Abstract 457: Utilizing the Comaneci Device for Dural Venous Sinus Thrombectomy

Purpose: The treatment of dural venous sinus (DVS) thrombosis is anticoagulation. In select patients, thrombectomy or thrombolysis can be considered based on clinical status. The following case demonstrates the potential benefits of an off‐label application of the Comaneci device for DVS thrombectomy. Case: A 47‐year‐old female patient presented with right‐sided weakness, nausea, and vomiting. Imaging revealed thrombosis of the superior sagittal sinus (SSS) extending to the torcula, right transverse sinus (TS), and right sigmoid sinus (SS) with a hemorrhagic venous infarct in the left parietal lobe. The patient was started on anticoagulation. However, her symptoms worsened with repeat imaging showing a new left frontal lobe hemorrhagic infarct. The decision was made to proceed with mechanical thrombectomy. Arterial and venous access was obtained in the right groin. Angiography showed venous sinus thrombosis of most of the SSS and torcula with focal occlusion of the right TS. A Zoom 71TM catheter was advanced into the anterior SSS. Pharmacomechanical thrombolysis was performed using a Scepter balloon that was intermittently inflated along the SSS while 5 mg tPA was infused. This yielded minimal improvement. Therefore a combination of mechanical thrombectomy using a Comaneci 21 device and aspiration thrombectomy using a Zoom 88TM catheter was performed in the SSS torcula, and right TS. The rapid inflation‐deflation (RID) technique of fast cycling the expansion and closure of the Comaneci over a period of time allowed for dislodgment of hard thrombus while concurrent aspiration of dislodged thrombus into the Zoom 71 intermediate and Zoom 88 guide catheters was employed. Post‐treatment angiogram confirmed resolution of occlusive thrombus with improved rate of angiographic arterial to capillary phase transgression. Only small volume non‐occlusive thrombus in the SSS, right TS, and right SS remained. Result: The patient was continued on therapeutic systemic anticoagulation post‐procedure. Follow‐up imaging showed stable left parietal and frontal lobe infarcts with stable hemorrhage and near‐complete resolution of prior DVS thrombus. She was discharged on hospital day 6. Conclusion Multiple endovascular techniques for DVS thrombosis have been described, which include aspiration, angioplasty, and lysis. To our knowledge, this is the first reported use of the Comaneci device for the treatment of DVS thrombosis. Following suboptimal results from balloon‐assisted thrombolysis, we used the Comaneci device and RID technique to actively macerate hard thrombus and allow for more effective aspiration. The Comaneci device is typically utilized with cerebral aneurysm coiling interventions or treatment of intracranial arterial vasospasm. Our case demonstrates a novel approach of rapid inflation‐deflation utilizing the Comaneci device for a successful DVS thrombectomy.