The purpose of this study was to describe a balloon-assisted double-lumen microcatheter technique to perform a controlled and tight coil packing of a vascular segment for vessel occlusion. This technique can be performed immediately after a test occlusion with the balloon kept in place and was, as illustrated in six cases, in our experience safe, straight forward to use and fas

Abdo, G.

Bijlenga, P.

De Tribolet, N.

Handa, A.

Lovblad, K.

Rufenacht, D.

Wetzel, S.

Yilmaz, H.

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IntroductionEndovascular parent artery occlusion may be used totreat a variety of vascular disease, such as aneurysms,pseudoaneurysms and arterio-venous ﬁstulas. Vesselocclusion is also considered in some cases to facilitatetumor surgery. The current standard-of-proceduretechniques request test occlusion prior to permanentvessel occlusion. To obtain a reliable result of the testocclusion, it is usually required to position a temporaryballoon occlusion at the same level as the permanentocclusion is planned. Test occlusion is performed over aperiod of about 30 min or interrupted, if not tolerated.During the occlusion test, currently evaluation includesangiographical visualization of satisfactory collateralsupply and clinical neurological and neuropsyochologi-cal tests without signifcant changes, even under addi-tional hemodynamic stress, i.e., a condition simulatedwith drug-induced lowering of the blood pressure afterinitial tolerance has been revealed. Additional tests mayinclude semi-quantitative measurements of brain perfu-sion using EDC SPECT [1].Formerly, as in other centers, non-detachable siliconeballoons (Endeavour, 8501, BSC) for temporary anddetachable latex balloons (Nycomed) for permanentparent artery vessel occlusion have been used mostA. HandaG. AbdoH. YilmazS. G. WetzelK. O. LovbladP. BijlengaN. De TriboletD. A. RufenachtDouble-lumen balloon microcatheter-assistedocclusion of cerebral vessels with coils:a technical noteReceived: 25 October 2003Accepted: 8 March 2004Published online: 5 June 2004 Springer-Verlag 2004Abstract The purpose of this studywas to describe a balloon-assisteddouble-lumen microcatheter tech-nique to perform a controlled andtight coil packing of a vascularsegment for vessel occlusion. Thistechnique can be performed imme-diately after a test occlusion with theballoon kept in place and was, asillustrated in six cases, in our expe-rience safe, straight forward to useand fast.Keywords Double-lumen balloonmicrocatheter Æ Parent artery occlu-sion Æ Endovascular technique ÆTest occlusion Æ CoilNeuroradiology (2004) 46: 577–582DOI 10.1007/s00234-004-1206-2 INTERVENTIONAL NEURORADIOLOGYA. Handa Æ G. Abdo Æ H. YilmazS. G. Wetzel Æ K. O. Lovblad (&)D. A. RufenachtDivision of Neuroradiologyof the Department of Radiology,Geneva University Hospital,Rue Micheli-du-Crest 24,1211 Geneva, SwitzerlandE-mail: karl-olof.lovblad@hcuge.chTel.: +41-22-3727045Fax: +41-22-3727072S. G. WetzelDivision of Neuroradiology of theDepartment of Radiology, KantonsspitalBasel/University Clinics, Basel,SwitzerlandP. Bijlenga Æ N. De TriboletDepartment of Neurosurgery,University Hospital, Geneva, Switzerlandfrequently [1, 2, 3, 4]. With the advent of detachableplatinum coils, and because of the lack of commerciallyavailable coaxially detachable balloon systems, there hasbeen a trend to use coil occlusion to achieve permanentarterial occlusion [5]. With regard to technical aspectsduring coil placement, Graves et al. [6] reported theutility of temporary ﬂow arrest by using a non-detach-able balloon in order to reduce the risk of distal emboliand preclude diﬃculties in deploying coils in the arterialﬂow stream. We describe a modiﬁcation of this tech-nique. Thereby, a double-lumen balloon was used thatallowed, after test occlusion, the obtaining of a tightpacking of the vessel with detachable platinum alloycoils in the immediate vicinity of the balloon.Materials and methodsMethodsSix patients underwent balloon test occlusion and sub-sequent temporary ﬂow arrest using double-lumen bal-loon microcatheter-assisted and endovascular vesselocclusion with microcoils at our institution from March2002 to April 2003. The patients included two males andfour females, who ranged in age from to 28 to 71 years(mean 42.7 years). Three carotid arteries and three ver-tebral arteries were treated using this technique. Twopatients had endovascular occlusion for unrupturedinternal carotid ophthalmic artery aneurysms, two fordissecting aneurysms of vertebral arteries, two for pre-surgical tumor resection of an invasive malignant tumorof the nerve sheaths at the cervical level and of a glomusjugular tumor (Table 1).Balloon test occlusion was performed in each patientbefore the permanent occlusion. This procedure wascarried out in awake patients under local anesthesia andlight sedation. A bilateral femoral approach was estab-lished using a 6–7 F and a 4–5 F, respectively. Afterendovascular access was gained, the procedure was donein the following way (Fig. 1): (1) an occlusion test wasperformed using a microballoon catheter (Grapewine)inﬂated just proximal to the planned occlusion site. Thiswas carried out like usual occlusion tests (see Intro-duction) and was tolerated without neurological deﬁcitin all patients. (2) For deﬁnitive treatment, the balloonwas kept inﬂated in place, and microcoils were intro-duced through the double-lumen balloon microcatheterto form a stable basket. For this purpose, we choseeither a spiral or spherical coil of a slightly oversizeddimension. (3–4) The creation of a coil distal basket wasfollowed by placement of a series of microcoils untilocclusion was thought to have been obtained. Whilemicrocoils were delivered, the balloon was kept inposition, which allowed for packing the coils tightly inthe space between the already introduced coils and theproximal continuously inﬂated balloon. In all cases, wecould observe a stepwise backwards movement of themicroballoon, whereas the distal coils stayed in the ini-tial position, meaning that the pack of coils were in astable position. The whole procedure was done underheparinization to keep the activated partial thrombo-plastin time of about twice that of the control.Table 1 Summary of cases ondouble lumen balloon catheter-assisted occlusion of cerebralvessels with coilsCase Age (years)/sex Location Diagnosis Complications Outcome1 36/F Rt. IC IC-oph An* None Good2 49/F Rt. VA Dissecting An None Good3 71/F Lt. VA Dissecting An None Good4 32/F Rt. VA Invasion of tumor None Good5 40/F Rt. IC IC-oph An* None Good6 28/F Rt. IC Glomus jugular tumor None GoodFig. 1 Drawing of the double-lumen balloon catheter-assistedvessel occlusion technique. (1) Test occlusion: the balloon isinﬂated slightly proximal to the occlusion site. (2) First coils: spiralor spherical coils are deployed to form a stable basket (‘‘anchor’’).(3) Subsequent coils: now spiral, spherical as well as long J-shapedcoils can be used to ﬁll the space between the ‘‘anchor’’ and theballoon. Here, a slight backward movement of the balloon isobserved. (4) Permanent occlusion578Case examples:In case 1, a 36-year-old woman with longstandingheadache, but without an episode of subarachnoidhemorrhage, was found to have a right-sided internalcarotid-ophtalmic artery aneurysm on MR angiogra-phy. Digital subtraction angiography showed a smallcarotid cave aneurysm and adjacent intradural oph-thalmic aneurysm with a multilobular and irregularappearance of the right internal carotid artery(Fig. 2A, B). Due to technical diﬃculties encounteredwhile trying to deliver stents in an in-vitro replica madeof poly vinyl alcohol hydrogel replica, we decided totreat the patient’s large carotid-ophthalmic aneurysmby endovascular occlusion of the internal carotid artery(ICA) at the level of the ophthalmic artery origin andextending proximally. Under anticoagulation using4,000 IU of heparin, an occlusion test was performedusing a 4-mm diameter Grapevine catheter-10 system(Medtronics Micro Interventional Systems, Sunnyvale,Calif.) inﬂated in close proximity to the aneurysm(segment C4 of the carotid siphon), which was toler-ated without neurological deﬁcit. For deﬁnitive treat-ment, the balloon was kept inﬂated in place, and a ﬁrstspherical coil (Micrus coil: MICRUS CORPORA-TION, Sunnyvale, Calif.) was introduced through thedouble-lumen balloon microcatheter to form a stableanchor in the artery at the level of the aneurysm neck(Fig. 2C). This was followed by placement of 11mechanically detachable coils (DCS-11, COOK) for atotal length of 79 cm of coils. The initial introductionof spiral coils was followed by delivery of longJ-shaped coils. While the J-coils were delivered, theballoon was kept in the position, which allowed thecoil to form tight packing between the distal ‘‘coil-anchor’’ (the already introduced coils) and the proxi-mal inﬂated balloon (Fig. 2D). The ﬁnal controlshowed a total occlusion (Fig. 2E). No neurologicalsymptoms occurred during or after coil embolization,and the follow-up at 1 year showed disappearance ofthe aneurysm, a permanent occlusion of the rightinternal carotid artery and normal appearance of thebrain.In case 6, a 28-year-old woman with a large rightglomus jugular tumor showed encasement of theFig. 2 A AP view, B lateral view. Cerebral digital subtractionangiography showed a small carotid cavernous aneurysm andadjacent intradural ophthalmic aneurysm with a multilobular andirregular appearance of the right internal carotid artery. C Anocclusion test was performed using a balloon catheter inﬂated inclose proximity to the aneurysm (segment C4 of the carotidsiphon). For deﬁnitive treatment, the balloon was kept inﬂated inplace, and a ﬁrst spherical coil was introduced through the double-lumen balloon microcatheter to form a stable anchor in the arteryat the level of the aneurysm neck. D While the J-coils weredelivered, the balloon was kept in position, which allowed the coilto form a tight packing between the distal ‘‘coil-anchor’’ (thealready introduced coils) and the proximal inﬂated balloon. E Theﬁnal control showed a total occlusion579petrous segment of the internal carotid artery(Fig. 3A). Among the presurgical preparationsinvolving devascularization of the tumor, the occlusionof the right ICA was requested. Since tumor resectionincluding resection of the petrous segment of the ICAwas planned, we performed balloon test occlusion atthe C4 segment of the carotid siphon, with theintention to coil the C3 and the C4 segments of theICA. A 4-mm diameter Grapevine catheter-10 (Med-tronics Micro Interventional systems, Sunnyvale,Calif.) was inﬂated, and clinical testing revealed noneurological and neuropsychological deﬁcits. Therewas a slight asymmetry at the parenchymographystudy and back-pressure measurements revealed adrop of the mean pressure from 80 to 48 mmHg. Thepermanent vessel occlusion was carried out whileproximal ﬂow arrest was maintained in a mannersimilar to that described in case 1 (Fig. 3B, C). Since asegmental resection of the petrous portion of the ICAwas planned, we avoided introducing coils in thisportion, and a second proximal occlusion of the cer-vical ICA was performed to achieve trapping. Again, asimilar coil introduction technique was used (Fig. 3D).For the distal occlusion, a total of 14 coils for a totallength of 117.6 cm of coils was used, and for theproximal occlusion these numbers were 7 coils for atotal of 85.6 cm. A combination of 0.010 and 0.018coil systems were used.The ﬁnal control showed a total occlusion of the ICA(Fig. 3E). This was followed by other presurgial endo-vascular and direct puncture devascularization proce-dures. The whole procedure was done underheparinization to keep the activated partial thrombo-plastin time of about twice that of the control, andanticoagulation was maintained at preventive levels overnight. No neurological symptoms occurred during orafter coil embolization, and surgical removal was facil-itated, satisfying the surgeon’s expectations.ResultsAll six parent arteries were occluded successfully, andocclusion length could be limited to the intendedextension. All lesions were successfully treated, resultingin no complications, no neurological deﬁcits and goodoutcomes. Permanent vessel occlusion was performedusing 10 to 29 coils (either GDC, DCS or Micrus) with atotal length of 79 to 185 cm.The above-described technique allowed the perfor-mance of a controlled and tight coil packing of thevascular segment intended to be occluded. This tech-nique was performed immediately after the test occlu-sion with the balloon kept in place and was, asillustrated in the six cases, in our experience safe,straight forward to use and fast.Fig. 3 A Lateral view: a largeright glomus jugulare tumorshowed encasement of the pet-rous segment of the internalcarotid artery. B Lateral view:on the balloon test occlusion,the balloon catheter was in-ﬂated at the C4 segment of thecarotid siphon. C Lateral view:the permanent vessel occlusionwas carried out while proximalﬂow arrest was maintained.D Lateral view: a second prox-imal occlusion of the cervicalICA was performed to achievetrapping. E Lateral view: theﬁnal control showed a totalocclusion of the ICA580DiscussionRegarding the procedural aspects of parent vesselocclusion with microcoils, in two case series diﬀerenttechniques have been described. Graves et al. [6] passeda microcatheter through the lumen of a still-inﬂated testocclusion balloon to the level selected for permanentocclusion to deploy the coils. Their rationale forapplying a proximal ﬂow arrest was two-fold: ﬁrst, ﬂowarrest has been shown to reduce the risk of distal emboliduring coil deployment in a canine model [7]. Second,the authors found ﬂow arrest to reduce the risk of coilmigration and to allow for precise placement of the coils.In contrast, Barr et al. [8] subsequently reported that,according to their results, ﬂow arrest for coil placementwas unnecessary if intravenous heparin and heparinizedcatheter ﬂush solutions were used. They remarked thatin the canine model cited above, anticoagulation had notbeen employed. Choosing coils that were 33 to 50%larger than the diameter of the artery to be occluded asthe ﬁrst coils placed, they encountered no inadvertentdistal coil migration.We used a slightly modiﬁed technique compared tothat described by Graves et al. [8]. It diﬀered from theirtechnique in two aspects. First, the double-lumen bal-loon allowed for test occlusion close to the intendedocclusion site. Second, the function of the double-lumenballoon was to pass the coils directly to the site electedfor permanent artery occlusion without the need ofbringing in a separate microcatheter or balloon deﬂationafter the successful testing. Third, the microballoonhelped the coil deployment, similar to techniques appliedwhen performing ‘‘remodeling techniques’’ [10] duringaneurysm coiling. After initial introduction of slightlyoversized spherical or spiral coils, which form ananchor, it was possible to keep the vessel occlusion overa short segment involving a minimum of about 2.5 cmfor the size of a 5 mm lumen ICA. The balloon assis-tance further allowed for use of long J-shaped coils(DCS, COOK), as the balloon served as the proximallimit preventing the proximal extension of unshapedcoils. In our experience, use of such J-coils may reducesigniﬁcantly the number of coils required to obtain areliable vessel occlusion. Furthermore, mechanicallydetachable coils exhibit features that make themadvantageous for parent vessel occlusion [8] because ofits rapid and reliable detachment time when comparedto other detachment systems. Detachment of mechani-cally detachable coils was in our cases no more than 25 sper coil. When unavailable, instead of using a double-lumen balloon microcatheter, one could use two mi-crocatheter systems that are used independently fortemporally occluding and for delivery to the coils,respectively.The currently described detachable balloon techniquefor vessel occlusion has some advantages, for example, itis easier to perform test occlusion and detach the balloonjust after the test is ﬁnished, and it is cheaper thancoiling. However, there is the risk of a prematuredetachment, perhaps slightly reducing patient safety.Furthermore, there is a lack of commercial availabilityof coaxial detachable balloon systems.ConclusionsFollowing a test occlusion, endovascular occlusion ofthe parent artery can be accomplished in a fast, accurateand eﬀective way with coils assisted by a double-lumenballoon kept in place inﬂated.References1. Serbinenko FA (1974) Balloon cathe-terization and occlusion of major cere-bral vessels. J Neurosurg 41:125–1452. Larson JJ, Tew JM Tomsick TA, vanLoveren HR (1995) Treatment ofaneurysms of the internal carotid arteryby intravascular balloon occlusion:long-term follow-up of 58 patients.Neurosurgery 36:26–303. Lewis AI, Tomsick TA, Tew JM (1995)Management of 100 consecutive directcarotid-cavernous ﬁstulas: results oftreatment with detachable balloons.Neurosurgery 36:239–2444. Fox AJ, Vinuela F, Pelz DM, PeerlessSJ, Ferguson GG, Drake CG, DebrunG (1987) Use of detachable balloons forproximal artery occlusion in the treat-ment of unclippable cerebral aneu-rysms. J Neurosurg 66:40–465. Braun IF, Hoﬀman JC Jr, CasarellaWJ, Davis PC (1985) Use of coils fortranscatheter carotid occlusion. AmJ Neuroradiol 6:953–9566. Graves VB, Perl J 2nd, Strother CM,Wallace RC, Kesava PP, Masaryk TJ(1997) Endovascular occlusion of thecarotid or vertebral artery with tempo-rary proximal ﬂow arrest and micro-coils: clinical results. Am J Neuroradiol18:1201–12067. Hughes SR, Graves VB, Kesava PP,Rappe AH (1996) The eﬀect of ﬂowarrest on distal embolic events duringarterial occlusion with detachable coils:a canine study. Am J Neuroradiol17:685–6915818. Barr JD, Lemley TJ (1999) Endovascu-lar arterial occlusion accomplishedusing microcoils deployed with andwithout proximal ﬂow arrest: results in19 patients. Am J Neuroradiol 20:1452–14569. Cloft HJ, Kallmes DF, Jensen ME,Lanzino G, Dion JE (1999) Endovas-cular treatment of ruptured, peripheralcerebral aneurysms: parent arteryocclusion with short Guglielmi detach-able coils. Am J Neuroradiol 20:308–31010. Murphy KJ, Houdart E, Szopinski KT,Levrier O, Guimaraens L, Kuhne D,Solymosi L, Bartholdy NJ, RufenachtDA (2001) Mechanical detachableplatinum coil: report of the Europeanphase II clinical trial in 60 patients.Radiology 219:541–544582

Double-lumen balloon microcatheter-assisted occlusion of cerebral vessels with coils: a technical note

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Double-lumen balloon microcatheter-assisted occlusion of cerebral vessels with coils: a technical note

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