Retrograde Trans-Posterior Communicating Artery Snare-Assisted Rescue of Lost Access to a Foreshortened Pipeline Embolization Device: Complication Management

BACKGROUND AND IMPORTANCE: The Pipeline embolization device (PED; Covidien Vascular Therapies, Mansfield, Massachusetts) is a promising, yet experimental, vascular reconstruction device for the treatment of complex intracranial aneurysms. We present a PED-related complication and describe a salvage strategy. CLINICAL PRESENTATION: A 64-year-old woman underwent PED-assisted parent vessel reconstruction for her giant cavernous internal carotid artery (ICA) aneurysm. During placement of the first PED, the proximal part of the PED foreshortened and was displaced into the aneurysm sac. Multiple subsequent attempts to recatheterize the PED failed, and, ultimately, distal access through and beyond the PED was lost. Therefore, completion of the Pipeline construct by stacking PEDs for definitive treatment was prevented. Retrograde access of the PED was gained from the distal ICA through a microwire that was advanced from the basilar artery through the posterior communicating artery. The microwire from the distal ICA was grasped with a snare from the proximal ICA and pulled down to the cervical ICA. The opened snare around the microwire was used as a lasso to advance a microcatheter from the cervical ICA through the PED to regain distal access. Five more PEDs were used to achieve complete parent vessel reconstruction and aneurysm obliteration. CONCLUSION: Maintaining distal access is critical until the entire parent vessel is reconstructed, especially when multiple PEDs are required. The salvage technique described may help regain distal access if it is lost during the procedure.