Mechanical Thrombectomy of Acutely Occluded Flow Diverters

Background: Embolization of intracranial aneurysms with the pipeline embolization device (PED; Medtronic, Dublin, Ireland) is a widely used technique. Despite adequate dual antiplatelet therapy and intraprocedural anticoagulation, in-stent thrombosis has been described. There is limited evidence for best management of this complication.

Objective: To describe in detail the technique used to perform thrombectomy of a recently placed PED with in-stent thrombosis. The aim of the procedure is to leave the PED in place and only perform thrombectomy of the luminal clot.

Methods: We describe two cases of successful thrombectomy with a stentriever of acutely occluded PEDs. A total of 2 patients underwent PED embolization of 2 previously clipped aneurysms. Despite optimal deployment of the PEDs and excellent angiographic results, both patients developed symptoms of right hemispheric stroke within 1 h of the procedure. A thrombectomy was performed in each patient with the stentriever within the newly deployed PED. Thrombectomy was successful and there was no evidence of PED displacement of vascular injury.

Results: Stentriever thrombectomy of intraluminal clot can be performed effectively when the entire stentriever device is deployed within the PED. We did not experience any PED displacement, vessel damage, spasm, or device malfunction using this technique.

Conclusion: We report the use of a stentriever to perform thrombectomy for in-stent thrombosis after PED placement as an additional treatment option of acute occlusion. This technique has not been previously described.