Neurointervention.  2021 Jul;16(2):149-157. 10.5469/neuroint.2021.00192.

Long Vascular Sheaths for Transfemoral Neuroendovascular Procedures in Children

• Dmytriw AA
• Ha W
• Bickford S
• Bhatia K
• Shroff M
• Dirks P
• Muthusami P

• KMID: 2517740
• DOI: http://doi.org/10.5469/neuroint.2021.00192

Abstract

Purpose
To evaluate the safety and efficacy of long vascular sheaths for transfemoral neuroendovascular procedures in children.
Materials and Methods
A retrospective evaluation of transfemoral neuroendovascular procedures in children <18 years, using long sheaths was undertaken analyzing procedure type, fluoroscopic times, technical success, access site and systemic complications. Twenty-seven consecutive procedures were included over a two-year period. Mean age was 8.4 years (standard deviation [SD] 6.3) (range 17.0 months–16.3 years).
Results
Patients were 44% female and mean weight was 35.0 kg (SD 22.8) (range 9.8–72.2 kg). A third of the procedures were performed in ≤15 kg children. The most common procedure was for embolization (n=13, 48.1%) and the most common indication was dual microcatheter technique (52%). The most common device used was the 5 Fr Cook Shuttle sheath. Mean fluoroscopy time was 61.9 minutes (SD 43.1). Of these procedures, 93% were technically successful. Femoral vasospasm, when present, was self-limiting. Complications (3/27, 11.1%) included groin hematoma (n=1), neck vessel spasm that resolved with verapamil (n=1), and intracranial thromboembolism (n=1), with no significant difference between the ≤15 kg and >15 kg subcohorts. There were no aorto-femoro-iliac or limb-ischemic complications.
Conclusion
Long vascular sheaths without short femoral sheaths can be safely used for pediatric neuroendovascular procedures as they effectively increase inner diameter access without increasing the outer sheath diameter. This property increases the range of devices used and intracranial techniques that can be safely performed without arterial compromise, thus increasing the repertoire of the neurointerventionist.

Keyword

Angiography; Catheter; Pediatrics; Feasibility study; Radiology

Figure

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  Fig. 1. Dual microcatheter via single transfemoral long sheath. Ten-month female with retinoblastoma. (A) Initial ultrasound performed to confirm adequate size of the common femoral artery. The artery measured 4.1×3.9 mm. (B) Hemodynamic modulation performed by balloon occlusion across the ostium (arrow) of the middle meningeal artery, in order to permit antegrade ophthalmic arterial flow. (C) Common carotid injection showing dual supply to the usually located ophthalmic artery. Arrow pointing to the tip of the microcatheter in the ophthalmic arterial ostium.

• 

  Fig. 2. Triaxial support for mechanical thrombectomy in a 12-year old girl. (A) Long sheath (Neuron Max, 6 Fr, 0.088 inch inner diameter [ID]) with tip in the internal carotid artery, permits use of intermediate catheter (Sofia Distal Access Catheter, 5 Fr, 0.055 inch ID), while also permitting aspiration during thrombectomy. A complete occlusion by clot of the terminal internal carotid artery is seen, extending into the post-bifurcation middle cerebral artery (B) Angiogram following first passage of stent retriever (Trevo 4×30 mm), with complete large vessel recanalization. A second pass was subsequently performed for post-bifurcation-middle cerebral artery (MCA) clot.

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