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УДК 616.831-005.1-036.1-089.819.1
MANAGEMENT OF ACUTE ISCHAEMIC STROKE DUE TO SHELDON CATHETER INSERTION INTO THE RIGHT COMMON CAROTID ARTERY USING THE ASPIRATION THROMBECTOMY: A CASE REPORT
PATRYCJA ANTOSIK, MALGORZATA FILUS, MACIEJ BLASZYK, ROBERT JUSZKAT
Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poland
*Conflict of Interest Statement (We declare that we have no conflict of interest).
*Заява про конфл^ штереав (Ми заявляемо, що у нас немае шякого конфлiкту штереав). *Заявление о конфликте интересов (Мы заявляем, что у нас нет никакого конфликта интересов).
*No human/animal subjects policy requirements or funding disclosures.
*Жодний Í3 об'екпв дослщження (людина/тварина) не тдпадае тд вимоги полiтики щодо роз-криття шформацп фiнансування.
*Ни один из объектов исследования не подпадает под политику раскрытия информации финансирования.
*Date of submission — 01.02.19 *Date of acceptance — 13.02.19
*Дата подачi рукопису — 01.02.19 *Дата ухвалення — 13.02.19 *Дата подачи рукописи — 01.02.19 *Дата одобрения к печати — 13.02.19
Accidental carotid cannulation using a large-bore catheter is one of the complications of central venous catheter insertion, reported in 1 % of performed procedures. Management of arterial catheterization contains direct manual compression, endovascular treatment, and open surgical repair. Inadvertent arterial cannulation can lead to hemorrhage, pseudoaneurysm, arteriovenous fistula, stroke or death. Mechanical removal of thrombotic material is presently the most effective method of stroke treatment. Rapid and early restoration of blood flow is crucial for the improvement of the neurological condition. This report describes a case of a patient with signs of severe stroke after management of accidental carotid catheterization using balloon tamponade. Aspiration thrombectomy was successfully performed to manage acute ischaemia of the brain.
Key words: mechanical thrombectomy; acute ischaemic stroke; carotid catheterization; balloon tamponade; interventional radiology.
DOI 10.26683/2304-9359-2019-1(27)-76-80
List of abbreviations
CVC Central venous catheterization
DSA Digital subtraction angiography
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Introduction
Hemodialysis is one of the indications for central venous catheterization (CVC). The preferred site for cannulation is right internal jugular vein. During catheterization, serious complications may occur, including infection, haema-toma, pneumothorax, nerve injury, thrombosis, and incidental arterial insertion [1, 2]. Inadvertent arterial cannulation using a large-bore catheter is reported in 1 % of performed procedures [3]. However, it can lead to hemorrhage, pseudo-aneurysm, arteriovenous fistula, stroke or death [2-5]. Management of arterial catheterization contains direct manual compression, endovascu-lar treatment, and open surgical repair. Despite the advantages, none of these procedures guarantee complete elimination of life-threatening problems, notably severe stroke. Mechanical thrombectomy is presently the most effective managing method of acute ischaemic stroke caused by occlusion of a large cerebral artery [6].
We report a case of the patient with signs of severe stroke after management of accidental carotid catheterization using balloon tamponade. Aspiration thrombectomy was successfully performed to manage acute ischaemia of the brain.
Case presentation
A 79-year-old male patient with end-stage renal failure was admitted to the Department of General and Vascular Surgery, because of arterial cannulation due to Sheldon catheter (12 French) insertion. Based on the condition of the patient, he was qualified for endovascular balloon tamponade. Vascular access was achieved by the Seldinger method and the digital subtraction angiography (DSA) of the brachiocephalic trunk was performed. DSA revealed a presence of the Sheldon catheter in the common right carotid artery and ascending aorta (Fig. 1). Balloon catheter measuring 8 x 40 mm was inserted into the damaged area under fluoroscopy. During continuous manual compression, Sheldon catheter
Patrycja ANTOSIK
Department of General
and Interventional Radiology,
Poznan University of Medical Sciences, Poland
ul. Dluga Street 1/2, 61-848 Poznan, Poland
Phone: +48618549280;
E-mail: [email protected]
https://orcid.org/0000-0001-7922-7467
Fig. 1. DSA examination. Presence of the Sheldon catheter in the common right carotid artery and ascending aorta
was removed and the balloon was repeatedly inflated for 2 min. The patient was in logical contact during the procedure. According to control angiography, there were no signs of hemorrhage from the common right carotid artery. After angiography, involuntary limb movements, weakness of muscle strength on the left side and speech disorders occurred (NIHSS scale, 16 points). Subsequent angiography revealed occlusion of the middle cerebral artery (Mj-segment) (Fig. 2).
Fig. 2. Occlusion of the lumen of the middle cerebral artery (M-segment)
K^imnm Binia.ik'ii
Fig. 3. Control DSA examination.
Restoration of blood flow through cerebral vessels after successful mechanical thrombectomy
Analgosedation and intra-arterial thrombolysis were administered. Aspiration thrombectomy using Penumbra Indigo System was performed and restoration of cerebral vascularization was achieved in less than 1 hour (Fig. 3). Control DSA examination of the brachiocephalic trunk revealed a place of extravasation of the contrast agent in an initial segment of the common right carotid artery. Angioplasty with implantation of the stent graft (Bentley BeGraft Peripheral Stent Graft System) measuring 10 x 57 mm was performed. Vascular access was closed with the Angio-Seal system. The patient in a stable condition was transferred to another hospital. Small hypodense areas of white matter of right frontal gyri, which may indicated small damages of blood brain barrier, but no other severe changes connected with acute stroke were revealed by computed tomography scanning of the head.
Discussion
Proper CVC is required for efficient hemodialysis. The commonly used technique is based on anatomical landmarks. Unfortunately, it is associated with the risk of arterial catheterization, because of the vicinity and anatomical variation of the carotid artery and internal jugular vein [1]. Ultrasound-guided catheterization decreases the risk of mechanical complications, but does not eliminate them [1, 3].
No standard guidelines were established for the management of arterial puncture. Selection of method depends on several factors - diameter and localization of catheter, surgical access, and possible complications.
Previous evidence has reported that catheter with a diameter greater than 7F, especially in localization difficult to compress, should not be removed using direct manual compression, because it is associated with high complication rate (94.4 %) [2, 3, 5].
Endovascular therapy is an appropriate option for arterial injury located behind or below the clavicle and in sites with difficult surgical access [2]. Embolic stroke and hemorrhage were reported as complications of endovascular therapy, but its success rate reaches 94.6 % and it is suggested to use when possible [5]. Balloon tamponade is used for accidental subclavian artery cannulation with success rate reaches 100 % in case of single lumen injury. It is less invasive than surgical treatment, does not involve inserting foreign bodies and can be converted into more invasive managing options [4]. According to Dixon et al. surgery is the optimal method without any reported complications so far, but may be inefficient in the area with difficult access, as it requires general anesthesia [5].
Ischaemic stroke is commonly caused by the thrombotic or embolic material closing lumen of a large cerebral vessel. The duration of ischaemia has significant influence on the appearance of the clinically important and permanent neurological deficit. Therefore rapid and early restoration of blood flow is crucial for the improvement of the neurological condition. The most effective treatment method of ischaemic stroke caused by occlusion of a large cerebral artery is mechanical thrombectomy, irrespective of patient characteristics or geographical location. Goyal et al. in their analysis confirm benefit of endovascular thrombectomy in groups of the patients with symptom onset later than 300 min, patients not receiving intravenous alteplase and the elderly [6, 7].
Simultaneous application of thrombolysis and mechanical thrombectomy has become a standard of management of severe ischaemic stroke. Mechanical thrombectomy performed by experienced team significantly decreases the risk of failure and postoperative complications
[7]. Management of the acute ischaemic stroke in this specific situation was primary procedure despite the fact of previous catheter removal from the artery. According to application of the intra-arterial thrombolysis, as the next step, area of catheterization was sequred with the peripheral stent graft (Bentley BeGraft Peripheral Stent Graft System).
Penumbra System is a first-generation mechanical thrombectomy device aspirating the thrombus by negative pressure suctioning. Penumbra System has a comparable duration of the procedure to retrievable stents. The successful recanalization ranges 86.6 % using Penumbra System and 92.9 % utilizing retrievable stents. However, the 3-month mortality rate was respectively 20.7 % and 12.3 % [8]. There are no signi-
References
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ficant differences in safety and efficiency between the Solitaire and Penumbra devices in acute ischaemic stroke caused by occlusion of the middle cerebral artery or intracranial internal carotid artery [9]. The ASTER Randomized Clinical Trial indicated that the contact aspiration compared with retrievable stents, both used as the first-line thrombectomy, did not increase successful re-vascularization rate at the end of the procedure. There were no significant differences between revascularization rate and early improvement in neurological outcomes in these two groups [10].
In conclusion, catheterization of the artery is connected with life-threatening problems such as acute ischaemic stroke. Mechanical removal of thrombus has revolutionized the treatment of severe ischaemic stroke.
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7. Evans MRB, White P, Cowley P, Werring DJ. Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Pract Neurol. 2017;17:252-65. https://doi.org/10.1136/practneurol-2017-001685
8. Almekhlafi MA, Menon BK, Freiheit EA, et al. A meta-analysis of observational intra-arterial stroke therapy studies using the Merci Device, Penumbra System, and Retrievable Stents. Am J Neuroradiol. 2013;34:140-5. https://doi.org/10.3174/ajnr.A3276
9. Caranfa JT, Nguyen E, Ali R, et al. Mechanical en-dovascular therapy for acute ischemic stroke: An indirect treatment comparison between Solitaire and Penumbra thrombectomy devices. PLOS ONE. 2018;13:e0191657. https://doi.org/10.1371/journal. pone.0191657
10. Lapergue B, Blanc R, Gory B, et al. Effect of endo-vascular contact aspiration vs stent retriever on re-vascularization in patients with acute ischemic stroke and large vessel occlusion. The ASTER Randomized Clinical Trial. J Vasc Surg. 2017;66:1910. https://doi. org/10.1016/jjvs.2017.10.034
Л1КУВАННЯ ГОСТРОГО 1ШЕМ1ЧНОГО 1НСУЛЬТУ ШЛЯХОМ АСШРАЦШНО1 ТРОМБЕКТОМП З ВИКОРИСТАННЯМ КАТЕТЕРА SHELDON КР1ЗЬ ПРАВУ ЗАГАЛЬНУ СОННУ АРТЕР1Ю: КЛ1Н1ЧНИЙ ВИПАДОК
PATRYCJA ANTOSIK, MALGORZATA FILUS, MACIEJ BLASZYK, ROBERT JUSZKAT Вщдшення загально1 та ^ервенцшно!' радюлогп, Познаньський утверситет медичних наук, Польща
Випадкова катетеризащя сонно'1 артерп катетером великого дiаметра е одним Í3 ускладнень уведення центрального венозного катетера, яке виникае в 1 % випадюв. Керування катетери-защею артерп передбачае пряму мануальну компреаю, ендоваскулярне л^вання та вщкрите
xipypri4He втручання. Випадкова артерiальна катетеризацiя може призвести до крововиливу, псевдоаневризми, артерювенозно'1' норицi, iнсyльтy або смерть Мехашчна тромбектомiя нинi е найефективнiшим методом лiкyвання iнсyльтy. Швидке та ранне вiдновлення кровотоку мае виршальне значення для полiпшення невролопчного станy. Наведено клiнiчний випадок хворого з ознаками тяжкого шсульту тсля випадково'1 катетеризацп сонно'1' артерп пiд час ви-користання балонно'1' тампонади. Для лiкyвання гостро'1' шеми головного мозку була yспiшно виконана астрацшна тромбектомiя.
Ключов1 слова: мехашчна тромбектомiя; гострий iшемiчний iнсyльт; катетеризащя сонно'1' артерп; балонна тампонада; штервенцшна радiологiя.
ЛЕЧЕНИЕ ОСТРОГО ИШЕМИЧЕСКОГО ИНСУЛЬТА ПУТЕМ АСПИРАЦИОННОЙ ТРОМБЭКТОМИИ С ИСПОЛЬЗОВАНИЕМ КАТЕТЕРА SHELDON ЧЕРЕЗ ПРАВУЮ ОБЩУЮ СОННУЮ АРТЕРИЮ: КЛИНИЧЕСКИЙ СЛУЧАЙ
PATRYCJA ANTOSIK, MALGORZATA FILUS, MACIEJ BLASZYK, ROBERT JUSZKAT Отделение общей и интервенционной радиологии, Познаньский университет медицинских наук, Польша
Случайная катетеризация сонной артерии катетером большого диаметра является одним из осложнений введения центрального венозного катетера, которое возникает в 1 % случаев. Управление катетеризацией артерий предусматривает прямую мануальную компрессию, эндоваскулярное лечение и открытое хирургическое вмешательство. Случайная артериальная катетеризация может привести к кровоизлиянию, псевдоаневризме, артериовенозному свищу, инсульту или смерти. Механическая тромбэктомия в настоящее время является наиболее эффективным методом лечения инсульта. Быстрое и раннее восстановление кровотока имеет решающее значение для улучшения неврологического состояния. Приведен клинический случай пациента с признаками тяжелого инсульта после случайной катетеризации сонной артерии при использовании баллонной тампонады. Для лечения острой ишемии головного мозга была успешно выполнена аспирационная тромбэктомия.
Ключевые слова: механическая тромбэктомия; острый ишемический инсульт; катетеризация сонных артерий; баллонная тампонада; интервенционная радиология.
