A decision was made to treat this recurrent aneurysm with further coiling. With the widespread use of endovascular treatment for aneurysms comes the new consideration of retrieving dislodged foreign bodies intravascularly. No “gold standard” method has been identified for retrieval or repositioning of the migrated foreign bodies, but several different techniques and devices are described in the literature [5–9]. We are committed to sharing findings related to COVID-19 as quickly as possible. Oxford University Press is a department of the University of Oxford. An intracranial run showed that the distal ICA and its branches were normal in caliber without vasospasm or thromboembolism. The introduction of the second microwire eliminated the step off between the microwire and microcatheter, providing a stronger rail and easier navigation of the microcatheter, without aggressive pushing. Of these patients, there were 21 occurrences of coil prolapse, which includes four of the nine patients with postprocedure ischemic events. The microwire was then removed, and a Merci V 2.0 Firm Retriever was advanced. The microcatheter was then advanced over the microwire into the right superior cerebellar artery distal to the aneurysm. A Merci V 2.5 soft Retriever was then advanced to the ICA. Migration of coils or stents from their targets represents one of the most challenging complications of endovascular neurosurgery and contributes significantly to thromboembolic events following endovascular embolization [4]. found that aneurysm size and coil protrusion were the only two variables with significant association to postprocedure ischemic events [4]. Vora et al. Intended for reliable stability and flexibility. Part 2: preliminary clinical experience,”, G. Guglielmi, F. Vinuela, I. Sepetka, and V. Macellari, “Electrothrombosis of saccular aneurysms via endovascular approach. Registry Assessment of Peripheral Interventional Devices Objective Performance Goals for Superficial Femoral and Popliteal Artery Peripheral Vascular Interventions. Coil migration is not an uncommon occurrence and increase the risk of cerebral thromboembolism. Multiple fragments of the coil were retrieved. Guidewire OD: 0.010in (0.25mm) Distal; 0.012in (0.30mm) Proximal. He had a history of Grade I SAH in 2004 from a ruptured 15 mm ACOM aneurysm. Flow in the ICA and its branches were normal (Figures 1(i) and 1(j)). Pearls. The decision was made to retrieve the coil with a Merci retriever, but the angle of the left A1/A2 junction was too acute to allow delivery of the Merci device from the left. The coils and the stent were pulled to the tip of the guiding catheter. A retrospective study of 1811 endovascularly treated aneurysms demonstrated coil migration in 2.5% [16]. On three-month followup the patient remains neurologically normal (modified Rankin score = 0); and she has 20/20 vision bilaterally. An 8F Merci balloon guide catheter (Concentric Medical Inc, Mountain View, CA, USA) was also exchanged to replace the 6 F Envoy catheter and placed in the right ICA with the aim to diminish flow by inflating the balloon at the tip of the Merci guide while we are retrieving the coil. Currently, flow diverters require a 0.027-inch microcatheter for deployment. The Merci Retriever device can be utilized successfully for removal of migrated coils and stents in endovascular neurosurgery. Distal Segment: 35cm Considering the support of the Synchro-2 microwire, which maintained the PED at the ‘outflow position’, the balloon was deflated and then navigated through the PED over the wire (figure 3A, B). Even in Guglielmi’s original clinical series, coil migration into the parent artery was a recognized possibility, but it was considered only prior to coil deployment when it could be readily corrected [2]. A dual microwire rail technique involving two 0.014-inch Synchro 2 microwires was used to advance the VIA microcatheter past the dissecting artery aneurysm ostia for PED deployment. Postoperatively the patient remains neurologically intact and was scheduled for a repeated coiling in the future. During coiling embolization several loops of the coil bulged into the parent artery (Figures 2(c) and 2(d)). Superselectively, the aneurysm was catheterized with a SL-10 microcatheter and a Synchro 10 microwire. The patient had an uneventful postoperative course and was discharged to home neurologically intact. At this point the coil/stent mass dislodged from the Merci device. A Neuroform-3 (4 × 20 mm) stent (Boston Scientific, Natick, MA, USA) was deployed across the aneurysm neck. The catheter was then taken distal to the coil, and a V2.0 soft Merci retriever was deployed and successfully ensnared the migrated coil (Figures 3(d) and 3(e)). For additional product information please contact your sales representative. Update my browser now. Two HydroCoil 10 coils (2 mm × 4 cm) (MicroVention, Aliso Viejo, CA, USA) were initially deployed into the aneurysm through a SL-10 microcatheter (Boston Scientific). She reported significant improvement in her subjective retroorbital pulsation. Catheter selection is paramount. A. Awad, “Endovascular therapeutic approach to peripheral aneurysms of the superior cerebellar artery,”, A. O'Hare, J. Thornton, and P. Brennan, “Coil migration through a neuroform 3 stent during endovascular coiling: a case report,”. Technical details are described. A decision was made to deploy an overlapping stent to hold the coil mass in the aneurysm. A Prowler Select Plus microcatheter (Cordis Endovascular, Miami Lakes, Florida, USA) led by a Synchro 2 soft microwire (Boston Scientific, Natick, MA, USA) was advanced into the distal ICA. Open surgery may also be an option in cases where endovascular retrieval is not possible, but this is obviously more invasive and not necessarily more effective [24–29]. The risk of coil prolapse can be mitigated when treating wide-neck aneurysms by the use of a stent- or balloon-assisted technique [15]. Don't already have an Oxford Academic account? He was treated initially with endovascular coiling in 2004, and a repeated coil embolization was performed in 2008. A Hydrosoft 10 helical 4 × 6 mm coil (MicroVention, Aliso Viejo, CA, USA) was then chosen to continue the embolization. Review articles are excluded from this waiver policy. Coil migration risk is thought to increase as the width of the aneurysm neck increases. Death at 1 month from respiratory failure. Postembolization runs showed optimal wall apposition and contrast stasis within the aneurysm, with successful flow diversion of the aneurysm. Copyright © 2012 David K. Kung et al. The patient gave informed consent for surgery and video recording. Clopidogrel 600 mg and aspirin 325 mg was given through a nasogastric tube at the beginning of the case. Enhances shape retention in Synchro² Guidewires. The 18 L Merci microcatheter led by a Synchro 2 soft microwire was again advanced into the distal ICA. The authors were not successful in removing this coil. The Merci Retriever, the 18 L Merci microcatheter, and the 6 F guiding catheter were then removed. The Merci device was utilized successfully for removal of the stent-coil complex, and the aneurysm was subsequently embolized. Please check your email address / username and password and try again. Digital subtraction angiogram demonstrated a 10 mm left supraclinoid ophthalmic artery aneurysm with a 5.5 mm neck. Nicardipine was infused intra-arterially with radiographic improvement. You do not currently have access to this article. In this scenario, the Merci Retriever was successful in grasping the misplaced coil; however the coil became caught on the stent at the time of retraction. Misplacement of intracranial coils or stents remains a potential hazard in endovascular neurosurgery. O’Hare and colleagues [13] reported migration of the coil from a PCOM aneurysm to the MCA, which once free in the MCA was successfully retrieved using an old-generation X6 Merci Retriever. The left A2 was then catheterized through the right A1 with an 18 L Merci microcatheter. Post-operative angiogram shows near complete occlusion of the aneurysm. Subsequently, a 2 × 4 mm Galaxy Xtrasoft coil (Codman & Shurtleff Inc, Raynham, MA, USA) was deployed in the aneurysm. An Amplatz 4 mm GooseNeck Microsnare (ev3 Endovascular, Inc, Plymouth, MN, USA) was then used for retrieval, but this resulted in further coils prolapse (Figures 1(e) and 1(f)). A postretrieval angiogram shows that the aneurysm was stable and the right ICA was patent without evidence of arterial dissection, pseudoaneurysm, or occlusion. Coil and stent migration is a potentially catastrophic complication in endovascular neurosurgery, which may lead to cerebral thromboembolism. Femoral artery access was established with a 7 F 11 cm sheath. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Our experience demonstrates that the Merci device can be used successfully to rescue patients with this potentially devastating complication. Because of the increased risk for thromboembolism, once detected, coil migration should be managed immediately. Comparative analysis of the Pipeline and the Derivo flowdiverters for the treatment of unruptured intracranial aneurysms - a multicentric study. If you originally registered with a username please use that to sign in. The procedure was performed under general anesthesia. A repeat angiogram 3 days later showed moderate vasospasm and a secured PCOM aneurysm. RESULTS: Working through a 6F guide-catheter positioned in the left cervical ICA, an SL-10 microcatheter, and 0.014-inch Synchro-2 microwire were manipulated across the anterior communicating artery and into the right M1 segment occlusion. A Merci V 3.0 firm Retriever was advanced into the ICA led by an 18 L Merci microcatheter (Concentric Medical Inc, Mountain View, CA, USA). The triaxial assembly consisted of a 9 Fr Cello™ (ev3) for BGC, the Arc™ catheter (Medtronic) as the intracranial AC, and the Excelsior® XT-27® microcatheter (Stryker Neurovascular), which was, in turn, navigated over a Synchro-2® microwire (Stryker Neurovascular) into … Occlusion of cerebral aneurysms by detachable coils through the endovascular approach has gained significant popularity over the last two decades and is now a common approach for securing cerebral aneurysms [1–3].