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. 2001 May 15;6(3):251–256. doi: 10.1177/159101990000600311

Retrieval of Malpositioned, Dislocated or Fractured Guglielmi Detachable Coils from Intracranial Vessels

A Report of Seven Cases

LEH Lampmann 1,1, M Sluzewski 1, WJJ Van Rooij 1
PMCID: PMC3679683  PMID: 20667204

Summary

Endovascular treatment of intracranial vascular disorders has become common practice, especially treatment of aneurysms with detachable coils. Detachable coils can be utilized with high success rates but technical complications such as misplacement and displacement of coils and/or fractures may occur.We describe our experience with retrieval of coil material utilizing the Lasso retriever (Balt, Montmorency, France) in seven patients.

Key words: Guglielmi detachable coil, micro coils, foreign bodies, interventional neuroradiology, microvascular retrieval

Introduction

In the last decade, treatment of intracranial aneurysms with detachable coils has become common practice, especially in patients who have surgically high risk aneurysms or who are in poor medical condition. In the application of these coils, technical complications may occur: coils may be malpositioned,dislocated or even fracture and prompt retrieval is usually indicated. From November 1994 to July 1999, 254 intracranial aneurysms in 212 patients were treated with GDC in our institution. In this report we describe our experience with retrieval of coils or coil fragments from intracranial vessels in seven patients.

Case Reports

Case 1

A 51-year-old male was treated with Guglielmi Detachable Coils (GDC, Target Therapeutics, Fremont,CA, USA) seven days after subarachnoid haemorrhage (SAH) from a 9 mm wide necked basilar tip aneurysm. An 8 mm GDC 18 coil was delivered into the aneurysm. Control angiography revealed protrusion of the coil into the basilar artery and it was decided to withdraw the coil. During withdrawal, friction between the coil and the microcatheter led to unraveling of the coil. Subsequent withdrawal of the microcatheter resulted in fracture of the coil, thus creating a situation in which the fractured coil extended from the basilar tip aneurysm down into the basilar artery. A Lasso retriever was inserted into the basilar artery and the fractured coil was caught and pulled out without complications. The procedure was terminated. The patient recovered completely and one month later the aneurysm was retreated with coils successfully.

Case 2

A 49 year old female was treated with GDC four days after SAH from an 8 mm left superior cerebellar artery aneurysm. Two coils were placed inside the aneurysm with satisfactory occlusion. After detachment of the second coil the microcatheter was pulled out of the aneurysm. However, the tip of the microcatheter partially dislodged the already detached coil into the upper basilar artery. A loop of this coil was grasped with a Lasso retriever and pulled out. In a second embolisation procedure after 12 days the remaining part of the aneurysm was successfully occluded.

Case 3

A 61 year old female presented with right sided ophthalmoplegia. Cerebral angiography demonstrated a large carotid cavernous aneurysm on the right side and an additional large carotid ophthalmic aneurysm on the left side. It was decided to treat both aneurysms with GDC.

The symptomatic right aneurysm was treated first. The neck of this aneurysm was difficult to discern on angiography but the first coil was detached into the assumption that it was inside the aneurysm. After placement of the second coil,impaired flow in the carotid artery made it obvious that both coils were partially in the carotid artery itself and that the aneurysm had no neck at all. The second coil was not yet detached and could be retrieved. The first coil could be grasped with a Lasso retriever and removed. In two later sessions, the ophthalmic aneurysm at the left side was successfully packed with GDC and the aneurysm of the right carotid artery was treated by carotid artery occlusion with detachable balloons.

Case 4

A 53 year old female had bled from a large basilar tip aneurysm. During GDC embolisation the eighth coil could not be completely delivered into the aneurysm. Withdrawal of the coil resulted in unraveling and the coil eventually fractured. The loose proximal end of the coil in the basilar artery could be caught with a Lasso retriever and the fractured coil was removed. A small neck remnant remained.

Case 5

A 58-year-old female who had suffered a SAH from an anterior communicating artery aneurysm was treated by surgical clipping. Cerebral angiography had revealed an additional small aneurysm in the cavernous part of the right carotid artery. After clinical recovery this small cavernous aneurysm was treated with GDC.

Insertion of the second coil caused the first already detached coil to be dislodged into the carotid artery. After withdrawal of the second coil the first coil could be grasped with the Lasso retriever and successfully retrieved. The aneurysm was left untreated.

Case 6

A 46-year-old female with an aneurysm on the posterior communicating artery was successfully treated endovascularly with coils. In the same session an associated cavernous aneurysm at the right side was treated with GDC. After detachment, subtle manipulation of the microcatheter dislodged this coil in the parent artery. A lasso retriever was unable to negotiate the bend in the tortuous petrous and cavernous segments of the carotid artery. In a further attempt, the lasso loop was after loaded over a 0.018 inch guidewire and both the guidewire and lasso were inserted through the guiding catheter.

The tip of the guidewire was manoeuvred in the vicinity of the dislodged coil and in a monorail fashion we were able to advance the lasso retriever to the dislodged coil which was successfully removed. In a later session, the aneurysm was treated with GDC, without complications.

Case 7

A 55-year-old female was treated with GDC for an additional para-ophthalmic carotid aneurysm. After detachment of the first coil, we were uncertain about the position of one of the loops. A balloon positioned in front of the aneurysmal neck confirmed the location of the loop being outside the aneurysm in the carotid artery. The already released coil on control angiography proved to bulge through the wide neck into the carotid artery despite utilization of a supporting balloon.

We retrieved this coil by means of the monorail technique because the lasso retriever failed to reach the supraclinoid segment of the carotid artery (figures 1A - 5). No complications occurred. A second session was successful and angiography after six months showed complete obliteration of the aneurysm (see figure).

Figure 1.

Figure 1

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A) Para-ophthalmic carotid aneurysm. B) Bulging loop of detached coil in carotid artery. C) An inflated balloon pushes the loop back into the aneurysm, confirming the malposition of the coil loop. D) Lasso loop afterloaded over guidewire. E) Catching of bulging loop. F) Retrieval of coil in guiding catheter.

Discussion

Endovascular treatment of cerebral aneurysms with GDC has proved to be a safe and effective alternative to surgical clipping1-16. Although these coils are designed only to be (electrolytically) detached after a satisfactory position is obtained, detached coils may still prove to be misplaced due to misjudgement. Moreover, correctly positioned coils can be dislodged into the parent artery by insertion of subsequent coils or manipulation of the microcatheter. Undetached coils can even fracture upon withdrawal, usually due to friction in the system, resulting in a loose end of the coil extending down from the aneurysm into the parent artery. Complications like these cause an undesirable situation to the patient due to the risk of thrombo-embolic complications and immediate retrieval of the dislocated or fractured coil is indicated17,18.

In a series of 254 aneurysms in 212 patients treated with GDC we had to retrieve a malpositioned,dislodged or fractured coil in seven cases. In all seven patients it was possible to retrieve the coils from the parent artery without complications. Wrong positioning of the coils due to malposition and maljudgement or underestimation of the width of the neck occurred in two patients (cases 3 and 7, early in our series). These incidents should be minimized with increasing experience in the endovascular treatment of cerebral aneurysms. Dislodgement of an already detached coil by a subsequent coil or manipulation of the microcatheter occurred in three patients (cases 2, 5 and 6). All of these three patients had wide necked aneurysms and the difficulty in treating these aneurysms is well known. The use of a temporary protecting balloon to cover the wide neck during coil delivery can overcome this problem, but this so-called remodelling technique increases the risk of the treatment. Fracture of the coil due to friction in the microcatheter occurred in two cases (cases 1 and 4). We have not faced this problem since the introduction of the newest generation braided and coated microcatheters.

Percutaneous devices have long been used for the retrieval of foreign bodies from major vessels, but only recently have micro devices been designed of a caliber suitable to use in the intracranial vascular system. Standard et Al. reported a retrieval technique of an unraveled unfractured coil using a dual guidewire technique 19. Tytle et Al described the Gooseneck (Microvena Corporation, White BearLake, Minnesota, USA) concept in microvascular retrieval of foreign material from the extracranial carotid artery as well as the intracranial circulation 20. Terada mentioned dual microcatheter guidewire snare technique to retrieve a stretched residual IDC, extending from the cavernous sinus to the femoral vein21.

In all of our seven cases we used the Lasso catheter to retrieve the coils. The Lasso catheter consists of a catheter with an indwelling pushable wire connected on the distal end of the catheter. Just by pushing the wire out a loop is formed and when retracting, the wire or foreign body will be caught,making it possible to retrieve the whole assembly within the 6 French guiding catheter. In five of our patients we were able to advance the lasso catheter into the vicinity of the coils. In the other two patients, however, we failed to reach the coils with the lasso catheter due to tortuosity of the intracranial vessels. In a second attempt we managed to reach the coils by advancing the lasso catheter over a 0.018 inch guidewire in a monorail fashion.

In case of malpositioning with protrusion in the parent artery, it was quite easy to catch a loop, but in case of unraveled, stretched and fractured coils retrieval presented great difficulties. The stretched portion of the coil is hardly visible on fluoroscopy and starting the retrieval at the stretched portion of the coil only made the coil unravel further. It is therefore advisable to try to capture the nonstretched portion of the coil close to the aneurysm. A major concern of any retrieval system is the ease with which it can be manoeuvred into position. All systems are characterized by moderate difficulty in negotiating tortuous and small vessels. Minimizing the diameter and increasing the flexibility of the micro retrieval system are likely to compromise the ability to open and close its loop. Future technical improvements will hopefully overcome these conflicting qualities.

We conclude that every neurointerventionist involved in coil embolisations of cerebral anerysms should be prepared for the possibility of retrieval of malpositioned, dislodged or fractured coils as described in this paper. Microretrievers are commercially available from several manufacturers but can also be handmade by tightening the tip of a 0.010 inch guidewire on the tip of a 0.018 microcatheter with a 00000 suture forming a loop (for example a Dasher 10 guidewire and a Turbotracker microcatheter (GDC, Target Therapeutics, Fremont, CA, USA). To date, the availabe micro retrieval systems have proved helpful but in case of tortuous and smaller intracranial vessels more sophisticated systems are needed.

Acknowledgments

Mrs. Jolanda Streekstra-van Lieshout for preparing the manuscript.

References

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letter Interv Neuroradiol. 2001 May 15;6(3):251–256.

Comment

Phillip J Porter a

This paper can be considered a technical note, as it deals mainly with the practical aspects of retrieving malpositioned, dislocated or fractured coils. As the authors mention, there have been previous reports addressing retrieval of intravascular foreign bodies, and it is known that a lasso system is an excellent device to capture coils or coil fragments. Their report contains seven cases from a consecutive, contemporary series of 254 GDC treatments over the past five years, giving some indication of the frequency with which this complication occurs (2.8l/o), at least in their institution. They discuss and reinforce a number of useful technical factors, such as methods to reach further distal in the case of tortuous vessels, and the advice to capture the non-stretched portion of the coil for retrieval.

It is useful to analyze the errors in technique or judgment that led to the need to retrieve coils, and suggest potential ways to avoid these problems. For example, several cases involved large neck lesions, which are known to give rise to such problems. One may now avoid many of the complications by clearly visualizing the neck of the aneurysm and its relationship to the parent artery and local branch anatomy before beginning to coil (if necessary employing either multiple oblique views or three-dimensional imaging), and using the remodeling technique or available 3-D or “stretch-resistan” coils in difficult situations. Several patients (cases 5, 6, one of the two aneurysms in case 3, and possibly case 7) had asymptomatic cavernous aneurysms treated, which many would regard as a questionable therapeutic indication.

We agree with the authors that GDC procedures should not be started without having the capacity for coil retrieval However; the balance of risks versus benefits of removing stray coils is not addressed in this article, and one cannot dogmatically state that retrieval of such coils is mandatory. It is our impression, in fact, that one should not consider that any loop or loops protruding into a parent artery must be retrieved. To know whether prompt retrieval of such coils is indicated requires knowledge of the risk of retrieving the coils and the risk of not doing so. This information is currently not available, to my knowledge. The fact that they had no complications in their seven cases provides some information about what is certainly the potential to create an unstable situation with devastating consequences, as one may displace previously deployed coils out of the aneurysm while attempting to eliminate protruding loops. The recent report by the Bicêtre team includes ten cases of a prolapsed loop (4) or loops (6) which were not retrieved and remained clinically silent, with appropriate antiplatelet or anticoagulant treatment to avoid embolic complications. We have had similar experience in Toronto with several cases and generally prefer medical treatment over attempts at mechanical retrieval.

In conclusion, this paper provides interesting and useful technical information regarding the retrieval of stray coils in intracranial aneurysm treatment. However, one must keep in mind that proper patient selection for coiling is the best way to avoid technical and clinical problems, and when these problems occur careful consideration of the risks versus benefits of retrieval is mandatory.

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