Single-center experience with a dual microcatheter technique for the endovascular treatment of wide-necked aneurysms

Abstract

Object. The endovascular treatment of wide-necked aneurysms can be technically challenging due to distal coil migration or impingement of the parent vessel. In this paper, the authors illustrate an alternative method for the treatment of wide-necked intracranial aneurysms using a dual microcatheter technique.Methods. The authors' first 100 consecutive patients who underwent coil embolization of a wide-necked aneurysm using a dual microcatheter technique are reported. With this technique, 2 microcatheters are used to introduce coils into the aneurysm. The coils are deployed either sequentially or concurrently to form a stable construct and prevent coil herniation or migration. Angiographic and clinical outcomes are reported.Results. The technical success rate of the dual microcatheter technique is 91% with a morbidity and mortality of 1% and 2%, respectively. Clinical outcomes are excellent with 93% of patients demonstrating a modified Rankin Scale score of 0-2 at long-term follow-up regardless of their score at presentation. Retreatment rates are 18%.Conclusions. The dual microcatheter technique may be a safe and efficacious first line of treatment for widenecked aneurysms.(http: //thejns.org/doi/abs/10.3171/2014.7.JNS132237) key WorDs • dual • microcatheter • wide-necked • aneurysm • outcomes • vascular disorders • interventional neurosurgeryAbbreviation used in this paper: mRS = modified Rankin Scale. * Drs. Durst and Starke contributed equally to this work. C. R. Durst et al. 1094J Neurosurg / Volume 121 / November 2014 Patient SelectionA wide-necked aneurysm was defined as one having a dome-to-neck ratio of less than 2 or a neck diameter greater than 4 mm. 8,11,14,19 During the evaluated period, true saccular aneurysms were treated using this technique, but dissecting or blister aneurysms were not. Interventional ProcedureAccess to the femoral artery is obtained in a standard fashion. The guiding catheter must be able to simultaneously accommodate 2 microcatheters. The microcatheters can be either preshaped or steam-shaped to improve navigability and stability. The first microcatheter is advanced over a microguidewire into the aneurysm under roadmap guidance. At this point, attempts may be made to coil the aneurysm using a single microcatheter. Once it is determined that the dual microcatheter technique will be needed, a second microcatheter is introduced and advanced into the aneurysm. To prevent inadvertent manipulation, the microcatheter that is not in use is covered with a towel. The second microcatheter is usually steam shaped with a curve different from that of the first catheter so that the 2 microcatheters will occupy different parts of the aneurysm. Care must be taken when positioning the second microcatheter, as it can cause the first microcatheter to migrate forward.Two different general strategies can be described: "interleaving" and "locking."Interleaving Technique. This technique is most often used in particularly wide-necked aneurysms. In such aneurysms it may not be possible to place the ...

Combination of Multicatheter Plus Stent or Balloon for Treatment of Complex Aneurysms

“…1,[18][19][20][21] The multicatheter technique also ranged from 0% to 13.3%. 5,13,22,23 Notably, in our series, treatment-related morbidity occurred in only 1 patient (1.6%), which is acceptable in comparison with the reported results from the literature focusing only on wide necks and is also remarkable because adding an adjunctive device may lead to an increase in adverse events like thromboembolism and intraprocedural rupture. 24,25 Another concern is a possible increase in the recanalization rate after frequent incomplete coiling due to the complicated characteristics of the aneurysm.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12] However, if wide-neck aneurysms have an incorporated branch and/or deeply lobulated sac, coiling is more difficult and there is potentially an increased risk of incomplete coiling, a thromboembolic event, or branching occlusion and posttreatment recurrence. The unique configuration of this aneurysm usually demands a more elaborate coiling technique and can be recognized as a complex and difficult aneurysm in view of the coiling procedure.…”

“…5,6,8,13 In a recent case series, treatment-related morbidity and mortality with a dual-microcatheter technique were 1% and 2%, respectively. 5 This technique can also intentionally protect the incorporated branch by placing 1 catheter or coil into the branch.…”

“…5,6,8,13 In a recent case series, treatment-related morbidity and mortality with a dual-microcatheter technique were 1% and 2%, respectively. 5 This technique can also intentionally protect the incorporated branch by placing 1 catheter or coil into the branch. 6,11,12,14 Although balloons and stents were originally designed for preventing coil prolapse and enhancing coil-packing attenuation, slight overinflation of a compliant balloon or "gator backing" of open cell stent struts can additionally protect the branch incorporated with the parent artery of a wide-neck aneurysm.…”

“…Some case series have already reported the feasibility of adjunctive techniques for aneurysms with difficult anatomic characteristics and have presented good procedural outcomes. [1][2][3][4][5][6] However, the coiling procedure of an aneurysm with a wide neck plus an incorporated branch and/or lobulated sac still remains a technical challenge. 6,7 In this regard, those aneurysms should be defined as "complex aneurysms."…”