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. 2019 Mar;29(1):143-151.
doi: 10.1007/s00062-017-0639-z. Epub 2017 Nov 2.

Iatrogenic Vessel Dissection in Endovascular Treatment of Acute Ischemic Stroke

Barbara Goeggel Simonetti  1   2 , Justine Hulliger  1 , Etienne Mathier  1 , Simon Jung  1 , Urs Fischer  1 , Hakan Sarikaya  1   3 , Johannes Slotboom  4 , Gerhard Schroth  5 , Pasquale Mordasini  4 , Jan Gralla  4 , Marcel Arnold  1
Affiliations

Iatrogenic Vessel Dissection in Endovascular Treatment of Acute Ischemic Stroke

Barbara Goeggel Simonetti et al. Clin Neuroradiol. 2019 Mar.

Abstract

Purpose: Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication.

Methods: Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID.

Results: Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissection and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS ≤ 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (p = 0.041), were more likely to be smokers (44% versus 19%, p = 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%, p < 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups.

Conclusion: The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy.

Keywords: Dissection; Endovascular treatment; Iatrogenic; Interventional neuroradiology; Ischemic stroke.

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Conflict of interest statement

Conflict of interest

B. Goeggel Simonetti, U. Fischer and S. Jung were supported by the Swiss National Science Foundation (SPUM-Grant 33CM30-124119). U. Fischer and J. Gralla received speaker fees from Covidien and are consultants for Medtronic. J. Hulliger, E. Mathier, H. Sarikaya, J. Slotboom, G. Schroth, P. Mordasini and M. Arnold declare that they have no competing interests.

Ethical standards

The local ethics committee approved the study and the patients or their next of kin gave written informed consent.

Figures

Fig. 1
Fig. 1
DSA of patient 4, a 64-year-old man with ID at the vertebrobasilar junction. a Left VA injection shows the occlusion of the proximal basilar artery with the tip of the microcatheter in the thrombus (arrow) during application of urokinase. b The underlying high-grade stenosis becomes visible after successful local intra-arterial thrombolysis and was treated by PTA. c The dissection following PTA is clearly visible on the DSA in lateral projection (arrow). d Stabilization of the dissection by insertion of a small self-expanding stent (arrows)
Fig. 2
Fig. 2
DSA of patient 1, a 64-year-old man with an ICA/MCA tandem occlusion. a The stump of the occluded ICA can be identified in the lateral projection of the DSA (arrow). b Frozen image of the DSA series performed via the aspiration catheter, which has passed the site of occlusion. The original shape of the ICA is subtracted and outlined as white shadow behind the dark course of the ICA after ipsilateral turn of the head. The site of the dissection is clearly visible as a buttonhole stenosis (arrow). c, d The site and extension of the dissection (arrows) become visible after initiation of general anesthesia and thrombus aspiration through the 8 F guiding catheter with its tip distal from the site of occlusion
Fig. 3
Fig. 3
Patient 8, 79-year-old man with tandem occlusion of the internal carotid and middle cerebral arteries. a DSA of the right common carotid artery in lateral projection shows the pseudo-occlusion of the ICA and absence of collaterals from the branches of the external to the internal carotid artery (ECA-ICA collaterals), a typical sign of acute ICA occlusion. b The anterior-posterior (a.p.) view shows the tip of the 5 F aspiration catheter in front of the occluding M1 thrombus. The coiling of the ICA was passed without wire and without any problems. c Control DSA following recanalization of the ICA and MCA confirms two small, hemodynamically irrelevant dissections (arrows) of the proximal and distal segments of the looping of the distal cervical segment of the ICA
Fig. 4
Fig. 4
Patient 9: 79-year-old woman with right ICA/M1 tandem occlusion. a The stump of the occluded ICA is well outlined in the a. p. projection of the DSA. b Anterior-posterior roadmap with the wire in the lumen of the occluded ICA pretends a straight course up to the petrous part. c Change of the course of the ICA following exchange of the stiff wire and placement of a filter wire (fine arrows) with a soft wire tip, which allows the ICA to reshape with a kinking below the skull base (bold arrow). d Dissection following stent placement extending into the now proximally kinked cervical segment of the ICA, which was treated with a second more flexible stent
See this image and copyright information in PMC

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