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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 2  |  Page : 377-378

Inadequate expansion lead to delayed Enterprise stent migration


1 Department of Cerebral Disease, People's Hospital of Zhengzhou University, Zhengzhou, China
2 Department of Intervention, People's Hospital of Zhengzhou University, Zhengzhou, China

Date of Web Publication10-Mar-2017

Correspondence Address:
Tianxiao Li
Department of Intervention, People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou - 450003
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_946_15

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How to cite this article:
Li L, Li P, Zhu L, Li T. Inadequate expansion lead to delayed Enterprise stent migration. Neurol India 2017;65:377-8

How to cite this URL:
Li L, Li P, Zhu L, Li T. Inadequate expansion lead to delayed Enterprise stent migration. Neurol India [serial online] 2017 [cited 2017 Mar 26];65:377-8. Available from: http://www.neurologyindia.com/text.asp?2017/65/2/377/201877


Sir,

A 58-year-old male patient was diagnosed to be having subarachnoid hemorrhage. A basilar apex aneurysm of size 8.0 × 10.0 mm with a 4.5 mm-wide neck was observed. The neck was deviated to the left side and the left posterior cerebral artery was arising from it. Stent assisted coil embolization was conducted. After placing three coils, the Enterprise stent (Cordis, Johnson & Johnson, USA) was placed. The distal end of the Enterprise stent was located in the origin of P2 and the proximal end of the Enterprise stent was located in the middle of the basilar artery. Coils were used to completely embolize the aneurysms. The check angiogram showed a satisfactory position of the stent, the aneurysm being completely embolized, and a patent parent artery. The follow-up cerebral angiography 18 months later demonstrated proximal migration of the Enterprise stent. The distal end of the Enterprise stent migrated from the original of P2 to the tip of the basilar artery [Figure 1]. The patient remained asymptomatic.
Figure 1: (a) A basilar apex aneurysm with wide-neck that involved the left PCA; (b) after some coils were detached, the Enterprise stent was released; (c) at the end of the treatment, the aneurysm was totally embolized and the parent artery remained patent. Red arrows shown the distal and proximal marks of the stent; (d) An 18 month follow-up showed migration of the stent. Red arrows showed the distal and proximal marks of the stent; (e) An 18 month follow-up showed total embolization of the aneurysm and patency of the parent artery

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Closed cell design of the Enterprise stent and the local anatomy were considered as the main mechanisms responsible for the delayed stent migration.[1],[2],[3] Up to now, four cases of delayed spontaneous stent migration have been reported [Table 1].[4],[5],[6],[7]
Table 1: Characteristics of previously reported cases and current case of delayed Enterprise stent migration

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Other reasons that might have contributed to the delayed migration of the Enterprise stent may also have existed. In our case, the manufacturer recommended the microcatheter pull-back unsheathing technique to release the stent. This technique may have resulted in the development of a significant incomplete apposition between the stent and the outer curve of the wall of the vessel. According to Heller and Malek,[3] a combined microcatheter pull-back and delivery microwire push technique to ensure that the microcatheter tip is centered within the lumen of the vessel during stent deployment is the best method to properly expand the Enterprise stent.

Furthermore, the timing of deployment of the stent, that is, whether it is done before or after the coil deployment, plays an important role in ensuring stent apposition to the vessel wall. In the case of wide-neck aneurysms, some loops of the first detached coil may protrude out of the aneurysmal sac into the lumen of the parent artery. At this time, though the Enterprise stent is released, it is hard to push the break-out coil loops back to the aneurysm sac because of limited radial force of this stent.

The two factors discussed above resulted in the incomplete stent apposition at the neck of the aneurysms. Inadequate expansion of the stent increases the gap between the diameters of the basilar artery (BA) and the posterior cerebral artery (PCA). The bigger the gap between the diameter of these vessels, the lower is the force required to drag the stent downward.

Overall, the delivery technique of 'dynamic push-pull' and 'stent release before coil filling the aneurysmal sac' method will help in better stent apposition to avoid its delayed migration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Gao B, Malek AM. Possible mechanisms for delayed migration of the closed cell-Designed enterprise stent when used in the adjunctive treatment of a basilar artery aneurysm. AJNR Am J Neuroradiol 2010;31:E85-6.  Back to cited text no. 1
    
2.
Kelly ME, Turner RD, Moskowitz SI, Gonugunta V, Hussain MS, Fiorella D. Delayed migration of a self-expanding intracranial microstent. AJNR Am J Neuroradiol 2008;29:1959-60.  Back to cited text no. 2
    
3.
Heller RS, Malek AM. Delivery technique plays an important role in determining vessel wall apposition of the Enterprise self-expanding intracranial stent. J Neurointerv Surg 2011;3:340-3.  Back to cited text no. 3
    
4.
Kelly ME, Turner RD 4th, Moskowitz SI, Gonugunta V, Hussain MS, Fiorella D. Delayed migration of a self-expanding intracranial microstent. AJNR Am J Neuroradiol. 2008;29:1959-60.  Back to cited text no. 4
    
5.
Rodriguez GJ, Maud A, Taylor RA. Another delayed migration of an enterprise stent. AJNR Am J Neuroradiol. 2009;30:E57  Back to cited text no. 5
    
6.
Lavine SD, Meyers PM, Connolly ES, Solomon RS. Spontaneous delayed proximal migration of enterprise stent after staged treatment of wide-necked basilar aneurysm: Technical case report. Neurosurgery. 2009;64:E1012.  Back to cited text no. 6
    
7.
Dashti SR, Fiorella D, Toledo MM, Hu Y, McDougall CG, Albuquerque FC. Proximal migration and compaction of an Enterprise stent into a coiled basilar apex aneurysm: A posterior circulation phenomenon? J Neurointerv Surg. 2010;2:356-8.  Back to cited text no. 7
    


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