Removal of distal fragments of liquid embolic agents during arteriovenous malformation embolization using the TIGERTRIEVER 13: a technical report

J Neurointerv Surg. 2020 Aug;12(8):794-797. doi: 10.1136/neurintsurg-2019-015474. Epub 2020 Feb 5.

Abstract

Background: Arteriovenous malformations (AVMs) are vascular lesions that may be treated by an endovascular approach using liquid embolic agents but the control of the liquid embolic agent remains poor and a potential complication may be distal migration of embolic material. The TIGERTRIEVER 13 is a new stent retriever designed for stroke thrombectomy and has a version ideal for distal occlusions. We report our experience in the removal of embolic agent which had migrated into the distal vessels using the TIGERTRIEVER during PHIL/Onyx embolization of AVMs.

Clinical presentations: Three patients with brain and spinal AVMs underwent endovascular embolization. During trans-arterial embolization of the AVM with PHIL/Onyx, retrograde filling of distal arterial feeders was followed by migration into the normal arterial branches (cortical middle cerebral artery, distal posterior cerebral artery, and anterior spinal artery). This resulted in occlusion or sluggish distal flow in these branches with potential significant neurological deficits. In all three cases, a Headway Duo microcatheter was navigated distally in the occluded vessel beyond the embolic material using a Traxcess microwire. The TIGERTRIEVER 13 was deployed with recanalization of the vessel after a single attempt. In all three patients there were no complications related to the retrieval of embolic agent.

Conclusion: Distal migrated embolic agents such as PHIL or Onyx can be removed from various arterial vascular territories using stent retrievers dedicated to small vessels.

Keywords: arteriovenous malformation; intervention; liquid embolic material; technique; thrombectomy.

MeSH terms

  • Embolization, Therapeutic* / methods
  • Humans
  • Intracranial Arteriovenous Malformations / diagnostic imaging
  • Intracranial Arteriovenous Malformations / surgery*
  • Middle Cerebral Artery / diagnostic imaging
  • Middle Cerebral Artery / surgery
  • Posterior Cerebral Artery / diagnostic imaging
  • Posterior Cerebral Artery / surgery
  • Stents
  • Thrombectomy
  • Treatment Outcome