Retrieval of a fractured embolic protection guidewire in the intracranial internal carotid artery using a self-made micro-snare: a case description

Introduction

Fracture and distal migration of an embolic protection guidewire during carotid artery stenting is rare but potentially catastrophic because retained intravascular foreign bodies may cause thromboembolism, vessel injury, and the need for urgent conversion to surgery. Endovascular retrieval is typically performed using dedicated endovascular snare devices or other retrieval devices, which have demonstrated high technical success in intravascular foreign body removal (1-3). However, retrieval becomes technically challenging when the fragment is located in the petrous-cavernous internal carotid artery (ICA) due to the long access route, limited working space, and the potential risk of vessel perforation, dissection, or intracranial hemorrhage with aggressive manipulation.

Here we describe a bailout technique to retrieve a fractured embolic protection guidewire fragment that migrated to the C4 segment of the ICA during carotid artery stenting, using a self-made, adjustable micro-snare constructed from commonly available neurointerventional components.

Case presentation

A 79-year-old woman presented with a 3-month history of dizziness and right-sided limb weakness. Computed tomography angiography demonstrated severe stenosis of the left ICA. Diagnostic cerebral angiography via femoral access confirmed >90% stenosis at the ostium of the left ICA (Figure 1A), and carotid angioplasty with stenting was planned. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying image. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Retrieval of a fractured embolic protection guidewire fragment in the intracranial ICA using a self-made micro-snare. (A) Angiography demonstrating severe ostial ICA stenosis. (B) Distal migration of the fragment to the C4 segment (arrow) after an unsuccessful attempt at guidewire twisting. (C) Construction of the self-made micro-snare by creating a small side hole (arrows) in a microcatheter and externalizing a microguidewire to form an adjustable loop. (D) Capture of the distal end of the fragment by tightening the loop. (E) En bloc retrieval of the fragment into the guiding catheter. (F) Final angiography after carotid angioplasty and stent implantation. This image is published with the patient’s consent. ICA, internal carotid artery.

An 8-French introducer sheath and 8-French guiding catheter were positioned in the left common carotid artery. A distal embolic protection system (Emboshield NAV6; Abbott Vascular, Santa Clara, CA, USA) was selected. The protection guidewire (BareWire; Abbott) crossed the stenosis and was advanced to the C2 segment. When the protection system was advanced across the tight ostial lesion, marked resistance was encountered and the distal portion of the guidewire was noted to be fractured at the C2 segment. The most plausible mechanism of fracture was severe resistance at the tight ostial lesion, combined with repeated rotation and forward pressure on the protection guidewire during lesion crossing.

A microguidewire (Synchro; Stryker Neurovascular, Fremont, CA, USA) was advanced across the lesion, followed by balloon predilation using a 2.5×20-mm balloon. An intracranial support catheter (Navien; Medtronic, Irvine, CA, USA) was advanced to the C2 segment. Because a suitably sized dedicated micro-snare was not available at Peking University First Hospital at that time, and we wished to avoid rescue stent implantation across otherwise healthy vascular segments, a guidewire twisting technique was attempted first. This technique involves advancing a second microguidewire alongside the retained fragment and gently rotating it to entangle the fragment for withdrawal. However, the attempt was unsuccessful and the fragment migrated distally to the C4 segment (Figure 1B) (4,5). Given the concern that a dedicated micro-snare might not be immediately available or readily deliverable through the long access route, we proceeded with a self-made micro-snare technique.

Self-made micro-snare construction and retrieval steps

• Side-hole creation: a microcatheter (Rebar; Medtronic) was prepared. Using a sterile needle, a small side hole was created near the distal portion of the microcatheter (Figure 1C).
• Loop formation: the microguidewire was advanced through the microcatheter and externalized through the side hole to form an adjustable loop at the catheter tip. Synchro guidewire first exited from the proximal lateral port, then loops back and sequentially passed through from the catheter tip to the distal lateral port. Synchro guidewire then knotted around itself outside the catheter. The loop diameter was kept as small as feasible to match the vessel lumen (Figure 1C).
• Capture: under roadmap guidance, the loop was advanced beyond the distal end of the fractured guidewire fragment. The loop was tightened by gently pulling the externalized wire limb to capture the distal end of the fragment (Figure 1D).
• En bloc retrieval: the microcatheter, loop, and captured fragment were withdrawn together as a unit into the guiding catheter under continuous fluoroscopy (Figure 1E).

The fractured guidewire was successfully retrieved without angiographic evidence of dissection, vasospasm, or distal embolization. Carotid balloon angioplasty and stent implantation were then completed (Figure 1F). The patient had no new neurological deficits peri-procedurally.

Discussion

Dedicated snares remain the mainstay for endovascular retrieval of intravascular foreign bodies and are widely used with favorable technical success and low complication rates (1-3). Low-profile and microcatheter-compatible retrieval devices have also been described for smaller vessels and more distal targets (1). In neurointerventional settings, snare loops have been used to retrieve migrated stents or devices within the ICA, supporting feasibility in intracranial circulation when performed cautiously (6).

In the present case, two key challenges were present: (I) the fragment migrated distally into the petrous-cavernous ICA (C4 segment), limiting working space; and (II) device availability/deliverability concerns along a long access route. The self-made micro-snare provided an immediately available alternative using materials already on the table, similar in principle to loop snare retrievers. Compared with strategies such as stent jailing/coverage—which may be considered in selected coronary or peripheral scenarios but adds implant burden and may not be desirable intracranially—retrieval removes the nidus for thromboembolism and avoids leaving foreign material behind (7).

Regarding reproducibility, the present construct was created using a Rebar microcatheter and a Synchro microguidewire, but the general principle may be adaptable to other commonly used intracranial microcatheters and soft-tipped microguidewires with similar profiles. Microcatheters with different inner diameters, shaft stiffness, or material properties may influence loop formation, deliverability, and resistance to deformation, and therefore should be selected cautiously. The Synchro guidewire was chosen because its relatively long soft distal segment was considered advantageous for intracranial navigation and vessel safety. Other microguidewires may also be feasible in selected situations, but this was not systematically evaluated in the present case.

Potential catheter weakening related to side-hole creation must be anticipated, particularly in tortuous anatomy. Creating a side hole may weaken the microcatheter wall and create a focal stress point; therefore, the hole should be kept as small as possible and positioned away from the most angulated segment. In this case, a Rebar microcatheter was selected because it is commonly used in intracranial interventions and was considered to provide an acceptable balance between navigability and support. Although the stability of the self-made snare was assessed during the procedure in vivo, formal bench testing was not performed. The loop should be minimized to reduce contact with the vessel wall, and traction should be gentle and coaxial. Operators should stop and reassess if significant resistance is encountered rather than applying force. Additionally, the technique should be reserved for situations in which the fragment can be safely engaged and the operator has sufficient neuroendovascular experience.

Limitations: this is a single-case description and does not establish comparative safety versus dedicated micro-snares. Future work could include standardized low-profile snares designed for long access routes with validated tensile strength and deliverability.

Conclusions

A self-made, adjustable micro-snare constructed from a microcatheter and microguidewire may serve as a low-cost bailout option to retrieve a fractured embolic protection guidewire fragment in the petrous-cavernous ICA when dedicated micro-snares are unavailable or cannot be delivered. Meticulous technique and strict risk control are essential to minimize vessel injury.

Acknowledgments

None.

Footnote

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1-2824/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying image. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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