Upload
myles-west
View
225
Download
0
Embed Size (px)
DESCRIPTION
Simple technique? Combination with adjunctive technique? such as balloon / stent assistance Selection of the microcatheter How about the steam shaping of the catheter tip? Interventional neuroradiologists often worry about the appropriate coiling procedure
Citation preview
Which factor increases procedural thromboembolic events in patients with unruptured paraclinoid internal carotid artery aneurysm treated by coil embolization?
Morio Nagahata, Rei Kondo*, Shinjiro Saito*, Atsuhito Takemura**, Toru Hatayama**
Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, Japan
* Department of Neurosurgery, Yamagata City Hospital SAISEIKAN, Japan**Department of Neurosurgery, Aomori City Hospital, Japan
Introduction
paraclinoid internal carotid artery aneurysm
Coil embolization is not always easy due to its anatomical location
or shape of the aneurysm.
• Simple technique?• Combination with adjunctive technique?
such as balloon / stent assistance• Selection of the microcatheter• How about the steam shaping of the catheter tip?
Interventional neuroradiologists often worry about the appropriate coiling procedure
Does the maneuver of
– exchanging microcatheter / coils
– combined adjunctive technique (assist balloon) lead to more frequent ischemic complication?
60F, unruptured left ICA aneurysm diameter: 6mm
coiling with balloon assistance
silent infarction
Purpose
To analyze the factors
which increase the frequency of thromboembolic events
during the coil embolization of the unruptured
paraclinoid internal carotid artery aneurysms.
Materials and Methods• December 2007 – April 2010• 14 consecutive patients with unruptured paraclinoid
internal carotid aneurysms– Treated with GDCs.– 1 male, 13 females– Aged 40-71, mean 58.6 y.o.– Max. diameter of aneurysm: 3.4-8.5, mean 5.5mm– Simple coiling in 7 patients– Balloon assisted technique in 7 patients
All patients
• Received dual antiplatelet agents preoperatively.
• Systemic heparinization during the procedure.
• Posttreatment DWI was performed within 4 days.
• A neuroradiologist and a neurosurgeon evaluated the DWI.
Analysis
Existence of the hyperintense lesion on postoperative DWI (within 4 days).
– Patients’ age, sex.– Maximum diameter of the aneurismal dome.– Coil packing density.– Use of assistant balloon.– Exchange of microcatheter.– Withdrawal of undetached coil.
Results• Neurologically symptomatic complications did not
occur in our series. • Silent procedure-related infarction was detected on
postoperative DWI in 6 cases (35.7%).
49 F, left ICA aneurysmaneurysm diameter: 4.0mmballoon assistance (+)
exchange of microcatheter (+)withdrawal of undetached coil (+)
packing density: 29.5%
silent infarcts (++)
n.s. n.s. n.s. n.s.
Sex M/F
Age (mean)
y.o.
max. diameter of aneurysm
(mean)mm
Coil packing density (VER)
(mean)%
ischemiccomplication
+
0 / 6 49-68(58.8)
3.4-6.0(4.72)
18.9-32.0(26.3)
ischemiccomplication
-
1 / 7 40-71(65.5)
4.1-8.5(6.10)
15.6-47.8(29.7)
withballoon
assistance
withoutballoon
assistance
ischemiccomplication
+3 3
ischemiccomplication
-4 4
Assist balloon (HyperGlide)
n.s.
Exchange of microcatheter
+
Exchange of microcatheter
-ischemic
complication
+3 3
ischemiccomplication
-1 7
Exchange of microcatheter during the procedure
n.s.
Withdrawalof coil
+
Withdrawalof coil
-ischemic
complication
+6 0
ischemiccomplication
-3 5
Withdrawal of undetached coilduring the procedure
P=0.031
• Silent infarcts found in 35.7% of our cases – 66.7% cases in which we needed to withdraw the
undetached coil during the procedure – versus 0% in patients without intraprocedural coil
withdrawal. (P=0.03)
• Patient’s age, sex• Aneurysm diameter• Packing density• Balloon-assisted technique• Exchanging maneuver of microcatheter
did not increase the frequency of silent infarcts.
Discussion
Previous reports (cerebral aneurysms treated by coils)– Symptomatic thromboembolic complication: 1-31%– Silent infarcts observed on postoperative DWI: 20-61%– Perioperative antiplatelet management reduce the risk
Our complication rate (IC paraclinoid aneurysm): 35.7%– Asymptomatic infarcts observed on DWI– Using dual antiplatelet agents.– May be acceptable rate!
Thromboembolic complication can occur more frequently – large or wide-neck aneurysms,– balloon-assisted technique
Soeda M, et al. AJNR 24: 127-132, 2003
Risky maneuvers during the balloon-assisted coiling– microcatheter repositioning, – coil removal and repositioning
Albayram S, et al. AJNR 25: 1768-1777, 2004
In the present study,
• Withdrawal of the unreleased coil the only factor increasing the rate of silent
infarcts.
• Aneurismal size, • Use of the assist balloon,
• Exchange of microcatheter during the procedure did not increase the frequency of silent infarcts.
• It has not been known which maneuver during the procedure may be responsible for most thromboembolic events.
• We should make an appropriate selection of the coil to avoid the coil withdrawal which may lead to thromboembolic complication.
Conclusion
Coil embolization of unruptured IC paraclinoid aneurysms
• Only the withdrawal of undetached coil from the aneurysm increased the frequency of the postoperative DWI abnormalities in our series.
• Appropriate coil selection, which may reduce the necessity of coil withdrawal, is important to perform safer embolization.