Elsevier

Surgical Neurology

Volume 66, Issue 6, December 2006, Pages 593-601
Surgical Neurology

Aneurysm
Balloon assistance as a routine adjunct to the endovascular treatment of cerebral aneurysms

https://doi.org/10.1016/j.surneu.2006.03.050Get rights and content

Abstract

Background

The technique of BAC is attractive because the balloon theoretically allows for (1) “control” of blood flow in the vessel; (2) improved stability of the microcatheter in the aneurysm; (3) denser packing with coils; and (4) improved delineation of the neck of the aneurysm. The purpose of this communication is to document our outcomes with this technique and help determine if this technique is of benefit.

Methods

Data on all endovascularily treated aneurysms have been gathered prospectively at our institution since March 2000. The first case of BAC was in November 2000. We have become very liberal in our indications, to the point where all aneurysms are considered for BAC. We document here our results obtained over a 1-year period, during which we treated 56 patients with 60 aneurysms in 58 coiling sessions using only bare platinum coils.

Results

Balloon-assisted coiling was attempted in 50 (86%) of the 58 coiling sessions. Successful embolizations were achieved in all but 1 patient in whom BAC was attempted. There was one technique-related complication. The packing density for the BAC cases was, on average, 35.7% (median, 34.6%; SD, 14.1%). Follow-up angiography revealed a 13% class 3 recurrence rate.

Conclusion

With experience, BAC can be used in the endovascular treatment of most cerebral aneurysms. Although complications are associated with its use, we feel that the risk/benefit ratio is favorable. Excellent coil packing density with bare coils is achievable with this technique.

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

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