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. 2022 Jun 10;12(6):760.
doi: 10.3390/brainsci12060760.

Intra-Arterial Injection of Thrombin as Rescue Therapy of Vessel Perforation during Mechanical Thrombectomy for Acute Ischemic Stroke

Tingyu Yi  1 , Wenhuo Chen  1 , Yanmin Wu  1 , Zhinan Pan  1 , Xiaohui Lin  1 , Dinglai Lin  1 , Rongcheng Chen  1 , Xiufeng Zheng  1
Affiliations

Intra-Arterial Injection of Thrombin as Rescue Therapy of Vessel Perforation during Mechanical Thrombectomy for Acute Ischemic Stroke

Tingyu Yi et al. Brain Sci. .

Abstract

Background: Vessel perforation during stent mechanical thrombectomy (MT) is a rare and disastrous complication. A routine rescue strategy includes balloon occlusion for tamponade, procedure suspension, and lowering or normalizing blood pressure. However, this complication is still associated with poor outcome and high mortality.

Objective: We present our experience with intra-arterial injection of thrombin in the treatment of vessel perforation secondary to microcatheter/microwire perforation, which prevents further deterioration in clinical outcomes.

Methods: Cases with intraprocedural vessel perforation during mechanical thrombectomy were included in the final analysis. Clinical data, procedural details, and radiographic and clinical outcomes were collected.

Results: Four patients with intraprocedural vessel perforation were included. Intraprocedural perforations occurred at the distal middle cerebral artery in two cases: the A2 segment in one case and the internal carotid artery terminus in one case. The etiology of four cases was intracranial atherosclerotic stenosis (ICAS). The ruptured vessels were effectively occluded in all cases. Endovascular therapy was continued in three cases, and mTICI ≥ 2b recanalization was achieved in all cases. The culprit artery was kept patent on CTA for 72 h post-operation. No active bleeding was detected on follow-up CT post-operation. During the 90-day follow-up period, one patient died, modified Rankle Scare (mRS) 3 was observed in two patients, and mRS 4 was observed in one patient.

Conclusions: The key benefit of this method is occluding the ruptured vessel without affecting the following MT. We propose that intra-arterial injection of prothrombin may be simple yet effective in managing vessel perforation complications during MT.

Keywords: acute ischemic stroke; mechanical thrombectomy; vessel perforation.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Diagram of management and outcome of patients with intraprocedural vessel perforation. LVO: large-vessel occlusion; MT: mechanical thrombectomy; IA: intraarterial; BGC: balloon-guided catheter; mRS: modified thrombolysis in cerebral infarction; NA: not applicable.
Figure 2
Figure 2
(A) DSA shows occlusion of the M1 segment of the right MCA. (B) A microcatheter is advanced into the M1/2 branch (the arrow indicates the tip of the microcatheter), where active contrast extravasation pointing to the location of vessel perforation can be observed (indicated with arrow). (C) After the injection of 400 U thrombin via the microcatheter and no following contrast extravasation, the contrast extravasation is stopped. (D) mTICI 3 reperfusion was achieved after the detachment of the stent retriever and administration of intravenous tirofiban. (E) Severe hyperdensity within the Sylvian fissure and ventricle was observed on C-arm CT performed during the procedure. (F,G) The hyperdense area was dismissed on follow-up CT and disappeared on dual-energy CT, which indicates that it was a contrast agent but not a blood product. (H) Patency of the culprit artery was observed on the follow-up CTA. MCA: middle cerebral artery; mTICI: modified thrombolysis in cerebral infarction; CTA: computed tomography angiography.
Figure 3
Figure 3
(A) DSA shows occlusion of the M1 segment of the right MCA. (B) The microcatheter advanced through the occlusion site, and a Solitaire 4–20 mm was unsheathed at the occlusion site. (C) Angiography showed contrast extravasation from the inferior trunk of the MCA (indicated by the black arrow). (D) No contrast extravasation after injection of 200 U thrombin via the microcatheter. mTICI 3 reperfusion was achieved when the microcatheter was re-advanced into the inferior trunk of the MCA over the microwire and retrieved back into the proximal segment of the MCA while the microwire remained in place. (E) Hyperdensity within the Sylvian fissure and ventricle was observed on C-arm CT performed during the procedure. (F,G) Hyperdense area dismissed on follow-up CT. (G,H) Patency of the culprit artery was observed on follow-up CTA and MRA. DSA: digital subtraction angiography; MCA, middle cerebral artery; mTICI: modified thrombolysis in cerebral infarction; CTA: computed tomography angiography.
Figure 4
Figure 4
(A) DSA shows occlusion of the left ICA terminus. (B) Active contrast extravasation was observed when the microcatheter attempted to advance into the MCA, which indicates that vessel perforation occurred at the left carotid artery terminus. (C) After the injection of 200 µ thrombin via a microcatheter plus inflation of the balloon for 20 min, contrast extravasation was stopped, and the occluded left carotid artery terminus was opened. (D) mTICI 3 reperfusion was achieved 10 min after the administration of intravenous tirofiban. (E) Hyperdensity within the Sylvian fissure and cisterna ambiens was observed on C-arm CT performed during the procedure. (F,G) The hyperdense area was dismissed on follow-up CT and disappeared on dual-energy CT, which indicates that it was a contrast agent but not a blood product. (H) Patency of the culprit artery was observed on follow-up CTA. ICA: internal carotid artery; DSA: digital subtraction angiography; mTICI: modified thrombolysis in cerebral infarction; CTA: computed tomography angiography.
Figure 5
Figure 5
(A) Vessel perforation occurred when attempting to advance the microcatheter into A3; the microcatheter was in the parenchyma (the black arrow indicates the tip of the microcatheter). DSA shows the occlusion of the A2 segment of the left anterior cerebral artery. (B) This ruptured vessel was immediately sealed with 2 mL of thrombin (total dose was 300 u). (C) C-arm CT showed hyperdensity in the cisterna ambiens and sylvian cisterna. (D) Post-procedure dual-energy CT showed bilateral frontal lobe infarction without new hemorrhage or brain edema.
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