Twining wire technique for an approach through the graft-repaired type A aortic dissection with residual false lumen for cerebral thrombectomy: illustrative case

Abstract

BACKGROUND

Neuroendovascular treatment for patients with large-volume residual false lumens in the dissected aorta is challenging. Here, the authors describe the “twining wire technique” as a bailout in cases with failed navigation of a guidewire into the true lumen due to a dissecting aorta.

OBSERVATIONS

A man with a previous history of open surgical repair of the ascending aorta and aortic arch for type A dissection was transferred to the authors’ hospital for recanalization of the occluded left middle cerebral artery (MCA). CT angiography showed a graft-repaired, deformed aortic arch with distally residual false lumen, narrowing the true lumen. During mechanical thrombectomy, a guidewire could not be navigated into the true lumen via transfemoral or transradial access due to the deformed aortic arch and distal residual false lumen. Another wire was therefore navigated transradially from the true lumen into the descending aorta by passing the narrowed segment of the aorta; the wire was used as a guide in the true lumen by twining both wires, achieving access to the true lumen via a transfemoral approach and recanalization of the occluded MCA.

LESSONS

The twining wire technique was useful to achieve access to the true lumen in a dissected aorta with a residual false lumen.

https://thejns.org/doi/10.3171/CASE25993

Unfavorable aortic anatomy is a common reason for failed thrombectomy.¹ In patients with type A aortic dissection, emergency aorta graft repair, stent coverage, and innominate artery reimplantation are common procedures. Up to 90% of survivors who have undergone conventional surgery have a residual false lumen in the descending aorta.² A guidewire via the transfemoral approach could thus be difficult to insert into the true lumen. In this report, we present a twining wire technique as a bailout in cases with failed navigation of a guidewire into the true lumen due to dissecting aorta.

Illustrative Case

A 59-year-old man presented with disturbance of consciousness. He had a history of atrial fibrillation treated with edoxaban 30 mg/day, chronic heart failure, and open surgical repair of the ascending aorta and aortic arch for type A dissection 12 years previously. He was referred to our hospital 4 hours after symptom onset. On arrival, his level of consciousness was Glasgow Coma Scale score 9 (eye 3, verbal 1, motor 5) with total aphasia, left gaze deviation, right hemiplegia, and right hemispatial neglect. The National Institutes of Health Stroke Scale score was 29. Blood tests revealed moderate renal dysfunction. Brain diffusion-weighted MRI showed areas of slight hyperintensity in the left middle cerebral artery (MCA) territory with an Alberta Stroke Program Early CT score of 5 (Fig. 1A). MR angiography (MRA) showed left MCA occlusion (Fig. 1B). CT angiography obtained 12 years earlier, when aortic graft replacement was performed, revealed a deformed aortic arch with a distal residual false lumen that narrowed the true lumen (Figs. 2, 3A, and 3B). We attempted mechanical thrombectomy via a right transfemoral approach with a 9-Fr sheath and 9-Fr OPTIMO balloon guiding catheter (Tokai Medical Products Inc.) under local anesthesia 5 hours after onset. However, for 30 minutes after femoral puncture, a 0.035-inch × 150-cm Silverway guidewire (Asahi Intecc Co.) could not be navigated into the true lumen due to the presence of a large-volume false lumen. A 6-Fr FUBUKI dilator kit (Asahi Intecc Co.) was therefore placed via the right radial artery. Since the ascending aorta had been deformed due to the aortic arch replacement, a curved 6-Fr Simmons inner catheter (Medikit Co.) could not be used. A 0.035-inch Radifocus guidewire (Terumo) likewise could not be inserted into the left common carotid artery. We were therefore unable to navigate a guiding catheter to the left carotid artery for 40 minutes after groin puncture. As the guidewire was inserted in an antegrade manner into the true lumen via a transradial approach, the wire was advanced to the descending aorta to twine both wires navigated from the transfemoral and transradial access points. The transfemorally navigated wire was then advanced into the true lumen of the thoracic aorta, twined with the transradially navigated wire. Finally, 50 minutes after groin puncture, the transfemoral guidewire was successfully inserted into the true lumen of the thoracic aorta. After removing the transradial guidewire, the transfemoral guiding catheter was advanced to the left internal carotid artery over the transfemoral guidewire and inner catheter. A 6-Fr SOFIA aspiration catheter (Terumo), Trevo Trak 21 microcatheter (Stryker Neurovascular), and 0.014-inch CHIKAI microwire (Asahi Intecc Co.) were coaxially navigated into the guiding catheter. Recanalization of the occluded left MCA was successfully achieved using an Embotrap III 5 × 37–mm revascularization device (Cerenovus, Johnson & Johnson) with Thrombolysis in Cerebral Infarction grade 2b at 6 hours after onset and 60 minutes after groin puncture. Diffusion-weighted MRI performed after treatment showed a high-intensity area identical to that on preoperative MRI without any new ischemic lesions (Fig. 4A). MRA showed recanalization of the left MCA (Fig. 4B). No immediate complications including aggravation of the aortic dissection were noted. The step-by-step procedure for the twining wire technique is shown in Video 1.

FIG. 1.

A:Axial diffusion-weighted MR images showing areas of slight hyperintensity in the left MCA territory, with an Alberta Stroke Program Early CT score of 5. B:MR angiogram showing an occluded left MCA in the proximal region.

FIG. 2.

CT angiogram of the whole body obtained 12 years before stroke onset, showing a graft-repaired aortic arch with distal residual false lumen.

FIG. 3.

Oblique-view CT angiogram of the chest obtained 12 years before stroke onset (A) and 3D reconstruction (B), showing the deformed graft-repaired aortic arch with distal residual false lumen narrowing the true lumen.

FIG. 4.

A:Axial diffusion-weighted MR images obtained after thrombectomy showing a hyperintense area matching that on preoperative MRI without any new ischemic lesions. B:MR angiogram showing recanalization of the left MCA.

VIDEO 1. Video clip showing the step-by-step procedure for the twining wire technique. Click here to view.

Informed Consent

The necessary informed consent was obtained in this study.

Discussion

Observations

We have reported the twining wire technique as a bailout for cases with failed navigation of a guidewire into the true lumen due to a dissecting aorta.

In cases with difficult access from the transfemoral or transbrachial routes for endovascular treatment, the pull-through technique is commonly utilized.¹ In this technique, a guidewire is passed from one sheath to another, often with the aid of a snare device.¹ Moreover, the pull-through technique can be achieved without using a snare device to insert the guidewire directly into another sheath.³ However, whether a guidewire can be successfully inserted into another sheath depends on the difference in size between the artery and the sheath used in this technique. Therefore, the guidewire should be inserted from the sheath in the femoral artery into the sheath in the radial artery, because of the smaller difference in size. In the present case, the transfemoral guidewire could not be successfully inserted into the true lumen due to obstruction by the surrounding large-volume false lumen. Use of the pull-through technique without a snare device was therefore impractical in the present case. Because of the steep angle and the distance between the reimplanted innominate artery and the top of the arch, a curved Simmons inner catheter could not be used, as previously reported.⁴ Therefore, a right transradial approach is highly likely to prove infeasible for patients who have undergone aortic arch replacement. While the left transradial approach has been found useful for neurointerventions,⁵ in the present case the left subclavian artery was also deformed due to the aortic arch replacement. Because the aortic arch and its branches often become deformed after aortic arch replacement, as in this case, the transradial approach is similarly challenging during neurointerventions. Furthermore, a narrow graft lumen and friction between the graft and devices could make both transradial and transfemoral approaches difficult.⁶ Using transfemoral or transradial approaches or a combination thereof might prove crucial, depending on the case.

Several investigators have reported the utility of direct carotid artery puncture for endovascular treatment in patients with difficult anatomical variations.^6–8 The main disadvantages of this technique are arterial dissection and hematoma formation, which may contribute to a critical condition.⁸ To avoid these complications, a surgical cut-down approach would be reasonable, although the longer duration of a more complex surgical procedure will inevitably delay recanalization in acute ischemic stroke cases.

Our twining wire technique is easy to perform and could reduce the time and cost of the procedure to gain access through difficult anatomical variations. We therefore believe the twining wire technique offers a feasible alternative, particularly in cases with failed navigation of devices from the dissected segment into an intact or repaired segment.

Lessons

The twining wire technique appears useful in cases with failed navigation of the devices from a dissected segment into an intact or repaired segment.

Disclosures

Dr. Itabashi reported personal fees from Daiichi Sankyo, Otsuka Pharmaceutical, Fuso Pharmaceutical Industries, Boston Scientific, Kyowa Kirin, Eisai, UCB Japan, Medtronic, Medico’s Hirata, Terumo, Bayer, Abbott Medical Japan, and Pfizer, outside the submitted work.

Author Contributions

Conception and design: Chida, Tabayashi, Itabashi. Acquisition of data: Chida, Nozaki, Tabayashi, Itabashi. Analysis and interpretation of data: Chida, Tabayashi. Drafting the article: Chida, Tabayashi. Critically revising the article: Akamatsu. Approved the final version of the manuscript on behalf of all authors: Chida. Administrative/technical/material support: Tabayashi.

Supplemental Information

Videos

Video 1. https://vimeo.com/1164378292.

Correspondence

Kohei Chida: Iwate Medical University, Shiwa-gun, Iwate, Japan. kchida@iwate-med.ac.jp.