After obtaining Institutional Review Board approval, we retrospectively identified patients who underwent endovascular coiling of intracranial aneurysms with balloon-assisted rapid intermittent sequential coiling from our Interventional Neuroradiology database. From June 2008 to January 2010, 11 patients (mean age 60 years, range 41-85 years, seven women) were treated with this technique. Clinical data and angiograms were collected from chart review and review of DI PACS records. Of 11 patients, six presented with subarachnoid hemorrhage (SAH) on NCCT, four had headache without SAH and one presented with third nerve palsy. Aneurysm location was as follows: basilar bifurcation (n=3), anterior communicating artery (A-comm, n=3), middle cerebral artery (MCA) bifurcation (n=2), internal carotid artery (ICA) bifurcation (n=1), posterior communicating artery (P-comm, n=1) and vertebrobasilar junction (n=1). All aneurysms were wide-necked. Mean aneurysm sac diameter was 10.4 mm (range 7 - 19 mm). Mean aneurysm neck length was 5.9 mm (range 5 - 11 mm) (Table ).
Demographics, clinical presentation and treatment outcomes in 11 wide-necked aneurysms treated with balloon-assisted rapid intermittent sequential coiling technique.
Indications for the technique
There were a total of 13 aneurysms in 11 patients. Balloon-assisted rapid intermittent sequential coiling was used to treat 11 out of these 13 aneurysms. Two aneurysms (narrow-necked) were treated in separate sittings using a conventional unassisted technique. We avoided stent-assisted coiling in six ruptured aneurysms due to a fear of exacerbating risk of recurrent hemorrhage with the use of antiplatelets. In five unruptured aneurysms, parent artery diameter was too small for stent deployment. This technique was used for coiling these aneurysms when the first framing coil was felt to be unstable after balloon deflation and was prolapsing back into the parent vessel.
All procedures were performed in a dedicated biplane neuroangiography suite (Siemens Axiom Artis, Siemens, Erlangen, Germany) under general anesthesia and systemic heparinization.
Our procedure for BAC included unilateral femoral arterial access and placement of a 7F access sheath (Pinnacle, Terumo Medical Corporation, Somerset, NJ, uSA). A 7F guiding catheter (Guiding softip xF, Boston scientific, Natick, MA, uSA) with two sequentially attached rotating hemostatic valves (Merit Medical Systems, utah, uSA) were used, one for the balloon catheter and the other for the coiling microcatheter. All patients were treated with platinum coils with a rapid detachment system (Micrus Microcoil system, Micrus endovascular, Mountain View, CA, USA). After reviewing the diagnostic angiogram including a 3D rotational angiogram, decision to attempt BAC was made.
We typically use either Hyperform or Hyperglide balloons with the xpedion wire (MicroTherapeutics Inc.) for balloon assistance. When using traditional balloon remodeling technique, temporary inflation of the balloon across the aneurysm is performed while placing a single coil within the aneurysm sac and subsequently deflating the balloon to ensure no coil loops migrate into the parent vessel before final detachment. If the first framing coil was felt to be unstable and the coil prolapsing back into the parent vessel after balloon deflation, a decision was made to attempt balloon-assisted rapid intermittent sequential coiling. Unlike the traditional approach, in this technique, we place a predetermined number of coils (usually between three and five coils per balloon inflation cycle) during a maximum balloon inflation time of 5 minutes. This allows multiple coils to brace each other within the aneurysm and form stable scaffolding for deployment of further coils.
The balloon is then deflated to allow cerebral reperfusion and to evaluate if any coil loops are prolapsing into the parent artery. Balloon inflation is never carried out for longer than five minutes to reduce ischemic time. The procedure is performed under full heparinization (activated thromboplastin time maintained at 250-300). The technique is repeated as necessary to achieve adequate intra-aneurysmal coil packing density.
A 54-year-old woman presented with subarachnoid hemorrhage related to a ruptured bilobed vertebrobasilar artery aneurysm (Figure ). In consultation with the cerebrovascular surgeon, an endovascular approach was chosen. Based on aneurysm and parent artery anatomy, balloon-remodeling technique was planned as adjunctive procedure for coiling. Stent-assisted coiling was not used to avoid antiplatelet administration in the acute phase of subarachnoid hemorrhage. Initial attempts at coiling using balloon inflation and placement of different sizes of coils proved unstable as the coil was prolapsing repeatedly into the parent proximal basilar artery. It was decided to attempt rapid deployment and detachment of multiple coils during a single balloon inflation cycle to allow the coils to brace each other and achieve a more stable coil configuration. This technique was successful and subsequent coiling resulted in good packing density within the larger left lobule (Figure ,). We repeated this technique for the smaller right lobule (Figure ,). There was intraprocedural dissection of intradural segment of right vertebral artery, which was stented later after the acute phase of SAH subsided. At six months follow-up, catheter angiogram showed no recurrence of aneurysm and continued patency of the basilar artery as well as preserved flow to both posterior inferior cerebellar arteries (Figure ).
Figure 1 A) Catheter angiogram shows bilobed vertebrobasilar artery aneurysm. B,C) Images obtained after balloon assisted rapid intermittent sequential coiling shows good coil position within the left lobe of aneurysm sac. D,E) Similarly rapid sequential coiling (more ...)