ELSEVIER MICROSURGICAL REMOVAL OF A FREE SEGMENT OF MICROCATHETER IN THE ANTERIOR CIRCULATION As A COMPLICATION OF EMBOLIZATION Servet hci, M.D., Osman Ekin 6zcan, M.D., Kemal Benli, M.D., and Isi1 Saatqi, M.D. Department of Neurosurgery and Radiology, School of Medicine, University of Hacettepe, Ankara, Turkey inci S, &can OE, Benli K, Saatci I. Microsurgical removal of a free segment of microcatheter in the anterior circulation as a com- plication of embolization. Surg Neurol 1996;46:562-7. Endovascular therapy for cerebral arteriovenous malfor- mations, although generally accepted to be a safe proce- dure, is not without risks. We present a patient with a 20 cm free segment of a catheter in the anterior circulation as a complication of embolization. This is a very rare complication. To our knowledge, only six cases have been reported in the literature. We believe this to be the first reported case of this complication treated surgically via craniotomy and arteriotomy. 0 1996 by Elsevier ScienceInc. KEY WORDS Cerebral arteriovenous malformation, complication, embo- lization, microcatheter. E ndovascular therapy for cerebral arterio- venous malformations (AVMs) has, in recent years, become an increasingly powerful and widely used therapeutic method [2,7,8,21,25]. Various complications related to embolization have been reported. In this paper, we report a very rare com- plication: a 20 cm free segment of microcatheter in the left middle and anterior cerebral artery. CASEREPORT This 25-year-old right-handed man had a long his- tory of seizures. Neurologic examination was re- markable for slight, right hemiparesis. CT scan showed an enhancing lesion involving the left pari- eta1 lobe. The digital subtraction angiogram re- vealed a large arteriovenous malformation fed by branches of the left middle cerebral artery and peri- Address reprint requests to: Dr. Servet inci, Emek mah, 4. cadde, No: 70/S, Ankara, Turkey. Received August 24, 1995; accepted March 22, 1996. 0090-3019/96/$15.00 PII SOO90-3019(96)00221-2 callosal artery (Figure 1) with venous drainage to the superior and inferior sagittal sinuses and inter- nal cerebral vein. As the patient refused direct open surgery, embolization of the AVM was undertaken. Embolization was performed in two stages. In both stages, the catheterization of feeding arteries was performed via the femoral route. All coaxial systems were continuously flushed with hepa- rinized saline solution. When the microcatheter was introduced, an additional dose of heparin was ad- ministered by the intravenous route to prevent clot formation in the coaxial system (70 units/kg bolus with one-half of the dose repeated every hour). For superselective catheterizations a Magic microcath- eter (Bait, Montmorency, France) with a 3F shaft, tapered to 1.8F distally, was used. To monitor the patient’s neurologic status, he was kept awake dur- ing the procedures. The catheterizations were per- formed using road mapping and digital subtraction fluoroscopy. A superselective angiography was then taken to exclude the presence of normal ves- sels. When the position was considered optimal, the system was thoroughly flushed with dextrose and then embolization was performed with cyano- acrylate mixture. On June 7, 1994, the patient was taken to the angiography suite for the first stage of emboliza- tion. A microcatheter was twice placed in the nidus, via the left middle cerebral artery branches. N-butyl cyanoacrylate (Histoacryl- B.Braun, Melsungen AC, Germany) was mixed with iophendylate in a 1:2 ratio. Then the AVM nidus was embolized. The em- bolizing liquid, clearly visible by fluoroscopy, filled a large part of the nidus. The catheter was with- drawn without any difficulty. No complication was observed and the patient remained neurologically unchanged. 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010