Mechanical Revascularization of Cerebral Venous Sinuses in Extensive Cerebral Venous Sinus Thrombosis Using Pipeline-Pigging Technique and Intra-Sinus Tenecteplase: Technical Note and Review of Literature

Anticoagulation therapy remains the cornerstone of treatment for cerebral venous sinus thrombosis (CVST). Endovascular therapy may be considered in selected patients with clinical deterioration despite optimal medical treatment. However, conventional mechanical thrombectomy using aspiration and/or stent-retrievers might be inadequate in extensive CVST because of large and organized thrombi and non-availability of venous thrombectomy devices. We present a technical modification using an angioplasty non-compliant (NC) balloon as an adjunct to suction thrombectomy for venous sinus mechanical thrombectomy in a case of extensive CVST. Conventional methods of thrombectomy failed to recanalize the sinuses; hence, an angioplasty NC balloon was used to decimate the clot with simultaneous suction thrombectomy to achieve near-complete recanalization of the affected sinuses with good clinical outcome. We name this the "Pipeline-Pigging" technique. The Pipeline-Pigging method of using a normal angioplasty NC balloon for venous sinus mechanical thrombectomy may serve as an effective and economical technical adjunct for extensive CVST refractory to conventional methods. This approach facilitates thrombus fragmentation, aspiration and improved delivery of thrombolytics and may expand the endovascular armamentarium for extensive CVST.