AneurysmBalloon assistance as a routine adjunct to the endovascular treatment of cerebral aneurysms
Introduction
Balloon-assisted coiling has become a generally accepted part of the endovascular armamentarium [1], [3], [11], [12], [15], [16], [17], [19]. By navigating balloons up the parent vessel and then inflating them to seal the neck of the aneurysm during coil insertion, Moret first demonstrated the use of BAC, which he called the “remodeling technique,” in wide-necked aneurysms that had previously been considered unsuitable for endovascular treatment [6], [7]. It has become evident over the last several years that this technique provides other potential benefits. Foremost, it allows for control of intraprocedural aneurysmal bleeding. Other advantages include the potential for denser packing, increased control of the catheter tip, improved delineation of the neck of the aneurysm, and also the ability to dilate the vessel at the time of treatment of the aneurysm to treat or prevent vasospasm. Placement and inflation of a balloon in a branch at a bifurcation can allow for microcatheter navigation into an otherwise inaccessible other branch by forcing the microcatheter to take that direction.
A prospectively gathered neuroendovascular database has been in place since March 2000 at our center. Our first BAC procedure was performed in November 2000. Between November 2000 and June 2003, 107 patients underwent 114 coiling sessions on 117 aneurysms. Balloon-assisted coiling was attempted in 76 treatment sessions on 79 aneurysms during this interval. We became impressed with the BAC technique and evolved our technique and indications to the point where in the latter half of this interval, we were liberally using BAC for endovascular aneurysm treatments. The purpose of this communication is to document our outcomes in the consecutive series of patients from the latter half of this experience.
Section snippets
Patient population
Between July 2002 and June 2003, 56 (80%) of 70 consecutive patients who presented to the senior author with cerebral aneurysms in need of treatment were determined to harbor endovascularly appropriate aneurysms. There were 58 coiling sessions, with 60 aneurysms treated, in this cohort of 56 patients. Two patients were treated twice for anatomically separate aneurysms.
Indications
All endovascularly treated aneurysms were considered for treatment with the assistance of balloons.
Technique
We used one 7F guiding
Results
In this series, BAC was attempted in 50 (86%) of the 58 treatment sessions on 53 aneurysms. Clinical grades of the patients are listed in Table 1, and anatomic locations of the aneurysms treated are in Table 2. Successful coil embolization was achieved in all but one patient in whom BAC was attempted. We were always able to completely fill the aneurysm with coils. In 9 (17%) of the 53, there was some residual contrast filling of the aneurysm noted at the end of the procedure. The packing
Discussion
Our experience suggests that BAC can be used on most cerebral aneurysms. We have achieved excellent results with BAC in the ICA, ACA, and BA territories with excellent 6-month to 1-year follow-ups (Fig. 3, Fig. 4, Fig. 5). Moret's group has demonstrated the use of the technique in the MCA territory [1]. We do not, however, advocate endovascular treatment of cerebral aneurysms in this location because of the higher risk of branch occlusion. For ICA, VA, and BA sidewall aneurysms, we generally
Conclusions
Balloon-assisted coiling is achievable in most cerebral aneurysms. Not only do balloons allow for the coiling of wide-necked aneurysms that would otherwise require a stent but they also offer advantages in microcatheter stability and flow control. Intuitively, also, BAC allows for denser aneurysm packing than that achievable without assistance of a balloon or stent. Our 35% average coil packing density with BAC suggests this to be the case. With BAC, cerebral vasospasm can be treated at the
References (26)
- et al.
Balloon-assisted coil placement of wide-neck bifurcation aneurysms by use of a new, compliant balloon microcatheter
AJNR Am J Neuroradiol
(2003) - et al.
Aneurysm packing with Hydrocoil Embolic System versus platinum coils: initial clinical experience
AJNR Am J Neuroradiol
(2004) - et al.
Utility of balloon-assisted Guglielmi detachable coiling in the treatment of 49 cerebral aneurysms, multicenter study
AJNR Am J Neuroradiol
(2001) - et al.
Determination of filling volumes in Hydrocoil-treated aneurysms by using three-dimensional computerized tomography angiography
Neurosurg Focus
(2005) - et al.
Microstent-assisted coiling for wide-necked intracranial aneurysms
Can J Neurol Sci
(2005) - et al.
Endovascular occlusion of intracranial aneurysms with electrically detachable coils: correlation of aneurysm neck size and treatment results
AJNR Am J Neuroradiol
(1994) - et al.
Preliminary experience using the Neuroform stent for the treatment of cerebral aneurysms
Neurosurgery
(2004) - et al.
Evaluation of the stability of small ruptured aneurysms with a small neck after embolizations with Guglielmi Detachable Coils: correlation between coil packing ratio and coil compaction
Neurosurgery
(2005) - et al.
Endovascular occlusion of intracranial aneurysms with Guglielmi Detachable Coils: correlation between coil packing density and coil compaction
Acta Neurochir (Wien)
(2001) - et al.
Treatment of intracranial broad-neck aneurysms with a new self-expanding stent and coil embolizations
AJNR Am J Neuroradiol
(2004)
Balloon-assisted Guglielmi detachable coiling of wide-necked aneurysms: Part II-clinical results
Neurosurgery
Balloon-assisted coil placement in wide-necked aneurysms. Technical note
J Neurosurg
Combined stent and coil in endovascular treatment of intracranial wide-necked and fusiform aneurysms
Chin Med J (Eng)
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2015, World NeurosurgeryCitation Excerpt :This facilitates treatment twofold: it allows the operator to densely pack or control the entry of coils into the aneurysm and to remodel or change the configuration of the aneurysm during a procedure. Ross and Dhillon described the utility of BAC for dynamic control of the placement of coils (88). The authors list an average packing density of 35%, which is higher than the 30% found in studies of coiling done without balloons or stents, though the calculation of packing percentage can vary between investigators.
Single-center experience with balloon-assisted coil embolization of intracranial aneurysms: Safety, efficacy and indications
2013, Clinical Neurology and NeurosurgeryCitation Excerpt :Coil embolization with balloon assistance has been widely used in many centers here and abroad for the treatment of complex aneurysms that would otherwise be unsuitable for endovascular therapy. However, there was some concern about the potential morbidity associated with this technique especially a high risk of thromboembolic complications [3–5]. This is attributed to the use of 2 microcatheters and the hemodynamic stasis generated by flow obstruction from balloon inflation.
Tiny aneurysms treated with single coil: Morphological comparison between bare platinum coil and matrix coil
2013, Clinical Neurology and NeurosurgeryCitation Excerpt :A high packing density was usually related to an immediate high complete occlusion rate and a low late recurrence rate [7]. The use of complex-shaped coil and neck remodeling techniques, such as a balloon or a stent, increases the packing density and improves the long-term angiographic results [8–11]. However, the use of hydrogel-coated coils, which increases packing density remarkably, did not decrease the recurrence rate as much as expected [12–15].