Usefulness of Coil-assisted Technique in Treating Wide-neck Intracranial Aneurysms: Neck-bridge Procedure Using the Coil Mass as a Support

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1 Journal of Neuroendovascular Therapy 2017; 11: Online December 14, 2016 DOI: /jnet.tn Usefulness of Coil-assisted Technique in Treating Wide-neck Intracranial Aneurysms: Neck-bridge Procedure Using the Coil Mass as a Support Hajime Nakamura, Takeo Nishida, Katsunori Asai, Yoshinori Kadono, and Tomoaki Murakami Objective: The coil-assisted technique (CAT) for delivering the wire or catheter to the vessel distal to large wide-neck intracranial aneurysms is described. Case Presentations: We present three cases treated with this technique. The first coil placed in the aneurysm without detaching is used as a support of the wire or catheter in its passing through the aneurysmal neck. This technique was used in order to deliver a guidewire and a balloon catheter in two cases, and to deploy neck-bridge stent in one case. Conclusion: CAT can be performed simply by changing the order of procedure without any use of additional devices. We think this technique might be useful in treating wide-neck intracranial aneurysms in order to get the distal vessel safely. Keywords intracranial aneurysms, wide-neck aneurysm, coil embolization, coil-assisted technique Introduction Even in case of wide-neck aneurysms, satisfactory embolization has become possible using balloon neck remodeling technique or stent-assisted technique. However, it is occasionally difficult to deliver the guidewire or catheter to the vessel distal to a wide-neck aneurysm located at the vessel bifurcation (e.g., basilar artery bifurcation aneurysm, middle cerebral artery bifurcation aneurysm) or on the outer side of a curved vessel (e.g., large internal carotid artery aneurysm). In such patients, the coil-assisted technique (CAT), by which the first coil is placed in the aneurysm without detaching and the catheter or guidewire is delivered to the distal vessel using the coil mass as a support, may be useful. The technique is outlined by presenting three cases that we treated. Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan Received: July 6, 2016; Accepted: October 26, 2016 Corresponding author: Hajime Nakamura. Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka , Japan hajime@nsurg.med.osaka-u.ac.jp This work is licensed under a Creative Commons Attribution-NonCommercial- NoDerivatives International License The Japanese Society for Neuroendovascular Therapy Case Presentations Case 1: Unruptured left middle cerebral artery aneurysm A 76-year-old male diagnosed with a left middle cerebral artery aneurysm visited our hospital, and coil embolization of the aneurysm was performed according to patient s request. The aneurysm, 7 mm in maximum diameter and 5 mm in neck length, was located at the left M1-M2 bifurcation (Fig. 1A). Since the aneurysm had low dome/neck ratio, we decided to use balloon-assisted technique in the treatment. The orifice was on the origin of the M2 superior trunk, so we first attempted to deliver CHIKAI-14 (Asahi Intecc, Aichi, Japan) to the vessel and place Scepter C 4 10 mm (Terumo, Tokyo, Japan) beside the aneurysmal neck. However, it was unattainable because the tip of CHIKAI-14 escaped into the aneurysm and could not be passed to distal vessel (Fig. 1B). We, therefore, placed Scepter C at the origin of the inferior trunk, to which CHIKAI-14 was easily delivered, as a precaution against aneurysm perforation, and then inserted the first coil into the aneurysm without adhering to secure the parent artery (Fig. 1C). Although a part of the coil escaped toward the parent artery as expected, CHIKAI-14 and Scepter C could be delivered to the superior trunk using the coil mass as a support (Fig. 1D). After this procedure, the coil was redeployed in the aneurysm by balloon-assisted 220

2 Usefulness of Coil-assisted Technique Fig. 1 Case 1: Left MCA aneurysm. (A) Pre-operative angiogram shows a wide-neck MCA aneurysm. (B) It is difficult to deliver guidewire through aneurysmal neck to M2 superior trunk. (C) First coil is inserted into the aneurysm. (D) Guidewire is successfully delivered to M2 superior trunk by support of the coil mass. (E) Ten coils are inserted totally. (F) Angiogram shows complete obliteration of the aneurysm. MCA: middle cerebral artery technique, and desirable framing was accomplished. Additional coils were inserted serially, and complete obliteration could be achieved without stent placement (Figs. 1D and 1E). Case 2: Unruptured anterior communicating artery aneurysm A 77-year-old male diagnosed with an anterior communicating artery aneurysm visited our hospital, and coil embolization of the aneurysm was performed according to patient s request. The aneurysm, 11 mm in maximum diameter and 7 mm in neck length, was located at the anterior communicating artery (Fig. 2A). Since the aneurysm had low dome/neck ratio, we decided to use balloonassisted technique or stent placement in the treatment. The orifice was on the origin of A2 segment of right anterior cerebral artery, so we attempted to deliver CHIKAI-14 to the vessel and place Scepter XC 4 11 mm (Terumo) beside the aneurysmal neck. However, the tip of CHIKAI- 14 escaped into aneurysm and this procedure seemed to be difficult without any support (Fig. 2B). We, therefore, placed Scepter XC on the origin of the right A1 as a precaution against aneurysm perforation, and inserted the first coil into the aneurysm without adhering to secure the parent artery. Since the depth of the aneurysm was relatively larger than its neck width, the first coil could be deployed in the aneurysm without escaping toward the parent artery (Fig. 2C). Then, we attempted to deliver CHIKAI-14 to the right A2 using the coil mass as a support; however, CHIKAI-14 fell into the coil mass and could not be passed to the distal part of right A2. Since the first coil was not escaping to parent artery, we decided to detach the first coil in this state and insert subsequent coils continuously. After inserting additional coils, delivery of CHIKAI- 14 to the right A2 became possible (Fig. 2D), and Scepter XC was placed on the proximal part of right A2 (Fig. 2E). At the final step, neck-bridge stent seemed to be essential to keep the patency of parent artery, so we deployed LVIS Jr mm (Terumo) from right A2 to right A1 and complete obliteration of the aneurysm was achieved (Fig. 2F). Case 3: Ruptured right internal carotid-posterior communicating artery aneurysm An 80-year-old female diagnosed with a ruptured large internal carotid-posterior communicating artery aneurysm (World Federation of Neurosurgical Societies [WFNS] grade 1) was transported to our hospital. The aneurysm, 13 mm in maximum diameter and 10 mm in neck length, was located at the posterior wall of right internal carotid artery, and posterior communicating artery originated near the neck (Figs. 3A and 3B). The anterior choroidal artery 221

3 Nakamura H, et al. Fig. 2 Case 2: Acom aneurysm. (A) Pre-operative angiogram shows a wide-neck Acom aneurysm. (B) It is difficult to deliver guidewire through aneurysmal neck to right A2. (C) First coil is inserted into the aneurysm. (D) Guidewire is successfully delivered to right A2 by support of the coil mass. (E) Scepter XC is inserted to distal A2 (arrow heads). (F) Angiogram after stent deployment shows complete obliteration of the aneurysm. Acom: Anterior communicating artery Fig. 3 Case 3: Right ICA aneurysm. (A) and (B) Pre-operative angiogram shows a large wide-neck ICA aneurysm (A) anterior-posterior projection, (B) right-left projection. (C) Guidewire is delivered to right middle cerebral artery, and microcatheters are positioned in aneurysm. (D) First coil is inserted into the aneurysm. (E) Coil loops in the parent artery are pushed into the aneurysm by stent (arrow head). (F) Angiogram after the procedure shows complete obliteration of the aneurysm. ICA: internal carotid artery 222

4 Usefulness of Coil-assisted Technique was likely to be adhered to the aneurysmal wall and marked calcification of internal carotid artery was detected by CT angiography, so we selected endovascular treatment rather than neck clipping. Since the length of aneurysmal neck was wide and transient neck remodeling by balloon-assisted technique seemed to be insufficient to get effective embolization, we decided to use stent-assisted technique. The guidewire and catheter could be easily delivered to the distal part of the aneurysm, and two catheters were placed in the aneurysm for embolization (Fig. 3C). Because of the width of the aneurysmal neck, we expected that the stent might escape into the aneurysm if it was deployed in the absence of coil mass. We, therefore, placed the first coil in the aneurysm without adhering to secure the parent artery, then deployed Enterprise VRD 37 mm (Johnson & Johnson, Miami, FL, USA) from middle cerebral artery to internal carotid artery (Figs. 3D and 3E). By deploying the stent, a part of the first coil displaced toward the parent artery was pushed back into the aneurysm by stent itself, and the coil mass worked well as a support to avoid displacement of the stent into the aneurysm (Fig. 3E). Thereafter, additional coils were inserted serially through the two catheters placed in the aneurysm. Eventually, sufficient embolization was achieved, and the patency of internal carotid artery and the posterior communicating artery could be preserved (Fig. 3F). Discussion Satisfactory embolization of wide-neck intracranial aneurysms has become possible using balloon-assisted technique or stent-assisted techniques. 1 3) However, it is prerequisite to deliver the catheter to the vessel distal to the aneurysm for use of these techniques. In delivering the guidewire to the vessel distal to the wide-neck intracranial aneurysms, we can easily expect that the wire tip escape into the aneurysm especially in case of M1-2 junction or basilar bifurcation aneurysms (Fig. 4A). Similarly, in case of a sidewall-type aneurysm developing toward the outside of the vascular curvature, the wire tip is also expected to escape toward the aneurysm. In treating such aneurysms, it may be needed to push the guidewire (or catheter) into the aneurysm and turn the direction along aneurysmal wall in order to deliver it to the distal vessel. With this procedure, undesirable stress may be applied to some part of the aneurysmal wall, and aneurysm perforation may occur in some cases. To solve this problem, we speculated that the coil mass build in aneurysm might prevent the wire escaping into aneurysm and help it to go into the distal vessel. We call this technique CAT for convenience in this paper. When we use this technique, the first coil should be a relatively rigid, thick, and long one with almost same size of the major axis of the aneurysm in order to get sufficient support. Additionally, the first coil should be deployed nearly its entire length to make a dense bundle of coils, possibly only in aneurysm. Regarding the guidewire, the tip should be firmly bended to J shape, not only to prevent it to move into the coil mass, but also to make it easily pass to the distal vessel (Fig. 4B). Since the coil used for CAT supposed to work as a temporary support to prevent the intrusion of the guidewire or catheter into the aneurysm, the procedure can be forwarded even if the coils have escaped toward the parent vessel (Figs. 4B and 4C). We, however, have to pay attention in patients with high risk of thrombus formation (e.g., no use of antiplatelet drugs). Once the distal vessel has been secured, the coil that has deviated into the parent artery has to be drawn back into the catheter until it seated only in the aneurysm (Fig. 4D), and the following procedure will be continued with balloon-assisted or stent-assisted technique (Fig. 4E). Even in case that the guidewire passed to the distal vessel through the coil mass, the entanglement between guidewire and coil mass is resolved by rewinding the coil until the interference disappear. When sufficient support cannot be obtained by a single coil as in Case 2, it may be reasonable to detach the first coil and insert additional coils to make the coil mass tough enough to use CAT. If the first coil escaped into the parent artery and the guidewire did not go to the distal vessel, we may have to give up CAT and attempt to get the distal vessel using a flow-guide catheter or a microcatheter with its tip bent sharply. When all these techniques did not work well, embolization itself may be abandoned to prevent procedure-related complications. Another thing we have to think of is the selection of balloon catheter. In the treatment with CAT, reshaping of the guidewire is often necessary and a double lumen-type balloon catheter is useful for this purpose. If we use a single lumen-type balloon catheter, blood flows back into the balloon lumen when we withdraw the wire from the catheter, and the balloon catheter must be re-filled with a contrast medium before re-insertion of the wire. On the other hand, with a double lumen-type balloon catheter, the wire can be withdrawn and reshaped frequently without withdrawing 223

5 Nakamura H, et al. Fig. 4 Guidewire delivery with CAT. (A) Guidewire delivery without coil mass is difficult. (B) Guidewire delivery with CAT is started. (C) Guidewire is delivered into the distal artery through the aneurysmal neck successfully. (D) Coil is pulled into microcatheter until the loops in the parent artery are removed. (E) Balloonassisted technique can be used as usual. (F) Embolization is completed. CAT: coil-assisted technique Fig. 5 Stent deployment with CAT. (A) and (B) Stent dislodgement into the aneurysm may occur in the case of a large wide-neck aneurysm. (C) and (D) Stent deployment with CAT is performed. Stent is stable and coil loops in the parent artery are pushed into the aneurysm. CAT: coil-assisted technique the catheter outside. We, therefore, think that a double lumen-type balloon catheter is more convenient than the singe lumen type from this point of view. In Case 1 of this report, we anticipated that the wire tip might be reshaped to get M2 superior trunk frequently, so double lumen-type balloon catheter was selected from the beginning. CAT is also useful when we place a neck-bridge stent in patient of large sidewall-type wide-neck aneurysm, not only for safe securing of the parent artery but also for prevention of stent displacement into the aneurysm (Fig. 5A). According to a report by Gao et al., stent dislodgement during subsequent procedures occurred in two cases (0.8%) of the 239 treatments for wide-neck intracranial aneurysms. 4) If stent dislodgement occurred in a large wideneck aneurysm located on the outer side of the vascular curvature, the stent may fall into the aneurysm (Fig. 5B). In Case 3 of this report, CAT was not necessary for securing the distal vessel, but we deployed a stent after placing the first coil without detaching in consideration of the possibility of stent dislodgement (Figs. 5C and 5D). Using this maneuver, stent was safely deployed and the coil mass was pushed back into the aneurysm by the stent. Conclusion The CAT was reported as a useful method to deliver a guidewire to the vessel distal to the aneurysmal neck. This method, which can be performed simply by changing the order of procedure without any use of additional devices, 224

6 Usefulness of Coil-assisted Technique might be worth attempting in case of large wide-neck aneurysm. Disclosure Statement The first author and coauthors have no conflicts of interest. References 1) Shapiro M, Babb J, Becske T, et al: Safety and efficacy of adjunctive balloon remodeling during endovascular treatment of intracranial aneurysms: a literature review. AJNR Am J Neuroradiol 2008; 29: ) Cekirge HS, Yavuz K, Geyik S, et al: HyperForm balloon remodeling in the endovascular treatment of anterior cerebral, middle cerebral, and anterior communicating artery aneurysms: clinical and angiographic follow-up results in 800 consecutive patients. J Neurosurg 2011; 114: ) Geyik S, Yavuz K, Yurttutan N, et al: Stent-assisted coiling in endovascular treatment of 500 consecutive cerebral aneurysms with long-term follow-up. AJNR Am J Neuroradiol 2013; 34: ) Gao X, Liang G, Li Z, et al: Complications and adverse events associated with Neuroform stent-assisted coiling of wide-neck intracranial aneurysms. Neurol Res 2011; 33:

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