TEACHING CASE # 5. Reocclusion Of Transverse And Sigmoid Venous Sinuses Mechanical and Chemical Thrombectomy

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1 TEACHING CASE # 5 Reocclusion Of Transverse And Sigmoid Venous Sinuses Mechanical and Chemical Thrombectomy CASE PRESENTATION 22M with right transverse and sigmoid venous sinuses occlusion s/p transvenous thrombectomy and thrombolytic administration 7 days back, now having worsened neurological status due to reocclusion of aforementioned venous sinuses. Emergent CT venogram was performed after patient became comatose and obtunded; CT venogram demonstrated reocclusion of right transverse and sigmoid venous sinuses with right hemispheric venous engorgement, and previously noted right temporal and inferior cerebellar venous infarctions. PRE- ANGIOGRAPHY IMAGING Complete occlusion of right transverse and sigmoid venous sinuses. There is dilatation of right hemispheric cortical veins. The parietal and frontal cortical veins drain into the superior sagittal sinus.

2 ANGIOGRAPHY Right internal jugular vein access A 5F Angle glide catheter was introduced over a inch guide wire and advanced through the 5F femoral vein introducer sheath into inferior vena cava, right atrium, left superior vena cava, right brachiocephalic vein, and right internal jugular vein. A 6F guide sheath was introduced over a inch J shaped stiff guide wire, which was placed through the 5F angle glide catheter as part of standard exchange. A Prowler PLUS inch two- tip microcatheter was advanced over the steerable inch guidewire (SYNCHRO- II guidewire) but could not be advanced through the right internal jugular vein occlusion into right sigmoid and transverse sinus. Left internal jugular vein access

3 6 Fr Envoy guiding catheter (Cordis, Miami Lake, FL USA) was introduced through a femoral sheath into the left internal jugular vein over a inch steerable guidewire using fluoroscopic guidance supplemented by road mapping technique. A Prowler PLUS inch two- tip microcatheter was advanced over the steerable inch guidewire (SYNCHRO- II guidewire) and advanced through left sigmoid and transverse sinus into right transverse and sigmoid sinuses. Radiopaque marker bands located at distal tip of the catheter were used to position the microcatheter under fluoroscopic visualization across the site of occlusion. A microcatheter angiographic injection was then carried out in order to confirm and define the vasculature distal to the thrombus.

4 Traversing the occlusion A Prowler PLUS inch two- tip microcatheter was advanced over the steerable inch guidewire (TRANSCEND 300 cm microwire) and advanced into right internal jugular vein. A SNARE 7 mm was introduced through the 6 F guide sheath already placed in right internal jugular vein. The microwire was ensnared by the SNARE and retracted into the 6 F guide sheath already placed in right internal jugular vein and subsequently withdrawn through the proximal end of guide sheath. The 300 cm microwire was externalized at both ends. Mechanical thrombectomy A Prowler PLUS inch two- tip microcatheter was advanced over the distal end of externalized inch guidewire (TRANSCEND 300 cm microwire) and advanced into right internal jugular vein and subsequently into right sigmoid and transverse venous sinuses. The externalized inch guidewire (TRANSCEND 300 cm microwire) was retracted and removed from the distal end. Another inch guidewire (TRANSCEND 300 cm microwire) was introduced through Prowler PLUS inch two- tip microcatheter was advanced into right internal jugular vein and subsequently into right sigmoid and transverse venous sinuses. The Prowler PLUS inch two- tip microcatheter was removed. The AngioJet Ultra Thrombectomy System Solent Dista 4F length 145cm was introduced over the new inch guidewire (TRANSCEND 300 cm microwire) into right sigmoid and transverse venous sinuses. Active aspiration and Power Pulse lytic delivery were used with multiple runs (23mL/min) with run time limited to <300 sec throughout the length of the right sigmoid and transverse venous sinuses and distal internal jugular vein right. The AngioJet Ultra Thrombectomy System and 6 F guide sheath were removed.

5 Transvenous thrombolytic administration 6 Fr Envoy guiding catheter in the left internal jugular vein over a inch steerable and Prowler PLUS inch two- tip microcatheter in right transverse and sigmoid sinuses was left in position for thrombolytic administration. Follow- up angiogram after 18 hours of transvenous thrombolytic (ACTIVASE) 1mg/hr infusion. There was complete recanalization of right transverse and sigmoid venous sinuses. There was no venous engorgement seen in right hemisphere. Transvenous ACTIVASE infusion was discontinued. Intravenous heparin was restarted after 6 hours (right femoral artery introducer sheath was removed followed by manual compression) FOLLOW- UP On day 2 neurological examination, patient opened eyes to gentle stimulation and followed commands on right side. On day 4 Opens eyes spontaneously and tracks visual purposeful movement right side.