World Live Neurovascular Conference, 2016, Shanghai, China

1. Stentectomy of detached Solitaire –
Novel techniques
Vipul Gupta
Medanta, The Medicity
New Delhi, India

2. Case report – Stentectomy case 1
• Case 1: Seventy one year old male presented within 2 hours with global aphasia and
right sided weakness (NIHSS – 22). Multimodal CT imaging revealed a NCCT
ASPECTS of 10, occlusion of left internal carotid artery (ICA) from the origin and
distal left M1 middle cerebral artery (MCA) and A2 anterior cerebral artery (ACA).
Intravenous thrombolysis was not offered due to recent history of stroke. TICI 3
reperfusion was established in the MCA territory after a single pass with SOLITAIRE
4 x 40 mm stent. Following that, during second pass for the A2 ACA thrombus stent
detachment occurred. The proximal radio-opaque marker of the detached stent was
noted abutting the wall at the proximal genu of the cavernous ICA. There was no flow
in the ACA territory. Snare retrieval with Amplatz goose neck microsnare (4 mm)
failed. Therefore, stent based retrieval was performed with a SOLITAIRE 4 x 40 mm
stent (Figure 1). TICI 3 reperfusion was established in the ACA territory and the 3
months mRS was 1.

3. A – Left A1 ACA and M1 MCA
occlusion
B – left A1 ACA occlusion; TICI 3
reperfusion in left MCA territory
C – native image showing
deployed stent in left A2 – A3 ACA
• 71 male; Global aphasia and right sided weakness (NIHSS – 22) – 2 hours
• NCCT ASPECTS of 10; Intravenous thrombolysis was not offered due to
recent history of stroke.

4. D: distal (white arrow) and
proximal (black arrow) markers
of the detached stent
E - distal end of the detached
stent(BOLD white arrow), distal end of
the second stent (black arrow),
proximal end of detached stent (white
arrow), Distal marker of the
microcatheter (BOLD black arrow)
Post stentectomy DSA -
TICI 3 reperfusion

5. Technique: A ‘deploy and engage’ technique was used to capture the
proximal end of detached stent. The ‘deployment’ step involves partial
deployment (distal radio-opaque markers have expanded and are
opposed to wall of the ICA) of an appropriately sized solitaire device
proximal to or within the detached stent. The ‘engagement’ step
involves advancing the ‘microcatheter - partly deployed stent
complex’ in an attempt to engage the proximal part of the detached
stent. The proximal stent is then re-sheathed to capture the proximal
legs/ struts of the detached stent. Following that, microcatheter,
device and detached stent are retrieved (Figure 2).

6. 3 month mRS - 1
Line art demonstrating the
technique of Stentectomy by
Deploy and engage technique

7. Stentectomy case 2
Case 2: A 50 year old female presented at 3.5
hours with global aphasia and right sided
weakness (NIHSS 21). Multimodal imaging
revealed left M1 MCA occlusion and a small
core. Intravenous thrombolysis was deferred
due to a recent history of myocardial
infarction. Stent detachment occurred during
the third pass with SOLITAIRE 4 x 40 mm. Both
snare and stent based retrieval failed. A ‘loop
and snare’ technique was employed and the
stent was retrieved successfully. TICI 2a
reperfusion was established.

8. A- occluded proximal left
M1 MCA
B- detached stent – distal
and proximal markers
(white arrow); left M1
MCA is occluded
C- distal end of the detached stent (white
double arrow heads); proximal marker of
detached stent (white single arrow head);
proximal and distal marker of the
microcatheter (single white arrow);
microwire (black arrow)
• 50 female; 3.5 hours; Global aphasia and right sided weakness
(NIHSS 21). NCCT ASPECTS – 8

9. D – snaring of the microwire Road map showing
distal and proximal
markers of the
removed stent
E- detached stent (white
arrow); Microcatheter
(BOLD white arrow); Snare
(SOLID white arrow)
F- TICI 2 A reperfusion

10. ‘Loop and snare’ technique: A small caliber
microcatheter with a curved tip (Steam shaped)
is advanced through the detached stent.
Following that, the microwire is navigated
through the struts and back into the parent
artery to form a loop. The microcatheter is
then navigated over the microwire into the
parent artery. A 4 mm snare is then advanced
into the parent artery and the microwire is
snared. Following that, the microcatheter and
the snare are pulled back together with an
attempt to retrieve the stent.

11. Line art demonstrating the
stentectomy technique –
Loop and Snare

12. Key learning points
• Why removal of detached stent (stentectomy) ? – avoids use
of lytic/ dual antiplatelet
• Stentectomy technique :
 Snare – however unsuccesful in many cases
 Deploy and engage
 Loop and snare
• Can be used to remove displaced stents during stent assisted
coiling

13. Acutely ruptured blister aneurysm –Prasugrel
loading followed FD placement
Case series

14. DSA – Blister aneurysm of left ICA
Antiplatelet protocol:
Ecosprin 150 mg
Prasugrel 50 mg
2 hrs prior to stent deployment
Heparin 3000 IU at start of procedure
1000 IU to 2000 IU prior to stent deployment
ACT 300 (x 2 upper limit of normal)
A 63-year-old female patient presented with Fisher
grade 2 subarachnoid hemorrhage.

15. Fig. 1 A & B – 3D reconstructed
images show a fusiform aneurysm
of supraclinoid ICA at the level of
PCOM with a prominent ventral
bulge (arrow, A). Another very
small aneurysmal bulge seen from
A1 segment of right ACA
(arrowheads, A, B). Small
aneurysm also seen in right ICA
paraclinoidal segment pointing
medially (arrow, B). C- DSA in
working projection. D- Pipeline
reconstruction device. E- native
image showing good opposition of
the flow diverter to the arterial
wall. F- Post stenting DSA shows
persistent filling of the aneurysm.
D E F
B CA B

16. Fig. 2 Follow-up
angiogram. A- DSA
shows complete
occlusion of the fusiform
aneurysm. Minimal
filling of left ACA seen.
B- Native image of DSA
shows intimal growth
over the stent. C & D –
3D reconstructed images
shows complete
occlusion of the ICA
aneurysms with minimal
opacification of ACA.
B
C D
A

17. 17 patients: SS, ODS, SS+Coil
1 rebleed (died)
Good outcome on f/u – 82%
Mortality – 18%
Blister Aneurysm

18. Our experience with FD vs non FD
Complete occlusion – 89% vs 71% i.f.o FD
Repeat treatment – none vs 11.7% i.f.o FD
Rebleed resulting in death – none vs 5.8% i.f.o FD
Submitted for publication

19. Learning points
• In our series loading with Prasugrel and Ecosprin was safe
and effective for flow diverter placement in acutely
ruptured blister aneurysms
• Timing is critical, we loaded two hours before the
procedure
•
• FD was safe and effective in these aneurysms and
compared favorably with our previously reported results
with stent(single/overlapping) and coiling

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Dr Vipul Gupta

21. Thank You