloon-anchoring technique for the realignment of a prolapsed Pipeline Embolization Device: a technical report. J Neurointerv Surg 2014;6:439-444. https://doi. org/10.1136/neurintsurg-2013-010806. Martínez-Gald amez M, Ortega-Quintanilla J, Hermosín A, et al. Novel balloon application for rescue and realignment of a proximal end migrated pipeline flex embolization device into the aneurysmal sac: complication management. BMJ Case Rep 2016. https://doi.org/ 10.1136/bcr-2016-012263. bcr2016012263. Kan P, Mokin M, Wakhloo A, et al. Techniques in distal access of wide-necked giant intracranial aneurysms during treatment with flow diversion. Surg Neurol Int 2015;6:284. https://doi.org/10.4103/2152-7806.157797.
The POP (Pull on Pipe) Maneuver: A Technical Note for Rescuing a Prolapsed Pipeline Device Jose Danilo Bengzon Diestro, MD,*,1 Carmen Parra-Farinas, MD,* Mohamed Akli Zetchi, MD,*,† Julian Spears, MD,*,† and Thomas R. Marotta, MD* Background: Flow diverters have revolutionized the treatment of large aneurysms. However, prolapse of the device into the aneurysm is a known complication that may have fatal consequences. Case: We present a case of a 21-year-old male with a giant aneurysm located in the cavernous segment of the right internal carotid artery. After Pipeline Embolization Device (PED) deployment, while retrieving the PED wire, the proximal end of the stent shortened, resulting in prolapse of the device into the aneurysm. We utilized the Pull on Pipe (POP) maneuver, characterized by the deployment of a second PED inside the lumen of the prolapsed device and gentle traction to restore the initial flow diverter into its proper position. The maneuver also allows for the immediate deployment of the second PED to improve proximal purchase and overall construct stability. Conclusion: The POP maneuver is a novel strategy for salvaging herniated flow diverters and establishing a more stable PED construct. Key Words: Endovascular—aneurysm—flow diversion—pipeline—prolapse © 2020 Elsevier Inc. All rights reserved.
Background The surgical treatment of large cavernous internal carotid artery aneurysms (>10 mm)1 is not straightforward. The use of coiling with or without stent assistance, only achieves a 67% complete occlusion at 3 months and 18% of these patients eventually need retreatment.2 An alternative treatment option shown to result in superior 3-month occlusion rates (93%) is parent artery occlusion.2 This latter procedure however requires the patient to pass an angiographic occlusion test first.3 The introduction of the Pipeline Embolization Device (PED) has revolutionized the treatment of these aneurysms. The PED provides a flow diverting construct that can bypass aneurysms resulting in occlusion even without the use of coils.4 Pooled analysis for the use of PED for all types of aneurysms shows an impressive 85.5% 1-year occlusion rate with a 3.0% retreatment rate.5 The device can
also be deployed over perforators and major arterial branches without shutting down flow into these vessels.6 Despite the ability of the PED to overcome features of “uncoilable” aneurysms such as wide necks and involvement of vital arterial branches, the use of the device is not without some peculiar difficulties. The overall complication rate of PED treatment found in a systematic review was 17.0%. Device migration and poor positioning accounted for 5.8%.7 Other complications included: in stent stenosis, branch occlusion, ischemic events, wire perforation, poor stent opening, and intracerebral hemorrhage. The propensity of the device to elongate with oversizing and to shorten with undersizing can affect the PED’s flow diverting effect and result in improper placement.8 Complete prolapse of 1 end of the device into the aneurysm can result in incomplete neck coverage or even worse, flow diversion into the
From the *Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada; and †Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada. Received November 13, 2019; revision received December 15, 2019; accepted January 1, 2020. Funding: This study did not receive any financial support. Address correspondence to Jose Danilo B. Diestro MD, Medical Imaging Room CC3-141, Department of Medical Imaging, St. Michael’s Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8. E-mail: [email protected]. 1 Institution where the work was performed: St. Michael’s Hospital, University of Toronto. 1052-3057/$ - see front matter © 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104647
Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2020: 104647
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aneurysmal sac. Thus, maneuvers to manage this complication are important parts of a neurointerventionist’s skill set. We present a case of a partially prolapsed PED during the treatment of a large cavernous internal carotid artery aneurysm. The stent was carefully repositioned using a novel technique, the “pull on pipe” (POP) maneuver.
Case Presentation The patient was a 21-year-old, right-handed, male, student who was previously well until June 2015 when he had sudden loss of consciousness followed by jerking movements of all his limbs while standing outside his home. Because of the facial injuries that he sustained after his seizure a cranial computed tomography scan was done and this revealed a cavernous sinus internal carotid artery aneurysm. He was started on levetiracetam. He had no pre-existing conditions such as infections, intracranial neoplasms, or metabolic derangements that could have provoked a seizure. Conservative management that consisted of annual clinic visits with serial imaging, was initially pursued. In the interim, he had 1-2 episodes of seizures yearly characterized a general feeling of unease followed by generalized tonic clonic movements lasting for 3 minutes. The breakthrough seizures usually occurred during missed doses of his antiepileptic drug. He was initially lost to follow-up from our clinic. Four years later after his initial presentation, he developed diplopia on rightward gaze. When we saw him in clinic, he already had limited abduction of the right, right eye ptosis, and miosis. These findings were consistent with a right cranial nerve 6 palsy with an accompanying Horner’s syndrome. We localized the findings in the right cavernous sinus, the site of his previous aneurysm. We suspected that further growth of the aneurysm resulted in irritation of the sympathetic nerves surrounding the cavernous segment of
the internal carotid artery and the adjacent cranial nerve 6. Our localization was confirmed by repeat neurovascular imaging that showed significant growth of the aneurysm from a previous 17 mm to 31 mm in greatest dimension (See Fig 1, A,B). Because he felt that levetiracetam was causing daytime somnolence, he was shifted to valproic acid. He has not had seizure episode this past year. He has no other comorbid conditions. He has no family history of aneurysms. His mother was diagnosed with epilepsy and maintained on antiepileptic drugs throughout her childhood until her seizures abated in adulthood. He occasionally drinks alcohol and uses marijuana. He previously smoked cigarettes but has already quit. On account of his ocular symptoms and significant increase in size of the aneurysm, treatment with flow diversion was planned.
Technical Note A 6 French Shuttle (Cook Medical) was navigated into the right common carotid artery over a 5 French Berenstein Tip Select Catheter (Penumbra) and a Glidewire Advantage guidewire (Terumo). Afterwards, a Navien 072 catheter (Covidien) was exchanged over the Advantage wire and brought into the right internal carotid artery (ICA). A 26 £ 28 £ 30 mm aneurysm was visualized in the cavernous segment of the right ICA (See Fig 1, C). An Excelsior SL-10 microcatheter (Stryker) was navigated over a Traxcess-14 mircowire (Microvention) into the M2 segment of the right middle cerebral artery (MCA). A Phenom 27 (Medtronic) microcatheter was exchanged over the microwire into the M1 segment of the right MCA. Subsequently a 5.0 £ 35 mm PED (Medtronic) was deployed from the cavernous ICA (distal to the neck of the aneurysm) to the petrous ICA (See Fig 2, A,D). In the process of retrieving the flow diverter wire with the microcatheter, the PED was inadvertently pushed into the aneurysm. The resulting partial prolapse moved the
Figure 1. Preoperative and postoperative images of a right cavernous segment internal carotid artery aneurysm (arrow). (A) Sagittal CT showing initial imaging in May 2015. (B) Sagittal CT done in June 2019 showing progression in the size of the aneurysm. (C) Three-dimensional reconstruction of digital subtraction angiogram done July 2019 showing the large aneurysm and its relationship to the cavernous segment of the internal carotid artery. (D) Sagittal CT taken 4 months post-op showing a dramatic decrease in the filling portion of the aneurysm and the PED above the aneurysm remnant. Abbreviations: PED, Pipeline Embolization Device.
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Figure 2. Lateral views of digital subtraction angiogram (DSA) with a superimposed graphical representation of the PEDs and x-rays documenting the treatment of the right cavernous segment internal carotid artery aneurysm. (A,D) Initial stent (red) deployment (B,E) PED prolapse into the aneurysm (C,F) Proper placement of the 2 PEDs (red and blue) after the POP maneuver; yellow arrow indicates the direction of pull of the second PED (blue). Abbreviations: PED, Pipeline Embolization Device.
proximal edge of the PED dangerously close into the aneurysm lumen (See Fig 2, B,E). Pulling on the microcatheter over the microwire only partly reduced the degree of prolapse. The POP maneuver was then performed to restore the PED into its desired configuration: 1. After removal of the wire, a second PED (5.0 £ 30 mm) was partially deployed in the mid aspect of the first PED. 2. After apposition of the deployed portion of the second PED inside the first PED, we pulled on the second PED to restore the positioning of the first PED. 3. The second pipeline stent was then completely deployed proximally on the petrous ICA (See Fig 2, C,F).
Outcome and Follow-Up The patient had transient severe right eye pain spanning the first postoperative month that was alleviated with an initial course of dexamethasone and pain medications. Neuroimaging repeated 4 months post-op showed marked regression of the residual filling of the aneurysm (See Fig 1, D). Four months after his surgery, diplopia was only present on the most extreme gaze. Clinical exam no longer showed any problems with ocular motility. From a modified Rankin Score (mRS) of 2 because his eye symptoms significantly affected with daily activities his score mRS is now down to 1. The entire case is summarized in a timeline (See Supplemental File 1).
Discussion The delivery wire was carefully removed from the system through the microcatheter. Final cerebral angiograms and cone beam CT demonstrated adequate positioning and wall apposition of both PEDs and beginning aneurysmal flow stasis.
The incidence of PED prolapse based on 2 institutional case series is between 1.2% (3/413)8 to 3.2% (5/155).9 Several case reports10-15 and case series8,9 have documented the phenomenon and several salvage techniques (See Table 1). Two cases11,15 that dealt with proximal end prolapse
ARTICLE IN PRESS J.D.B. DIESTRO ET AL.
Retrograde access with a microwire via the posterior communicating artery into the aneurysm was accomplished. The distal end of the microwire was caught with a snare going into the aneurysm proximally. A microcatheter coming proximally was then tracked past the aneurysm and the internal carotid artery and was used to deploy 2 more flow diverters and obtain optimal proximal purchase. Similar to the described technique above but utilized the anterior communicating artery instead of the posLeft internal carotid Between 2 telescoping terior communicating artery. artery (Cavernous flow diverters/intraprocedural, segment)/30 mm during postdeployment angioplasty Left internal carotid Distal/intraprocedural, A balloon was anchored in the middle cerebral artery and the microcatheter was gently pulled to align the artery (supraclinoid during postdeployment prolapsed end of the flow diverter to the distal internal carotid artery. This allowed for the deployment of segment)/26 mm angioplasty a second flow diverter to improve distal purchase. Left internal carotid Proximal/intraprocedural, A balloon was inflated under the floating proximal end of the flow diverter to align to the proximal internal artery (supraclinoid after deployment carotid artery and allow insertion of a microwire. Next, the balloon was maneuvered into the flow segment) 14 mm diverter and inflated. The balloon was gently pulled to align the construct better for the deployment of 2 more flow diverters into the proximal arterial landing zone. Proximal/intraprocedural, after deployment
MartinezGaldamez14/60
Crowley13/70
Kan15/58
Left internal carotid artery (Cavernous segment)/27.5 mm
Prolpased end/timing
Technique
Hauck11/64
The timely repositioning of prolapsed flow diverters is important in the prevention of complications. We believe that the POP maneuver is a simple but effective way of addressing prolapsed PEDs. It allows for repositioning of the initially deployed stent and elongation of the entire flow diversion construct for a more stable and proximal landing zone. Future research focused on salvage maneuvers done for improperly positioned flow diverters based
Aneurysm location/ largest aneurysm diameter
Conclusion and Recommendation
Author/ patient’s age (y)
regained access to the distal end of the PED with a microwire through the anterior communicating artery and posterior communicating artery. The use of a balloon was utilized in 2 cases13,14 to properly align the prolapsed side of the flow diverter with the aneurysm outlet. One patient with a giant ICA aneurysm terminus aneurysm underwent an external carotid artery-MCA bypass and manual extraction of the prolapsed PED.12 Our POP technique of partially deploying another telescoping stent and using the friction between the 2 stents as an anchor to reposition the original stent by pulling on the second stent has not been described elsewhere. The maneuver repositions the original PED and allows for the deployment of a second device to further improve the stability of the entire flow diverter construct. Unlike the aforementioned cases however, microcatheter access in the prolapsed PED was never lost in our case. A limitation of our maneuver is that it requires proximal access into the prolapsed PED. Similar to the other described maneuvers for proximal PED prolapse, inability to find this access into the prolapsed side precludes salvage maneuvers. The POP maneuver can also be used with the retrograde snare maneuver described in Table 1. The timing of prolapse varied among the reported cases, with some8,11-15 documented during the procedure while others8-10 are seen on repeat imaging done as part of routine monitoring or due to recurrence of symptoms. Similar to our patient, another case also had prolapse of a proximal end of the PED occur during distal wire capture.8 Three cases had intraoperative prolapse occurring during balloon angioplasty in an attempt to improve stent apposition.12,13,15 Emphasis should be placed in careful manipulation of the stent after deployment as the structure still has a tendency to change position. The threat of further migration of the partially prolapsed PED in our case prompted us to remedy the situation even before total herniation of the proximal end of the PED into the aneurysmal sac. Two cases of delayed presentation of PED prolapse, one involving the proximal segment (7 days post-op)10 and the other involving the distal segment (3 days post-op)9 both resulted in aneurysmal rupture and mortality. For 1 of these cases, the bailout procedure of placing another PED was delayed for a week.10 It was during this wait time when the aneurysmal rupture occurred. These cases emphasize that this complication should be addressed in an urgent manner.
Table 1. Salvage maneuvers for prolapsed flow diverters
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ARTICLE IN PRESS POP MANEUVER
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on large PED databases would be helpful for all neurointerventionalists.
Authors’ Contribution J.D.B.D., C.P.F., M.A.Z., J.S., and T.R.M. were responsible for conception, design, and aquisition of data. J.D.B.D., C.P.F., M.A.Z., J.S., and T.R.M. were responsible for drafting the article and revising it for critically important content. J.D.B.D., C.P.F., M.A.Z., J.S., and T.R.M. had final approval of the final manuscript. J.D.B.D., C.P.F., M.A.Z., J.S., and T.R.M. have agreed to be accountable for the article and to ensure that all questions regarding the accuracy or integrity of the article are investigated.
Informed Consent
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Written informed consent was obtained from the patient.
Declaration of Competing Interest
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The authors have no conflicts of interest for this article.
Supplementary materials Supplementary material associated with this article can be found in the online version at doi:10.1016/j.jstrokecere brovasdis.2020.104647.
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