Summary:For the treatment of patients with complex internal carotid artery (ICA) aneurysms, it may be necessary to occlude the parent artery following a bypass surgery. The bypass surgery may be low or high flow bypass, but selection criteria have not been established. We retrospectively analyzed our method using preoperative balloon test occlusion (BTO).Thirty-five patients with ICA aneurysms, 15 ruptured and 20 unruptured, were treated with parent artery occlusion with bypass surgery. Preoperative BTO was performed in 27 cases (all unruptured and 7 ruptured, chronic stage cases). When ischemic symptoms occurred during BTO, high flow bypass was performed followed by parent artery occlusion. Otherwise, single-photon emission computed tomographic findings during BTO were used for the bypass selection. If ipsilateral residual blood flow was 70-75% or less of the contralateral hemisphere, high flow bypass was chosen and if between 70-75% and 90%, superficial temporal artery-middle cerebral artery (STA-MCA) bypass was employed. In the acute stage of 8 ruptured cases, BTO was not performed and bypass selection was made according to angiographic findings only. After completion of the bypass, ipsilateral ICA occlusion (ICO) was performed either by direct or intravascular technique. The site of ICO was determined to completely block the blood flow into the aneurysm considering both conventional angiography and BTO findings.A total of 15 STA-MCA and 20 high flow bypasses were performed followed by ICO. There was no mortality or morbidity in unruptured cases. In ruptured cases, there were 3 complications related to surgical procedure such as perforator injury, but no patients showed insufficient ipsilateral cerebral blood flow postoperatively. One asymptomatic cerebral infarction developed due to BTO. In 5 cases, petrous portion collateral flow from external to internal carotid artery was seen, and the ICO was performed above the collateral using intravascular embolization.
Summary:After the publication of ISAT trial, intraaneurysmal coil embolization has become more widely used for treatment of aneurysm. There are, however, some disadvantages in intraaneurysmal coil embolization. One is how to treat wide neck aneurysm. Among several solutions, such as 3D coils and double catheter technique, neck plasty technique is the most effective method at present.A new balloon catheter, HyperForm balloon occlusion system (HyperForm), for neck plasty technique has recently been developed. This balloon, with a maximum diameter of 7 mm, is so soft that it is called supercompliant. We report our experiences using the balloon.The cases in this study were 13 aneurysms in 12 patients in whom intraaneurysmal coil embolization was performed using HyperForm. The site of the aneurysm was internal carotid artery (ICA) in 6, basilar bifurcation in 5, and middle cerebral artery (MCA) in 2. The procedure itself is similar to ordinary neck plasty method. Most different fashion is in the situation of basilar bifurcation aneurysm.Many basilar bifurcation aneurysms dominantly saddle one of the posterior cerebral arteries (PCAs).We usually try to navigate a neck plasty balloon through the PCA that is saddled more by aneurysm.However, during this procedure the guidewire tends to migrate inside the aneurysm. In other words, the less important it is to preserve the PCA, the easier it is to canulate. HyperForm inflates irregularly as if the balloon itself is searching for space. Thanks to this characteristic of HyperForm, the important PCA can be protected even as the HyperForm is navigated through the less important PCA.Therefore, HyperForm is very useful for intraaneurysmal embolization of basilar bifurcation aneurysm. Another possible advantage of HyperForm is its larger diameter. The largest diameter of the previously used balloon was 4.5 mm, but HyperForm has a maximum diameter of 7 mm, which is useful for ICA aneurysm. However, because of its softness, HyperForm tends to jump during treatment of ICA aneurysm. There were 2 complications in this series. Both were perforations by the guide wire, one was aneurysm and the other was perforator, in the treatment of MCA aneurysm.In conclusion, HyperForm is very useful for neck plasty technique, especially in treatment of wide neck basilar bifurcation aneurysm.
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