Stroke thrombectomy complication management

Abstract

Endovascular mechanical thrombectomy (EVT) is widely accepted as the first-line treatment for acute ischemic stroke in patients with large vessel occlusion. Being an invasive treatment, this method is associated with various preoperative, perioperative, and postoperative complications. These complications may influence peri-interventional morbidity and mortality and therefore treatment efficacy and clinical outcome. The aim of this review is to discuss the most common types of complications associated with EVT, the probable mechanisms of injury, and effective methods to manage and prevent complications.

Keywords: complication; stroke; thrombectomy.

Figure 1

(A) Digital subtraction angiography (DSA) of the right common carotid artery at the beginning of the procedure. (B) DSA run of the right internal carotid artery (ICA) with an arrow pointing to the tip of the balloon-guide catheter and narrowing of the vessel wall. (C) After endovascular thrombectomy a hemodynamically relevant and increasing stenosis due to a dissection can be observed in the cervical portion of the right ICA. (D) DSA run of the right ICA after stent placement in the dissected part of the vessel wall.

Figure 2

DSA run of the left middle cerebral artery after endovascular thrombectomy maneuver showing an extravasation in the (A) arterial and (B) parenchymal phase with origin at the previous position of the stent rettriever. (C) Owing to the persistent bleeding, embolization of the affected vessel segment by injection of n-butyl cyanoacrylate was performed.

Figure 3

Flow chart of a practical algorithm showing how to deal with residual occlusions or distal emboli to a new or target vascular territory in endovascular mechanical thrombectomy. ACA, anterior cerebral artery; IAT, intra-arterial; thrombolysis; mTE, mechanical thrombectomy; PCA, posterior cerebral artery; SR, stent retriever.

Figure 4

(A) DSA run of the right middle cerebral artery (MCA) after endovascular thrombectomy with repeated stent retriever retrievals, initially interpreted as residual vasospasm. (B) DSA run of the right MCA the next day showing a vessel wall irregularity. (C) DSA run after 2 years of follow-up showing formation of a dissecting pseudoaneurysm located in the treated vessel segment. (D) Black blood contrast enhanced axial T1 reconstructed MRI slice showing vessel wall enhancement on the right MCA bifurcation.