of Aneurysm Coiling



Fig. 1
Left femoral pseudoaneurysm









    Catheterization of Cerebral Vessels



    Dissection






    • Arterial dissection can occur during catheterization of the cerebral vessels with the guiding catheter.


    • Patients with atherosclerotic plaques are prone to this.


    • Patients with tortuous vessels where distal access is needed are also at a higher risk.


    • To reduce the risk, a soft-tip guiding catheter should be used.


    • For distal access (e.g., to position the tip of the guiding catheter in the petrous segment of the internal carotid artery (ICA)):



      • The guide catheter can be pushed over the microcatheter/guidewire combination rather than over a Terumo wire.


      • Another technique is to push the guide catheter over a softer (125 cm) vertebral or SIM catheter or catheters such as the Chaperon.


    Management






    • Small dissection does not usually require any further management.


    • If dissection is large enough to cause distal flow compromise, the dissected segment can be crossed with a microcatheter/guidewire combination.


    • Stenting the affected segment should then be considered.


    • Precaution with anticoagulants has to be considered if the patient subsequently needs treatment of ruptured aneurysm (Fig. 2a–d).

      A212264_1_En_8_Fig2_HTML.jpg


      Fig. 2
      (a) Left ICA injection demonstrates small dissections which occurred during microcatheterization in patient with Ehlers-Danlos connective tissue disorder. (b) Guide catheter placed in the petrous segment of ICA in order to get stability for balloon-assisted coiling of ACOM aneurysm. (c) Angiogram post-coiling shows dissection caused by guide catheter. (d) Angiogram in same patient shows post-stenting


    Thromboembolic Complications






    • These types of complications can occur while positioning the guide catheter or performing precoiling cerebral angiogram.


    • Thrombus can build up within the guide catheter if adequate heparinized saline flush is not maintained. Always check the pressure and flow in the heparinized saline infusion bags to maintain a steady flow.


    • Embolic thrombus can be a problem when passing guide catheters past atherosclerotic lesions at the ICA origin. In this scenario:

      (a)

      Place a self-expanding or balloon expandable stent at the stenosis.

       

      (b)

      Position the guide catheter in the common carotid artery (CCA), preferably with additional support with a long sheath (i.e., Destination or Arrow long sheath).

       


    • Treat the thrombus with IV aspirin and full-dose heparin once the aneurysm is secure. Occasionally, mechanical thrombectomy may be required in large clots.


    • Small embolic thrombus can cause distal vessel occlusion during angiogram. This is extremely rare if proper technique and care is used during catheter angiogram (Fig. 3a, b).

      A212264_1_En_8_Fig3_HTML.jpg


      Fig. 3
      (a) Demonstrates parietal hypoperfusion during precoiling angiogram. (b) Small embolus in M2 branch during placement of guide catheter and angiogram


    Iatrogenic Vasospasm






    • Induced mainly while catheterizing the intracranial vessels using guide catheter. To reduce the risk:



      • Use soft-tip guide catheters like the Neuron with Terumo wire if vasospasm is expected.


      • If distal access with the guide catheter is required, advance the catheter over microcatheter/guidewire combination rather than Terumo wire (Fig. 4a–c).

        A212264_1_En_8_Fig4_HTML.jpg


        Fig. 4
        (a) Demonstrates extreme vasospasm caused while trying to achieve distal guide catheter access in tortuous vessel. (b) Severe vasospasm of ICA post-catheterization with a guide catheter (different case). (c) Increasing the dose of nimodipine and 30 min wait restored normal vessel architecture, and the aneurysm was coiled


    Aneurysm Coiling






    • Most feared complications are intraprocedural iatrogenic aneurysm rupture and thromboembolic complications.


    • Studies report 2–5 % intraprocedural rupture rate while coiling aneurysms post subarachnoid hemorrhage.


    • Large series have reported procedural thromboembolic complications leading to mortality or morbidity of around 6 % in ruptured aneurysm and 1–3 % in treatment of unruptured aneurysm.


    • Incidence of silent thromboembolic events is higher and is in the region of 15–30 %.


    • Can be detected while performing diffusion-weighted magnetic resonance imaging (MRI).

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    Mar 20, 2016 | Posted by in INTERVENTIONAL RADIOLOGY | Comments Off on of Aneurysm Coiling

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