title: Fatal avulsion of choroidal or perforating arteries by guidewires. Case reports, ex vivo experiments, potential mechanisms and prevention.
abstract: Innovations in endovascular tools have permitted an increasingly broad range of neurovascular lesions to be treated via minimally invasive methods. However, some device modifications may carry additional risks, not immediately apparent to operators. A patient with a symptomatic, partially thrombosed basilar apex aneurysm was allocated balloon-assisted coiling. Attempts were made to place a microwire across the basilar apex through the posterior communicating artery. Overlapping courses of the posterior cerebral and posterior choroidal arteries on the roadmap images were not recognized and a flanged-tip microwire was inadvertently advanced deep into the choroidal artery. Following the wire with a microcatheter led to binding of arterial tissue within the microcatheter. Removing the wire led to an avulsion of the choroidal artery and a severe hemorrhagic complication which proved fatal. Tissue was identified on the tip of the guidewire. Pathology showed layers of vascular tissue within the laser-cut flanges of the distal wire tip. A similar complication, also fatal, occurred during balloon angioplasty of a distal vertebral artery, when an exchange wire was accidently introduced into a perforator from a posterior cerebral artery. Ex vivo catheterization of distal mesenteric arterial branches showed that the wall of small arteries can be entrapped by laser-cut, flanged, but not by smooth guidewire tips. Microwires with a flanged instead of smooth distal tip, when placed into small caliber vessels, may cause hemorrhagic complications from avulsions*.
authors: Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Center; Edmonton, Alberta, Canada - jean.raymond@umontreal.ca.
authors: Tim E
authors: TE
authors: Darsaut
authors: Service de Radiologie, CHU de Montpellier, Hôpital Gui de Chaulliac; Montpellier, France.
authors: Vincent
authors: V
authors: Costalat
authors: Laboratory of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Center; Montreal, Quebec, Canada.
authors: Igor
authors: I
authors: Salazkin
authors: Laboratory of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Center; Montreal, Quebec, Canada.
authors: Sara
authors: S
authors: Jamali
authors: Department of Anatomy and Pathology, Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital; Montreal, Quebec, Canada.
authors: France
authors: F
authors: Berthelet
authors: Laboratory of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Center; Montreal, Quebec, Canada.
authors: Guylaine
authors: G
authors: Gevry
authors: Department of Radiology, Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital; Montreal, Quebec, Canada.
authors: Daniel
authors: D
authors: Roy
authors: Laboratory of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Center; Montreal, Quebec, Canada - Department of Radiology, Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital; Montreal, Quebec, Canada.
authors: Jean
authors: J
authors: Raymond
mesh_terms: D000368:Aged; D002406:Catheterization, Peripheral / Q000009:adverse effects*; D002536:Cerebral Arteries / Q000293:injuries*; D017809:Fatal Outcome; D005260:Female; D057918:Fiducial Markers / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015641:Radiography, Interventional / Q000009:adverse effects*; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging / Q000209:etiology* / Q000517:prevention & control*
keywords: aneurysm; avulsion; complication; endovascular treatment; guidewire