Balloon-assisted Coil Embolization of Wide-necked Aneurysms of the Internal Carotid Artery: Medium-term Angiographic and Clinical Follow-up in 22 Patients
Peter Kim Nelson
,a and
David I. Levya
a From the Department of Radiology, Neurointerventional Service, New York University Medical Center, and New York-Presbyterian Hospital, Cornell University Medical Center, New York (P.K.N.); and the Department of Neurosurgery, Division of Neuroradiology, Kaiser Permanente Medical Center, San Diego, CA (D.I.L.).
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FIG 1. A and B, Frontal (A) and lateral (B) arterial phase images from digital subtraction angiography (DSA) of the left ICA show a large wide-necked aneurysm of the ophthalmic segment.
C and D, Road-mapped live subtraction images of the left ICA (lateral projection) show placement of the first coil. Note the herniation of a coil loop (arrow) through the neck of the aneurysm into the left ICA (C). In D, the balloon (thick arrow) has been inflated across the aneurysmal neck, permitting the framing coils to be deployed within the aneurysm. Arrowheads identify the indwelling 0.010-inch guidewire within the balloon microcatheter. An unextruded segment of a GDC (thin arrow) identi-fies the course of the coil-delivery microcatheter.
E and F, Frontal (E) and lateral (F) unsubtracted radiographs show deployment of a subsequent GDC. The images serve to orient the viewer with respect to the course of the ICA in relation to the aneurysmal base. The balloon (slanted arrow, E and F) has been inflated within the paraclinoid segment of the ICA, which sweeps lateral to medial across the face of the aneurysmal neck. The supraclinoid segment courses medial to the lower portion of the aneurysmal fundus and is partially obscured by the aneurysm in lateral projection. A small niche of aneurysm lying posterior to the ICA could not be angiographically thrown off the ICA by any of the views attempted. In this respect, the inflated balloon defines the boundary of the ICA lumen and assists the operator in coiling the aneurysmal base. The final segment of coil 14 (thin arrow, E) has been deployed in F. Note the alignment of the delivery wire marker with the proximal microcatheter marker (curved arrow, F). An indwelling 0.010-inch guidewire (arrowhead, E and F) identifies the course of the balloon microcatheter.
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FIG 1. Continued.
G, Mid-arterial phase image (frontal projection) from the immediate posttreatment left ICA DSA after deployment of the 18th GDC within the aneurysm. Coils are present throughout the aneurysmal base; however, minor opacification through the coil interstices is evident.
H and I, Frontal (H) and lateral (I) arterial phase images from the follow-up angiogram 18 months later confirm stable occlusion of the aneurysm.
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FIG 2. A, Arterial phase DSA image (lateral view) of the left ICA shows a small aneurysm of the superior hypophyseal segment.
B, Several attempts were made to coil the aneurysm initially. Road-mapped live subtraction image of the left ICA (lateral projection) shows extrusion of a 4-mm x 8-cm soft 0.010-inch GDC (arrow). A subsequent attempt to place a 3-mm x 8-cm coil was likewise unsuccessful.
C, Road-mapped live subtraction image of the left ICA shows deployment of a 4-mm x 8-cm soft GDC within the aneurysm during balloon inflation. The balloon (thick arrow) has been inflated across the proximal two thirds of the aneurysmal orifice, preventing coil herniation into the ICA and allowing coiling of the aneurysmal fundus. An indwelling 0.014-inch guidewire (arrowhead) and an unextruded coil segment (thin arrow) identify the balloon microcatheter and the GDC microcatheter, respectively.
D, Posttreatment image from a left common carotid DSA, 3 days later, shows occlusion of the aneurysm.
E, Mid-arterial phase image (lateral projection) from follow-up angiography of the left ICA at 22 months confirms stability of aneurysmal occlusion.
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FIG 3. A, Arterial phase image from a DSA of the left ICA (lateral projection) shows a small dural ring aneurysm with a broad neck. The aneurysm was occluded with five GDCs under balloon protection.
B, Follow-up angiogram 2 days after treatment confirms aneurysmal occlusion by GDCs.
C, A subsequent study at 8 months' follow-up shows a small recurrence (arrow) at the aneurysmal neck.
D, Repeat angiography 24 months after treatment shows negligible change in the size of the recurrence.
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