BALLOON ASSISTED COILING- ARE WE OVER DOING STENT ASSITED

COILING

Vipul GuptaInterventional Neuroradiology/Neurointerventional SurgeryInstitute of Neurosciences Medanta the Medicity

Major changes Length of balloon Double lumen 14 wire, easy to

reshape, stability, exchange

Placement of stents Distal infusion

Historical One of the major issues for coiling – broad

neck Prof J Moret – “Remodeling technique”

Interventional Neuroradiology 1997

Uses of balloon

Broad neck aneurysm Remodelling – J Moret Packing density Control of rupture Test occlusion

Remodeling- broad neck

Balloon assisted coiling

Intra-operative rupture

Test occlusion

ANATOMICAL RESULTS

IMMEDIATE TOTAL OCCLUSION

SUBTOTAL OCCLUSION

INCOMPLETE OCCLUSION

BRT 73% 22% 5%COILING ALONE

49% 39% 13%

FOLLOW UP

TOTAL OCCLUSION

SUBTOTAL OCCLUSION

INCOMPLETE OCCLUSION

BRT 72% 17% 10%COILING ALONE

54% 34% 11%

Shapiro et al AJNR 2008

BAC – complicationsM Piotin et al , Frontiers in Neurology, 2014

Remodeling technique for endovascular treatment of ruptured intracranial aneurysms had a higher rate of adequate postoperative occlusion than did conventional coil embolization with comparable safety.Pierot L Cognard C, Anxionnat R, Ricolfi F; CLARITY Investigators.

CONCLUSION –REMODELING TECH SAFE AND MORE EFFICACIOUS IN TERMS OF POSt OP OCCLUSION THAN THE CONVENTIONAL COILING TECH

Radiology. 2011 Feb;258(2):546-53.

POSTOP ANATOMICAL RESULTS

Technique Sidewall- compliant balloon, if overinflation

needed and aneurysm not large supercompliant

Bifurcation- Supercompliant Usually balloon with 014 wire Wire – usually choice, Synchro 6 F (.70) Guiding catheter , long sheath

(Raphe, Cook) Choose the right branch (even if takes time,

effort…)- more involved, lobule near neck

Usually check after first coil placement

Thereafter – multiple coils in single inflation – 5min (may be more)

Increase heparinization, BP maintenance

If unruptured- anti-platelet beforehand

Overall – 70-80% of cases (our practise- 90% ruptured, 80% small)- trend towards balloon coiling in all broad neck aneurysms

Choice of artery …

Placement angle….

A B C

STENT ASSISTED COILING TECH VS STAND ALONE COILING

ADVANTAGES – Scaffolding, haemodynamic effect, straightening of vessels

DRAWBACKS WITH SACT:

• looser aneurysm packing, lesser immmediate angiographic occlusions rate than the stand alone coiling

• DUAL ANTIPLATELET – RISK OF HEMORRHAGIC COMPLICATION

• MORE THROMBOEMBOLIC RISKS

AT FOLLOW UP COMPLETE OCCLUSION RATE WITH SACT INCREASED TO 73.4% IN SACT VS 54% IN SAC

MORBI-MORTALITY WITH STAND ALONE COILING OR BRT

MORBI-MORTALITY WITH STENT ASSISTED COILING

Nishido et al.(AJNR 2014) unruptured and ruptured aneurysms

5.6% 9.4%

Shapiro et al. (AJNR 2012) review, unruptured and ruptured aneurysms

NA 12.2%

GeyIk at al (AJNR 2013)

NA 6.4%

Stent assisted coiling .. Complication rateM Piotin et al , Frontiers in Neurology, 2014

Balloon – specific situations

Branch from aneurysm – overinflation tech.

Near the neck rupture – catheter reposition tech.

Unstable catheter coils- Single inflation

Circumferential involvement- end hole technique

Very small aneurysm – partial inflation tech

Displaced coil loop – balloon reposition

Balloon assisted MC placement

Branch from aneurysm- Overinflation technique

A B

Near the neck rupture

Multi-lobulated aneurysms-

Catheter reposition

Single inflation technique

Circumferential involvement-End hole

Follow-up

Very small aneurysm- partial inflation technique

Displaced coil loop(s)- Balloon repositioning

Stents in acute SAH• 548 aneurysms ; 35 aneurysms in 33

patients Loading dose of double antiplatelets

(Ecospirin -300 mg and Clopidogrel -450mg/Prasugrel -50mg)

• Wide Neck aneurysms - 16 ; Dissecting /blister aneurysms - 19

• Single (28) or double overlapping (5) stents with additional coil placement in 26 aneurysms. 28

2 30

5

10

15

20

25

30

mrs 0-2 mrs 3-5 mrs 6

Good outcome - 28/33 (84.9%)Management Morbidity - 2/33 (6.1%)Management Mortality - 3/33 (9.0%)

TE – 5, Rupture – 1, ICH/IVH at EVD site - 2

Review of literature

Neurosurgery. 2012 Jun;70(6):1415-29; discussion 1429. doi: 10.1227/NEU.0b013e318246a4b1.Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: experience in 65 patients.Neurosurgery. 2013 Jun;72(6):953-9. doi: 10.1227/NEU.0b013e31828ecf69.Treatment of ruptured intracranial aneurysms: comparison of stenting and balloon remodeling.

AJNR Am J Neuroradiol. 2011 Aug;32(7):1232-6. doi: 10.3174/ajnr.A2478. Epub 2011 May 5.Stent-assisted coiling in acutely ruptured intracranial aneurysms: a qualitative, systematic review of the literature.

Recurrences and neck • Small aneurysm with small neck – very

low need of retreatment – 3% (T Ries et al, AJNR 2007)

• Increased risk >10mm and >4mm neck • Raymond et al Stroke 2003, did not find

increased risk when neck > 4mm

• Small reccurences (2mm) amd residual necks – very low risk of rebleeding – (T Ries et al, AJNR 2007, Hayakawa M J Neurosurg 2000

• Repeat treatment is low risk (Henkes h et al Neurosurg 2006; Tries et al AJNR 2007)

When stent ?

• Large and giant aneurysms • Blister• Fusiform and dissecting aneurysms• Recurrent

Points to ponder …..

• Relevance of small neck • Significance of small residual in

unruptured ??• Are we behaving like clipping surgeons

– cure at a higher complication rate • If there is a trial in small aneurysms?• Controlling a disease vis a vis killing a

disease• Let us learn from experiences in other

diseases – AVM and carotid trials …..

Balloon assisted coiling Extremely versatile technique Almost essential in treating

difficult ruptured aneurysms Modern balloons – easier, better Overall doesn't increase

complication rate Stent when needed Personal balance

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Dr Vipul Gupta

Thank you