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Minimally Invasive Therapy & Allied Technologies

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Microballoon-related interventions in variousendovascular treatments of body trunk lesions

Tomohiro Matsumoto, Kosuke Tomita, Satoshi Suda, Kazunobu Hashida,Shunto Maegawa, Toshihiko Hayashi, Takuji Yamagami, Tetsuya Suzuki &Terumitsu Hasebe

To cite this article: Tomohiro Matsumoto, Kosuke Tomita, Satoshi Suda, Kazunobu Hashida,Shunto Maegawa, Toshihiko Hayashi, Takuji Yamagami, Tetsuya Suzuki & TerumitsuHasebe (2018) Microballoon-related interventions in various endovascular treatments ofbody trunk lesions, Minimally Invasive Therapy & Allied Technologies, 27:1, 2-10, DOI:10.1080/13645706.2017.1398174

To link to this article: https://doi.org/10.1080/13645706.2017.1398174

Published online: 07 Nov 2017.

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REVIEW ARTICLE

Microballoon-related interventions in various endovascular treatments ofbody trunk lesions

Tomohiro Matsumotoa,b�, Kosuke Tomitaa, Satoshi Sudaa, Kazunobu Hashidaa, Shunto Maegawaa,b,Toshihiko Hayashia, Takuji Yamagamia,c, Tetsuya Suzukib and Terumitsu Hasebea,b�aDepartment of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine, Tokyo, Japan; bCenter for Scienceof Environment, Resources and Energy, Graduate School of Science and Technology, Keio University, Kanagawa, Japan; cDepartmentof Radiology, Kochi University, Kochi Medical School, Kochi, Japan

ABSTRACTOcclusion balloon catheters of 5.2- or 6-French have been used for a few decades in variousendovascular treatments of body trunk vascular lesions. However, these catheters may be diffi-cult to place in cases of excessive vessel tortuosity, small vessels, and anatomic complexity.Recently, the introduction of the double lumen microballoon catheters for body trunk vascularlesions has allowed operators to advance them into more distal, smaller, and more tortuous ves-sels. Since the launch of the first generation microballoon catheters onto the market in Japan in2011, the microballoon catheters have evolved and are now generally available for clinical use.The purpose of this article is to review the evolution and current clinical applications of themicroballoon catheters in the field of interventional radiology.

ARTICLE HISTORYReceived 23 June 2017Accepted 15 September 2017

KEYWORDSMicroballoon catheter; flowcontrol; occlusionmicroballoon; interventionalradiology

Introduction

Occlusion balloon catheters of 5.2-French (Fr) with a9-mm diameter or of 6-Fr with a 20-mm diameterhave been used for a few decades in various types ofendovascular treatment of body trunk vascular lesions.In balloon-occluded retrograde transvenous obliter-ation (B-RTO) for gastric varices, it has been normalpractice to advance the balloon catheter through an 8-Fr sheath introducer into the gastrorenal shunt in aretrograde fashion [1]; likewise in transcatheter coilembolization for pulmonary arteriovenous malforma-tions (PAVMs), especially high-flow type PAVMs[2,3], and n-butyl cyanoacrylate (NBCA) embolizationin relation to the intrahepatic arterioportal shunt [4].Balloon catheters have been used for flow control inembolization and for preventing procedure-relatedcomplications such as systemic migration of embolicmaterials. However, these balloon catheters may bedifficult to place in cases of excessive vessel tortuosity,small vessels, or anatomic complexity. Recently, theintroduction of double lumen microballoon cathetersfor treatment of body trunk vascular lesions hasallowed operators to advance them into more distal,smaller, and tortuous vessels following the launch of

the first generation of microballoon catheters(Attendant LP and Attendant 8mm; Terumo, Tokyo,Japan) onto the market in Japan in 2011. Since then,the microballoon catheters have evolved and they arenow generally available for various clinical uses. It isvery important for the operator to become familiarwith the features of microballoon catheters and tounderstand their clinical applications. The purpose ofthis article is to review the evolution and current clin-ical applications of microballoon catheters in the fieldof interventional radiology.

Double lumen microballoon catheters

First generation microballoon catheters (Table 1)

The first generation of microballoon catheters(Attendant LP and Attendant 8mm; Terumo, Tokyo,Japan) was launched onto the market in Japan in2011. The measured shaft diameters of Attendant LPand Attendant 8mm are 3.0-Fr at the proximal partof the microballoon and 2.2-Fr at the catheter tip.The diameter of the guidewire lumen is 0.017 inch. Acompliant microballoon made of polyurethane resin is14mm in length and 4.5mm in inflation diameter

CONTACT Terumitsu Hasebe hasebe@tokai-u.jp Department of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine,1838 Ishikawa-machi, Hachioji, Tokyo 192-0032, Japan�Both authors contributed equally to this work.� 2017 Society of Medical Innovation and Technology

MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES, 2018VOL. 27, NO. 1, 2–10https://doi.org/10.1080/13645706.2017.1398174

with an injection volume of 0.2ml of 150-mgI con-trast agent (recommended limit volume) in AttendantLP, and is 8mm in length and 8mm in inflationdiameter with an injection volume of 0.3ml of 150-mgI contrast agent (recommended limit volume) inAttendant 8mm. These microballoon catheters arecompatible with a 5-Fr guiding catheter and have apurge hole at the tip. With the tip of the balloon cath-eter submerged in saline, all the air can be allowed toescape from the purge hole by adopting a slow injec-tion technique.

Second generation microballoon catheters(Table 1)

Second generation microballoon catheters, launchedin 2013, were developed to improve on the first gen-eration microballoon catheter shaft to make it moreflexible and thinner. There are two types of second

generation microballoon catheters: Attendant Delta(Terumo, Tokyo, Japan) and Logos (Piolax,Yokohama, Japan) [5]. The diameter of the AttendantDelta is “2.7-Fr”; however, this is not the diameter ofthe actual microballoon catheter tip but the diameterof the more proximal part of the microballoon. Themeasured shaft diameter of Attendant Delta is taperedfrom 1.98-Fr at the distal part of the microballoon to1.8-Fr at the catheter tip, and a radiopaque marker islocated just proximal to the catheter tip. The diameterof the guidewire lumen is 0.017 inch. The compliantmicroballoon made of polyurethane resin is 5.5mm inlength and 4mm in inflation diameter with an injec-tion volume of 0.1ml of 150-mgI contrast agent (rec-ommended limit volume). Logos has a non-tapered1.8-Fr catheter tip at the distal part of the microbal-loon. The diameter of the guidewire lumen is0.018 inch. A compliant microballoon made of polyur-ethane resin is 12mm in length and 3–5mm in

Table 1. Microballoon catheters.Generation Microballoon catheters Microballoon segment Key characteristics

First Attendant 8mm(Terumo, Tokyo, Japan)

5-Fr guiding catheter compatiblePurge hole at the tip

Attendant LP(Terumo, Tokyo, Japan)

5-Fr guiding catheter compatiblePurge hole at the tip

Second Attendant delta(Terumo, Tokyo, Japan)

1.8-Fr tip microballoon catheter4-Fr angiographic catheter compatible

Logos(Piolax, Yokohama, Japan)

1.8-Fr tip microballoon catheter4-Fr angiographic catheter compatible

Third Attendant Nexus/Occlusafe(Terumo, Tokyo, Japan/TerumoEurope N.V., Leuven, Belgium)

1.8-Fr tip microballoon short tip cath-eter

4-Fr angiographic catheter compatible

Logos ST(Piolax, Yokohama, Japan)

1.8-Fr tip microballoon short tip cath-eter

4-Fr angiographic catheter compatible

Fr: French.

MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 3

inflation diameter range, with a volume of <0.21mlof 150-mgI contrast agent (recommended limit vol-ume). The distal side of each catheter surface is coatedwith hydrophilic polymer. In addition, of particularnote is the fact that both types of microballoon cathe-ters are compatible with the diagnostic 4-Fr catheter.These comprise double lumen microballoon catheters;therefore, the proximal side consists of two ports: oneis the microguidewire lumen and the other is themicroballoon lumen.

Third generation microballoon catheters(Table 1)

Third generation microballoon catheters include twotypes: Attendant Nexus (in Japan)/Occlusafe (inEurope) (Terumo, Tokyo, Japan/Terumo Europe N.V.,Leuven, Belgium), and Logos ST (Piolax, Yokohama,Japan) [6]. Attendant Nexus has the same characteris-tics as Attendant Delta except for microballoonlength, which is 10mm, and microballoon location,which is 3.5mm from the microballoon catheter tip.Logos ST has the same characteristics as Logos exceptfor microballoon location, which is 3mm from themicroballoon catheter tip.

As stated above, since the appearance of first gen-eration microballoon catheters in the market, micro-balloon catheters have evolved and are now availablefor various clinical uses.

Clinical applications of microballoon catheters

Balloon-occluded transarterial chemoembolization(B-TACE)

Transarterial chemoembolization (TACE) for hepato-cellular carcinoma (HCC) has been performed formore than 30 years [7]. Now, TACE is the most fre-quently used treatment for unresectable HCC, withproven improvement in survival in selected patients[8,9]. Conventional TACE (C-TACE) performed usingLipiodol (LPD) (Andre Guerbet, Aulnaysous-Bois,France) emulsion mixed with anticancer drugs fol-lowed by porous gelatin sponge particles, has been inmainstream use in Japan. Dense LPD accumulationafter C-TACE is one of the significant prognostic fac-tors affecting local recurrence [10,11]. Recently, Irieet al. noted that balloon-occluded TACE (B-TACE)using a first generation microballoon catheter(Attendant LP) induced dense LPD accumulation inHCC nodules in most treatments in which balloon-occluded arterial stump pressure (BOASP) was64mmHg or less [12]. B-TACE has rapidly become

popular in Japan over the past few years since theemergence of reports that B-TACE has the potentialto improve cancer nodule control locally, comparedwith C-TACE [13,14], and second and third gener-ation microballoon catheters have come to the fore.In B-TACE, a new platinum-based anticancer agent,miriplatin hydrate (MPT) (Dainippon SumitomoPharma Co., Ltd., Osaka, Japan), which is easily sus-pended in Lipiodol, has been widely used as an anti-cancer drug [5,13–18]. MPT-LPD suspensiondeposited within HCC nodules will gradually releaseactive platinum compounds into tumor tissues,thereby exerting prolonged antitumor effects; how-ever, it is minimally transferred into the systemiccirculation.

The B-TACE procedure was performed as follows:The microballoon was inflated to a diameter 5–10%larger than that of the occluded artery on DSA asdescribed Irie et al. [12] (Figures 1(B,C)). LPD sus-pension infusion was continued under balloon occlu-sion until the HCC nodule was filled with LPDsuspension or the portal venous branches were begin-ning to be filled with LPD suspension (Figures1(A–D)). 1-mm gelatin sponge particles (NipponKayaku, Tokyo, Japan) were injected to obstruct thetumor-feeding branch under microballoon inflation[5]. As described, the double lumen microballooncatheters are always needed for B-TACE because LPDsuspension and gelatin sponge particles must beinjected into the guidewire lumen.

There may be some limitations to B-TACE. As aspecific complication of B-TACE, aneurysmal dilata-tion (6.5%) due to overinflation of the microballooncatheter was confirmed in our previous study [5]. Weprofited from a helpful learning curve developed fromthe use of the microballoon catheter and found thatcareful inflation of the microballoon to a suitable sizeto occlude the target vessel under fluoroscopy guid-ance was important to avoid aneurysmal dilatationdue to overinflation of the microballoon. There maybe limitations to B-TACE. As treatment outcome ofB-TACE, Matsumoto et al. reported that B-TACE atthe lobar hepatic artery should be avoided for per-forming effective B-TACE and B-TACE at A1, 4, 8and anterior segmental hepatic arteries may becomeless effective than at the other segmental or subseg-mental hepatic arteries [6]. The results may explainthat blood inflow through the communicating arteryin the hilum, which is an anastomosis between theright and left hepatic arteries and originates mainlyfrom A4 on the left side and from the anterior seg-mental hepatic artery or the right hepatic artery on

4 T. MATSUMOTO ET AL.

the right side [19], blocks decrease of the BOASP.Kawamura et al. reported the predictive factors werepresence of portal vein visualization during B-TACE,tumor on the subcapsular portion and subsegmentalartery embolization [17].

However, there has not been enough high qualityevidence forthcoming to confirm the efficacy ofB-TACE. Therefore, further prospective studies areneeded to remedy this.

Coil embolization using microballoon cathetersin parent vessels

Microballoon catheters create the benefit of flow con-trol even in tortuous vessels, resulting in tight pack-ing, which is more compact in parent vesselembolization (Figures 2(A,B)) and the avoidance ofsystemic migration of embolic materials [20,21]. Forthis clinical situation, both single and double lumen

microballoon catheters can be used. However, wemust advance another microcatheter into the targetvessel for coil embolization in using a single lumenmicroballoon catheter for flow control.

Coil embolization using the microballoon catheterhas some limitations; currently used microballooncatheters disable complete flow control in large vesselswith diameters of �8mm. Furthermore, microballooncatheters in current use are not always compatiblewith all microcoils because the diameter of the guide-wire lumen is 0.017 or 0.018 inch. Therefore, develop-ment of a microballoon catheter with a largermicroballoon or inner diameter may be desirable tocircumvent this problem.

Liquid embolization using microballoon catheters

Liquid embolic agents include absolute ethanol,n-butyl-2-cyanoacrylate (NBCA) (Histoacryl;

Figure 1. Balloon-occluded transarterial chemoembolization (B-TACE) for hepatocellular carcinoma (HCC) nodule in the anteriorsuperior subsegment of the liver. (A) The nodule at the anterior superior subsegment of the liver shows hypervascularity on thearterial late phase image of CT and wash out on the delayed phase of CT. (B) Fluoroscopic image shows Lipiodol (LPD) emulsionmixed with miriplatin is accumulated in the HCC nodule (arrows) at the beginning of the injection under microballoon occlusionof the anterior superior subsegment artery (arrowhead). (C) Fluoroscopic image shows the portal vein (arrow) markedly demon-strated in the whole embolized area at the end of the injection under microballoon occlusion of the anterior superior subsegmentartery (arrowhead). (D) Contrast medium-enhanced CT scan obtained 14 months after B-TACE shows dense LPD accumulation inthe tumor (arrow) without local recurrence.

MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 5

B. Braun, Aesculap, Tuttlingen, Germany) and non--adhesive liquid embolic agents (Onyx; Covidien,Irvine, CA, USA/Medtronic, Dublin, Ireland).

Ethanol causes tissue infarction by inducingdenaturation of proteins with resultant acute throm-bosis and subsequent fibrosis. The use of an occlusionballoon to prevent reflux in cases in which nontargetembolization is unlikely, such as in the kidney, hasbeen recommended in ethanol embolization [22,23].A microballoon catheter in current use can be select-ively advanced into the branch of a renal arterybecause the catheter shaft is more flexible and thinner.Therefore, dedicated use of a microballoon cathetermay be appropriate for ethanol embolization of renalangiomyolipoma (Figure 3(A)) to avoid reflux intothe proximal renal artery or aorta (Figures 3(B–D)).

NBCA is an effective adhesive agent used for themanagement of small-arterial disorders when micro-catheters cannot be cannulated. However, NBCAhas been associated with various problems includingproximal embolization, distal migration, fragmenta-tion, reflux, catheter adhesion, and glue particleattachment during catheter pullback. Hamaguchiet al. have developed a microballoon-occludedNBCA embolization (B-glue) technique to overcomethese problems [24]. The use of the B-glue tech-nique may allow efficient control of NBCA deliveryfor a longer injection time without reflux. On theother hand, this technique may pose a heightened

risk of microballoon catheter adhesion becausemicroballoon catheters have a larger adhesion areawith NBCA than microcatheters. This is a problemthat needs to be taken into account.

Onyx is composed of ethylene vinyl alcohol(EVHO) copolymer dissolved in dimethyl sulfoxide(DMSO) mixed with micronized tantalum powder forradio-opacity. Microballoon catheters in current usemust not be employed because they are not DMSO-compatible.

The double lumen microballoon catheters arealways needed because ethanol or NBCA must beinjected into the guidewire lumen.

Balloon-assisted technique for visceral arteryaneurysms using microballoon catheters

Moret et al. initially described the balloon-assistedtechnique for wide neck intracranial aneurysms [25].The technique consists of temporary balloon-inflationin front of the aneurysm neck during coil placement.The indication for endovascular treatment by usingthe technique has been increasingly extended to caseswith an unfavorable anatomy. According to two largemulticenter prospective series using the balloon-assisted technique in unruptured (Analysis ofTreatment by Endovascular approach of NonrupturedAneurysms [ATENA]) and ruptured (Clinical andAnatomical Results in the Treatment of Ruptured

Figure 2. Preoperative coil embolization of the common hepatic artery (CHA) under distal microballoon inflation in a man in his50 s with pancreatic adenocarcinoma at the pancreatic body. (A) Radiograph during coil embolization shows a tight widthwiseframe. The microcatheter is inserted into the CHA via the celiac artery under microballoon inflation (white arrow). Note that a thirdgeneration microballoon catheter can be inserted into the distal CHA via the pancreatico-duodenal arcades from the superior mes-enteric artery (SMA). (B) Superior mesenteric arteriography after coil embolization (arrow) shows blood flow from the SMA to theproper hepatic artery via the pancreatico-duodenal arcades (white arrowheads).

6 T. MATSUMOTO ET AL.

Intracranial Aneurysms [CLARITY]) aneurysms, theballoon-assisted technique is as safe as the standardtreatment with coils [26,27]. The technique usingmicroballoon catheters in current use can be appliedto visceral artery aneurysms. For this clinical situation,both single and double lumen microballoon catheterscan be used. In particular, the technique should beused for embolization of wide-neck renal arteryaneurysms (Figure 4(A)) because the parent arterymust be preserved due to lack of collateral flow to therenal parenchyma (Figures 4(B,C)). However, develop-ment of a double lumen microballoon catheter with alonger microballoon may be desirable for this purpose

because currently used microballoon catheters are upto 14mm in length.

B-RTO using microballoon catheters

B-RTO has been widely accepted as an effective treat-ment for gastric varices. In this method, there are twomain situations in which usage of microballoon cathe-ters is useful. One is gastric varices without the gas-trorenal shunt in which microballoon catheters maybe applicable for B-RTO through the pericardiaco-phrenic or inferior phrenic vein [28]; Attendant 8mmmay be suitable for B-RTO through the

Figure 3. Ethanol embolization under microballoon inflation for left renal angiomyolipoma (AML) in a woman in her 80 s. (A) CTimage shows the 41-mm left renal AML (white arrow). (B) Left renal angiography shows that the AML is vascularized by twobranches of the left renal artery (white arrowheads). (C) Ethanol–Lipiodol (LPD) (the ratio of ethanol to LPD was 3 to 1) for theAML embolization is injected under microballoon inflation (arrows) into each feeding branch of the renal artery by selectivelyadvancing a third generation microballoon catheter. Total volume of ethanol–LPD is 10ml (5 and 5ml into each branch, respect-ively). (D) Post embolization angiography shows complete devascularization (white arrow).

MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 7

pericardiacophrenic or left inferior phrenic vein.Another is that gastric varix with the gastrorenalshunt and communication between gastric varices andsystemic veins are also developing, whereupon thedouble balloon technique using a 5.2- or 6-Fr ballooncatheter and 3- or 1.8-Fr microballoon catheter maybe performed in B-RTO [28,29]. The double lumenmicroballoon catheters are acceptable for B-RTObecause an embolic agent such as ethanolamine oleateiopamidole can be injected into guidewire lumen.Paralleling the development of microballoon catheters,opportunities to use this device would increase in theB-RTO procedure and microballoon catheters mayproduce a higher success rate of B-RTO [30].

Conclusions

Microballoon catheters are very versatile devices thatallow interventional radiologists to treat safely andeffectively various conditions in body trunk lesionsincluding challenging vascular lesions such as thoseinvolving tortuous or small vessels. Becoming familiar

with the features of the microballoon catheters, com-bined with meticulous technique to adapt the micro-balloon catheters to various clinical applications, arekey points to ensure successful endovascular therapy.

Acknowledgements

We would like to thank Dr. Yuki Natsuyama and Dr.Takahiko Mine of the Department of Radiology, TokaiUniversity Hachioji Hospital, Tokai University School ofMedicine, for continuing support and encouragement. Wealso would like to thank Mr. Masamitsu Nakayama, Centerfor Science of Environment, Resources and Energy,Graduate School of Science and Technology, KeioUniversity, for drawing the illustrations.

Declaration of interest

The authors report no conflict of interest.

Funding

A part of this work was supported by JSPS KAKENHIGrant Numbers JP17K16487.

Figure 4. Balloon-assisted technique for renal artery aneurysm (RAA) with fibromuscular dysplasia (FMD) in a woman in her 60 s.(A) Right renal arteriography reveals 20mm right main RAA (white arrow) associated with a radiographic appearance of a “stringof beads (arrowheads),” which characterizes FMD. (B) A first generation microballoon catheter through a 5-Fr guiding catheter isplaced along the aneurysm neck to protect branch arteries during the embolization procedure (white arrow). The RAA is embol-ized with detachable coils. (C) Completion angiography shows exclusion of the aneurysm by means of coil embolization (arrow-head). Flow to the right kidney has been preserved.

8 T. MATSUMOTO ET AL.

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