Wingspan stent delivery catheter fracture and the TRAP technique for endovascular salvage

Abstract

Background Intracranial atherosclerotic disease may result in ischemic infarction and has a high rate of recurrent ischemic strokes despite medical therapy. Patients who fail medical therapy may undergo endovascular treatment with cerebral artery angioplasty and possible Wingspan stent placement. We present a unique case of Wingspan delivery microcatheter fracture that resulted in a retained foreign body and an endovascular salvage maneuver. Case description An elderly patient presented with an acute ischemic stroke due to a severe stenosis in the proximal left middle cerebral artery (MCA). The patient failed non-invasive medical treatment and underwent endovascular treatment with angioplasty and Wingspan stent placement. Following Wingspan stent deployment, the stent delivery catheter fractured, and the retained catheter fragment resulted in MCA occlusion. The foreign body was retrieved by balloon catheter inflation within an intermediate catheter adjacent to the proximal end of the fractured catheter and removal of the entire construct (TRAP technique). Conclusions Wingspan delivery microcatheter fracture is a rare event. The TRAP technique may be used for successful retrieval of a retained foreign body.

Keywords: Stroke; Wingspan; angioplasty; foreign body; intracranial atherosclerotic disease.

Figure 1.

Presentation CT, CTA, and CTP in a patient with left MCA ICAD. (a) Non-contrast head CT does not show any evidence of acute ischemic infarction. (b) Maximum-intensity projection images from a CTA demonstrate a calcified lesion with an associated severe stenosis in the left ICA terminus and M1 segment of the left MCA (arrow). (c) Time-to-maximum images from CTP demonstrate a perfusion deficit in the left MCA territory (arrow).

Figure 2.

Cerebral angioplasty and Wingspan placement for left M1 stenosis treatment with retained foreign body. Images (a)–(g) and (i) are in the anteroposterior (AP) projection. Image (h) is in the lateral projection. (a) Left ICA DSA demonstrates a partially occlusive filling defect and stenosis within the left ICA terminus and left M1 segment (arrow). Poor filling of the superior (dashed arrow) and inferior (arrowhead) post-bifurcation M1 segments is noted. (b) A balloon microcatheter is inflated across the left ICA terminus/M1 stenosis (arrow). (c) DSA following angioplasty demonstrates improved flow through the treated left ICA terminus/M1 stenosis (arrow). (d)–(f) Subtracted (d), unsubtracted (e), and magnified unsubtracted (f) angiographic images after Wingspan placement show an improved caliber of the left ICA terminus/M1 segment (arrows, (d)–(f)). The superior post-bifurcation M1 segment is now occluded (dashed arrows, (d)–(f)) distal to the Wingspan (*, (d)–(f)), and the microwire remains present within this segment. A new triangular density (arrowhead, (e), (f)) is present near the origin of the occluded post-bifurcation M1 segment. ((g), (h)) Unsubtracted AP (g) and lateral (h) views during Navien (*, (g), (h)) flushing demonstrates contrast opacification of a retained Wingspan delivery microcatheter fragment. A proximal marker in the retained catheter (curved arrow, (g), (h)) is present, and contrast (dashed arrows, (g), (h)) extends through the distal tip of the retained catheter (arrows, (g), (h)). The retained distal catheter tip abuts the triangular density identified after Wingspan deployment (arrowhead, (g), (h)). (i) Left ICA following successful retrieval of the fractured delivery catheter shows improved flow through the left ICA terminus/M1 stenosis (arrow) and recanalization of the post-bifurcation M1 segment that supplies the superior division (dashed arrow).

Figure 3.

MRI, MR angiogram, and MR perfusion following Wingspan placement and foreign body retrieval. (a) Diffusion-weighted imaging shows a small cerebral infarction in the left cerebral corona radiata (arrow) and caudate. (b) Maximum-intensity projection images from a MR angiogram demonstrate excellent flow-related signal in the left MCA vessels (arrow). (c) Time-to-maximum images from MR perfusion demonstrate no residual perfusion deficit in the left MCA territory.