Management of per operative bleeding during mechanical thrombectomy

Presentations of a complication encountered by a specialist. The case is analyzed and discussed live by the panel.

Case: Perforation of the artery with microwire while passing the clot (point of the perforation is behind or at the level of the clot)

Performed by Dr Gregory Gascou

Angiographic clues to identify: you suddenly felt a drop in resistance and the wire is moving loosely not following anatomical basis of the course of the artery

Clinical clues to identify: bradycardia + hypertension 

How to confirm:

• angiography to confirm the suspicion 
• CBCT, but because of the clot, you may not see the extravasation

How to avoid: always pass the clot with J shape wire

What to do: 

Technique of Prof. Tudor Jovin:

•  Keep the microwire in its position and perform the over the wire exchange on 10 inch microcatheter (you need to have a long 300 cm wire)
• Once you have your microcatheter in proper position, inject to confirm that you are out of the vessel, and then do the Onyx embolization of the hole 

Technique of Dr Marc Ribo:

• Pass the clot with microwire and microcatheter and open up a stent-retriever 
• Perform control angiography: if there is bleeding, resheath the stent-retriever and wait, then repeat the procedure again
• If there is no more bleeding, perform the thrombectomy

Technique of Prof. Christophe Cognard:

• Occlude the point of the perforation with coils and wait
• Once the bleeding is stopped, perform the thrombectomy

Technique of Dr Gregory Gascou:

• Perform aspiration only (to not pass the clot)
• Do the control run – in presented case there is still extravasation at the level of previous perforation
• Perform the BCG inflation in order to reduce the flow to ICA
• Make the conversion from sedation/local anesthesia to general anesthesia
• In the meantime prepare a remodeling balloon and position it just before the occlusion – in presented case in ICA-M1 segment 
• Remark: do not inflate the remodeling balloon at the level of the perforation because you can enlarge the tear)
• Wait 5-15 minutes and perform the control run 
• Remark: if you want to confirm efficacy of the remodeling balloon in flow blockage, you may perform the run on BCG deflated – it is very important to deflate the BCG, otherwise you may rupture the artery)
• Perform CBCT to evaluate the extent of the SAH

Final message:

Do not let the perforation stop you from performing effective thrombectomy.

It is likely that the patient will be more harmed by ischemic consequences of failed reperfusion than a bleeding, if managed properly.