Description of Event or Problem · 1
MICROCATHETER BROKE DURING INTERCRANIAL PROCEDURE. BROKEN FRAGMENT WAS RETRIEVED. PATIENT WITH MULTIPLE CEREBRAL ANEURYSMS. PLANNED COIL EMBOLIZATION OF RIGHT INTERNAL CAROTID ARTERY TERMINUS ANEURYSM. THE PATIENT WAS THEN BROUGHT TO THE FLUOROSCOPY SUITE AND PLACED SUPINE. AFTER GENERAL ANESTHESIA WAS ADMINISTERED, BILATERAL GROINS WERE PREPPED AND DRAPED IN THE USUAL STERILE FASHION. FIRSTLY, AN ACCESS WAS OBTAINED INTO THE RIGHT COMMON FEMORAL ARTERY WITH 5 FRENCH MICROPUNCTURE SET AND THE ARTERIAL SYSTEM WAS CATHETERIZED WITH 6 FRENCHSHUTTLE SELECT SYSTEM ALONG WITH COAXIALLY PLACED 6.5 FRENCH CATHETER AND GUIDE WIRE. THE 6 FRENCH SHUTTLE SHEATH WAS PLACED IN RIGHT COMMON CAROTID ARTERY AND AN ARTERIOGRAM OF RIGHT COMMON CAROTID BIFURCATION WAS PERFORMED. THIS DOES NOT REVEAL ANY SIGNIFICANT ATHEROSCLEROTIC DISEASE AT THE CAROTID BIFURCATION. AFTER MAKING SURE THAT THE CAROTID BIFURCATION WAS NORMAL, THE SHUTTLE SHEATH WAS ADVANCED OVER CATHETER AND GUIDE WIRE UTILIZING ROADMAPPING INTO THE RIGHT INTERNAL CAROTID ARTERY. AT THIS POINT, A 3-D ANGIOGRAM OF THE RIGHT INTERNAL CAROTID ARTERY WAS PERFORMED WITH DIGITAL SUBTRACTION ANGIOGRAPHY CENTERED OVER THE HEAD. THIS REVEALED AN APPROXIMATELY 4 MM RIGHT INTERNAL CAROTID ARTERY TERMINUS ANEURYSM WHICH IS DIRECTED ANTERIORLY. THIS ANEURYSM HAS RELATIVELY WIDE, 2.5 MM NECK. OTHER ANEURYSMS OF THE RIGHT INTERNAL CAROTID ARTERY WHICH WERE PREVIOUSLY DEMONSTRATED AT RIGHT CAVERNOUS CAROTID SEGMENT AND MIDDLE CEREBRAL ARTERY BIFURCATION WERE ALSO AGAIN NOTED AND HAVE REMAINED STABLE SINCE THE PRIOR ANGIOGRAM SEVERAL MONTHS AGO. AT THIS POINT, WENT AHEAD AND CATHETERIZED THE RIGHT INTERNAL CAROTID ARTERY TERMINUS ANEURYSM WITH WIRE AND MTI ECHELON 10 CATHETER. AN ATTEMPT WAS MADE TO PLACE 4 X 6 GDC 10, 3-D COIL INTO THE ANEURYSM, BUT THE CATHETER SLIPPED OUT OF THE ANEURYSM AT THIS POINT. AN ATTEMPT WAS MADE TO REMOVE THE COIL BUT RESISTANCE WAS MET. WHEN AN ATTEMPT WAS MADE TO REMOVE THE COIL AND REDEPLOY THE MICROCATHETER, THE MICROCATHETER BROKE. A SMALLER BROKEN FRAGMENT COULD BE REMOVED FROM THE SHEATH BUT THE LARGER PORTION OF THE CATHETER WAS RETAINED IN THE VASCULAR SYSTEM. THE DISTAL TIP OF THIS CATHETER WAS IN THE RIGHT CAROTID TERMINUS ANEURYSM AND THE BROKEN END EXTENDED INTO THE RIGHT COMMON CAROTID ARTERY. MULTIPLE ATTEMPTS MADE TO SNARE THE MICROCATHETER DOWN. THIS INCLUDED THE USE OF IN TIME RETRIEVAL DEVICE, 2 MM AND 5 MM GOOSENECK SNARES AND 10 MM LOOP SNARES. ATTEMPTS TO SNARE THE CATHETER DOWN WERE UNSUCCESSFUL. AT THIS POINT, THE DECISION WAS MADE TO PUNCTURE THE LEFT COMMON FEMORAL ARTERY WITH 5 FRENCH MICROPUNCTURE SET. A 7 FRENCH SHUTTLE SELECT SHEATH WAS ADVANCED WITHIN THE LEFT FEMORAL ARTERY. THE PLAN WAS TO PERFORM AN INTRAVASCULAR ULTRASOUND TO DEFINE THE LOOSE END OF THE MICROCATHETER AND ATTEMPT TO SNARE IT DOWN. AN ATTEMPT WAS MADE TO REMOVE THE ARTERIAL SHEATH FROM THE RIGHT GROIN. DURING THESE ATTEMPTS, IT WAS SEEN THAT THE 10 MM LOOP SNARE WAS INTERTWINED WITH THE FREE END OF THE MICROCATHETER. THE CATHETER WAS GRABBED AND COMPLETELY PULLED OUT OF THE PATIENT. WHEN THE MICROCATHETER WAS WITHDRAWN, AN ATTEMPT WAS MADE TO AGAIN COIL THE ANEURYSM. AGAIN THE RIGHT INTERNAL CAROTID ARTERY WITH SHUTTLE SELECT SYSTEM WAS SELECTED AS DESCRIBED PREVIOUSLY. FIRSTLY, 10 STRAIGHT AND 90 DEGREE TIPPED CATHETERS WERE PLACED IN THE ANEURYSM BUT THESE WERE NOT STABLE. THE MICROCATHETER SYSTEM WAS UPSIZED TO 14 CATHETER ALONG WITH A GUIDE WIRE. THIS CATHETER SEATED WELL IN THE ANEURYSM. A 4 X 6 3-D GDC 10 COIL WAS DEPLOYED INTO THE ANEURYSM. THIS COIL SEATED WELL INTO THE ANEURYSM. AT THIS POINT, TRIED TO DEPLOY A 2 MM X 1 CM GDC COIL INTO THE ANEURYSM. THIS HOWEVER KICKED THE CATHETER OUT OF THE ANEURYSM. REPEAT RIGHT ICA ANGIOGRAM SHOWED A GOOD SEATING OF THE PREVIOUSLY INSERTED 4 X6 GDC COIL. DID NOT ATTEMPT TO REACCESS THE ANEURYSM AGAIN THE MICROCATHETER AND SHUTTLE SELECT SHEATH WERE WITHDRAWN. THE POST ANGIOGRAM RUNS THAT BEST DEMONSTRATE THE END COILING RESULT USE 57 DEGREES ANTERIOR OBLIQUE AND -15 DEGREE CRANIOCAUDAL PROJECTIONS. ANOTHER ARTERIOGRAM OF RIGHT INTERNAL CAROTID ARTERY DISPLAYS PATENT ANTERIOR CEREBRAL AND MIDDLE CEREBRAL ARTERY BRANCHES WITH NO EVIDENCE OF ABRUPT CUTOFF OR FILLING DEFECT. DURING THE ENTIRE PROCEDURE, AN ATTEMPT WAS MADE TO KEEP THE ACTIVATED CLOTTING TIME IN THE 280-300 SECOND RANGE. AFTER THE PROCEDURE, EFFECT OF HEPARIN WAS REVERSED WITH 50 MG OF SLOW INTRAVENOUS PROTAMINE SULFATE. BILATERAL GROIN CATHETERS WERE REMOVED AND HEMOSTASIS WAS ACHIEVED. THERE WERE NO IMMEDIATE COMPLICATIONS.