British Journal of Radiology (2007) 80, e290-e292
© 2007 British Institute of Radiology
doi: 10.1259/bjr/52196291
Aortic dissection associated with a neurointerventional guidewire retained in a perforating branch of the right posterior cerebral artery
A A Konstas, MD, PhD
and
J Pile-Spellman, MD
Radiology, Columbia University Medical Center, 177 Fort Washington Avenue, New York 10032, USA
Correspondence: Dr Angelos Konstas, Radiology, Columbia University Medical Center, 177 Fort Washington Avenue, New York 10032, USA. E-mail: AKONSTAS{at}PARTNERS.ORG
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Abstract
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We report a case of a 55-year-old man with a 6.5 mm right posterior cerebral artery (PCA) aneurysm. Upon attempted Guglielmi detachable coil embolisation, the guidewire was lodged in a perforating branch of the right PCA and attempted retractions were unsuccessful. The retained guidewire was left in the patient. The patient died 10 weeks later due to a perforation that dissected through the wall of the ascending aorta resulting in haemopericardium.
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Case report
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A 55-year-old man presented with an episode of light-headedness, abnormal sense of smell and left lower extremity numbness. Upon brain CT, MRI and MRA, a 6–8 mm aneurysm arising from the right PCA was identified. At that time the aneurysm did not appear to be symptomatic, but the patient was referred for treatment because of the potential risk to his life.
The patient presented in July 1998 for a cerebral angiogram, balloon test occlusion and coil embolization. Digital subtraction angiography demonstrated a solitary 6.5 mm aneurysm arising at the junction of the right P1 and P2 segments of the PCA. Using road mapping and digital fluoroscopy, a tip marker tracker 18 catheter was advanced over a taper 14 flex tip guidewire through the 7 French guiding catheter into the right distal vertebral artery. The wire was then advanced smoothly to the P1/P2 junction. At this point, further advancement of the wire could not be performed. The wire could not be retracted either. Several attempts were made to remove the wire. Intraarterial verapamil was administered in an attempt to dilate the PCA before retraction of the guidewire. This manoeuvre was repeated several times. At this point, the wire and microcatheter were not manipulated for 20 min to allow any possible spasm to resolve. Subsequent attempts to remove the wire were unsuccessful. Repeat digital angiographies during the retraction attempts demonstrated complete patency of the right PCA without evidence of spasm or extravagation. After consultation with the neurological and neurosurgical services, the decision was made to leave the wire and sheath in place with heparinized saline infusion overnight in return for additional angiography and possible wire removal the following day.
Repeat angiography demonstrated a widely patent right PCA without evidence of dissection or vasospasm. The position of the retained wire was unchanged (Figure 1
). Given the patient's clinical course, no further attempts were made to remove the wire. The retained guidewire was dislodged from the sheath into the lumen of the external iliac artery. Neurological examination revealed drooping of the left lower face and mild left-sided hemiparesis. CT confirmed a new peduncular infarct. Over the following 10 days, the patient made a good recovery and was discharged to a rehabilitation hospital. The patient passed away 10 weeks after his discharge.
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Figure 1. Digital subtraction angiography taken during repeat angiography, 1 day after the retention of the taper 14 flex tip guidewire.(a) Anteroposterior view. (b) Lateral view. The right posterior cerebral artery (PCA) is widely patent without evidence of dissection, extravagation or spasm. The guidewire ends at the P1 segment, just proximally to the 6.5 mm right PCA aneurysm.
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At autopsy, there was a small amount of blood-tinged fluid in the pleural spaces bilaterally. There was evidence of haemopericardium and a large amount of liquid blood was released, apparently under tension, following a small opening in the pericardium. Gross examination of the aorta revealed an ecchymotic area with a linear groove along the posterolateral aspect of the ascending aorta, measuring 2.5x3.5 cm. A 0.2–0.3 cm perforation was located centrally within this area. Dissection of the aorta revealed two findings. The first was the presence of a wire loop within the aortic arch, which terminated in the ascending aorta. The second was a tear in the posterolateral aspect of the ascending aorta, which measured 3–4 cm in length. A section through this area showed dissection of blood within the aortic wall tracking to the pericardial reflection. The wire loop was traced distally and one portion of the loop entered the left subclavian artery, while the other entered the thoracic aorta. The wire was adherent to the aortic wall in two places: the proximal aspect of the descending thoracic aorta and at its point of origin in the right femoral artery. Endothelialization appeared to have occurred in both of these locations, but the wire was freely movable along its remaining extent. Cranial cavity examination revealed a patent right PCA and a fusiform aneurysm with no evidence of recent or past bleeding. The guidewire entered the right PCA from the basilar artery and then immediately entered a small parallel branch of the right PCA. The wire continued in this branch for a distance of less than 10 mm and was firmly embedded in this vessel.
The autopsy findings suggest that the wire loop in the ascending aorta was associated with the aortic perforation that dissected through the wall of the aorta in a retrograde fashion to the base of the heart, resulting in haemopericardium. There was associated aortic rupture with extravagated blood in the peritoneal cavity.
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Discussion
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Our case illustrates two serious and previously unreported complications of Guglielmi detachable coil embolization. First, the guidewire became lodged in a perforator branch of the right PCA. The retained guidewire was left in the patient's vasculature, freely extending distally until the right external iliac artery. A guidewire loop was formed that moved subsequently into the ascending aorta and eroded through the arterial wall, resulting in the second complication, the fatal aortic dissection and haemopericardium.
Although there are no reports of guidewires retained in the cerebral circulation, there have been several reports of microcatheters glued in cerebral arteries during embolization of arteriovenous malformations (AVMs) [1–5]. There have been reports of removal of catheter fragments with a snare or during surgical excision of an AVM [5]. In most instances, the retained catheter has simply been transected at the puncture site and allowed to retract into the iliac arteries [1, 3, 4]. The decision to leave the retained guidewire in the arterial system was largely based on the established management of retained microcatheters. Moreover, the retained guidewire was not thought to be the cause of the patient's neurological deficits (because the right PCA remained patent), making possible surgical removal of the guidewire the least preferred management option. However, with the hindsight of this rare complication, it is possible that retained guidewires may have a different natural history from retained microcatheters. Guidewires are thinner and may be more free-flowing in the arteries, increasing the possibility of loop formation with subsequent migration and lodging in the ascending aorta. Furthermore, all of the retained microcatheters were accidentally glued in cerebral arteries; there are no reports of microcatheters lodged in a small perforating artery. Guidewires may have a higher tendency to be lodged in small arterioles as they are thinner and can enter the arterioles accidentally.
Iatrogenic aortic dissection is usually associated with invasive retrograde catheter interventions or occurs during or much later after valve or aortic surgery [6]. To our knowledge, this is the first report of a retained neurointerventional guidewire associated with aortic dissection. This is a rare case of aortic dissection that illustrates our incomplete knowledge about the natural history of retained neurointerventional devices. In patients with retained guidewires, surgical removal of the wire may be safer than leaving the wire in the arterial system. Removal can be accomplished through the carotid approach by dividing the guidewire in the mid-common carotid artery and withdrawing the proximal segment. This surgical approach has been accomplished safely and effectively with a chronically retained neurointerventional microcatheter [1].
Received for publication June 20, 2006.
Accepted for publication September 15, 2006.
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References
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Abstract
Case report
