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Published on: October 20, 2017
Management of a fractured microcatheter during middle meningeal artery embolization
Matthew Webb1, Anqi Luo2,3, Fadi Al Saiegh2
1Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA WebbMR@uthscsa.edu.
Abstract:
Middle meningeal artery embolization (MMAE) is an effective adjunctive treatment for chronic subdural hematomas and carries a low risk of significant complications.1 Here we describe the management of a retained and fractured microcatheter following liquid embolic MMAE. A patient with chronic recurrent subdural hematomas underwent bilateral MMAE with Onyx liquid embolic material (Medtronic). The Headway Duo (Microvention) microcatheter was placed in a small distal frontal branch of the middle meningeal artery to aid in reflux into the posterior middle meningeal artery branches. Following successful MMAE, the microcatheter became trapped within the Onyx cast and, on attempted removal, the microcatheter fractured, resulting in a retained fragment extending from the middle meningeal artery cast to the guide catheter in the common carotid artery.To retrieve the fractured microcatheter, a stent retriever was deployed and resheathed multiple times until the retained microcatheter became visibly entangled with the stent retriever. Next, the stent retriever was pulled back into the guide catheter and continuous aspiration was performed through the guide catheter, and the fragmented microcatheter was successfully removed in entirety. Final angiography demonstrated no further catheter fragments, vessel damage, extravasation, flow limitation, or thromboembolic complications.Methods to avoid the complication include using a detachable tip microcatheter, dual lumen balloon microcatheter, allowing less reflux, embolizing from a larger caliber branch, and a slower microcatheter pull. Additional methods for managing the complication include using a snare, leaving the retained microcatheter and putting the patient on aspirin, and carotid stenting to tack the fractured portion down (video 1). neurintsurg;16/12/1214/V1F1V1Video 1 Management of a fractured microcatheter during middle meningeal artery embolization This case demonstrates the successful use of a stent retriever and aspiration to retrieve a retained and fractured microcatheter following liquid embolic MMAE.
Insights
Middle meningeal artery embolization (MMAE) for chronic subdural hematomas can lead to fractured microcatheters. A stent retriever and aspiration successfully removed a retained, fractured microcatheter, preventing complications.
Area of Science:
- Interventional neuroradiology
- Vascular neurosurgery
Background:
- Middle meningeal artery embolization (MMAE) is a recognized treatment for chronic subdural hematomas.
- Complications, though rare, can occur during MMAE procedures.
Observation:
- A microcatheter fractured during liquid embolic MMAE, leaving a retained fragment.
- The fragment extended from the middle meningeal artery cast to the carotid artery.
Findings:
- A stent retriever was used to entangle and retrieve the fractured microcatheter.
- Successful retrieval was achieved using the stent retriever combined with aspiration through the guide catheter.
- Post-procedure angiography confirmed complete fragment removal without complications.
Implications:
- This case highlights a novel technique for managing fractured microcatheters during MMAE.
- Stent retriever and aspiration offer a viable solution for complex embolization complications.
- Preventive strategies and alternative management options for fractured microcatheters are discussed.
