Abstract Number ‐ 110: Case Report of Glue Embolism Complication after Lingual Artery Embolization and Rescue Thrombectomy

Abstract

Introduction 68‐year‐old right‐handed female with right tongue‐base squamous cell carcinoma status‐post wide surgical‐excision and flap reconstruction, whopresented with large volume right‐sided orolingual hemorrhage. Due to concerns of impending airway compromise and a history of difficult intubation, Interventional Neuroradiology was consulted to perform an angiogram and embolization. Methods A 6FrEnvoy was advanced into the external carotid artery and the origin of the lingual artery. Despite repeated attempts using a variety of microsystems, distal access within the lingual artery could not be achieved (Fig. 1B). N‐butyl‐2‐cyanoacrylate was prepared and injected with adequate penetration. Negative pressure was applied to the microcatheter and withdrawn. The guide catheter was aspirated and rapidly withdrawn under negative pressure. A control angiogram was being prepared when an intracranial glue cast was seen and confirmed to be a proximal M2‐occlusion. 4000U of Heparin werebolusedat this time. An Advantage Exchange wire facilitated an exchange for an 8Fr groin sheath and a Walrus catheter. The glue was crossed with a microsystem microsystem and a Solitaire‐4×40mm was deployed. A ZOOM55 was advanced to the face of the glue caste and together these were pulled into the Walrus catheter. Serial angiograms revealed stenosis, but patency. Results Initial post‐thrombectomy exam revealed mild left‐hand paresis. However, the patient’s neurologic status declined and progressed to left arm hemiparesis, facial droop, and right gaze‐preference. An angiogram was performed, which revealed re‐occlusion of the left M2 trunk. Using aTrevo‐3×32mmstentriever, the M2‐occlusion was recanalized with persistent stenosis. Serial angiograms were concerning for progressing re‐occlusion. The patient improved with residual distal left hemiparesis. Conclusions •Distal access may be extremely difficult in select cases. The proximal location of the microcatheter relative to the origin of the lingual artery and the external carotid artery off the common carotid artery, likely contributed to the embolic event. The use of progressively smaller microcatheters to facilitate distal access in turn biased the choice of embolization materials. Lastly, there was evidence of vasospasm in the lingual artery, which may have contributed to proximal polymerization and adherence to the catheters during their removal. •After successful retrieval of the glue material, there was residual stenosis of unclear etiology, possibly due to denuded endothelium, dissection, or residual glue promoting in‐situ thrombosis. The eventual clearing of thebolusedheparin may have contributed to the delayed re‐occlusion. Recanalization after re‐occlusion was only possible after thrombectomy. •The use of an intermediate catheter may mitigate the risk of glue embolization by facilitating distal access and/or by providing an additional conduit for aspirating refluxed glue. If distal access into a culprit vessel can not be achieved, coil embolization may be a safer choice. Re‐canalized glue embolisms may be prone to re‐occlusion. Continuing a heparin drip may be prudent practice to prevent re‐occlusion.