Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms

Abstract

Of 68 patients with unclippable aneurysms treated by proximal artery occlusion with detachable balloons, permanent occlusion was achieved in 65; of these patients, 37 had carotid artery aneurysms below the origin of the ophthalmic artery, 21 had aneurysms arising from the supraclinoid portion of the carotid artery, six had basilar trunk aneurysms, and one had a distal vertebral aneurysm. Examination for treatment selection included assessment of the circle of Willis by compression angiography and xenon blood flow studies, with the ultimate evaluation being test occlusion under systemic heparinization with the balloon temporarily placed in the desired position. Of 67 patients who underwent a formal occlusion test, eight with carotid artery aneurysms did not initially tolerate the occlusion test, and ischemic signs disappeared instantaneously with deflation and removal of the balloon. During test occlusion, two additional patients had ischemic events that proved to be embolic; these reversed immediately upon balloon deflation. Of the 65 patients in whom permanent occlusion was effected by detachable balloon, there were nine instances of delayed cerebral events. One of these was a seizure leading to respiratory arrest and resuscitation 3 days following occlusion in a patient who had presented with seizures. The other eight cases were delayed ischemic events; seven were completely reversed and one patient had residual weakness in one leg (1.5% permanent morbidity). Extracranial-intracranial bypass procedures were performed in 25 of the 65 cases. All aneurysms of the carotid artery below the level of the ophthalmic artery presented angiographic proof of complete thrombosis. Ten of 21 aneurysms arising from the supraclinoid portion of the carotid artery were completely thrombosed by proximal occlusion alone, without additional trapping procedures. Similarly, in three of six basilar trunk aneurysms, proximal occlusion alone initiated complete aneurysm thrombosis without trapping. The conclusion is that proximal balloon occlusion for unclippable cerebral aneurysms is a convenient, safe, and effective way of producing arterial occlusion in these cases.

Therapeutic Internal Carotid Artery Occlusion for Large and Giant Aneurysms: A Single Center Cohort of 146 Patients

“…Data from the era of surgical ICA clamp occlusion without previous tolerance testing indicate that approximately three-fourths of patients can tolerate ICA occlusion. [16][17][18] In our cohort, the angiographic test indicated tolerance to permanent ICA occlusion in two-thirds of patients, which indicates that the proportion of false-negatives is probably limited. After ICA occlusion, all aneurysms thrombosed completely except one, which makes the treatment very effective.…”

Endovascular Treatment of Large and Giant Aneurysms

“…[21][22][23] However, with the availability of intracranial stents, these aneurysms can now safely be treated with sparing of the parent vessel, and parent vessel occlusion techniques are hardly ever indicated for these aneurysms.…”

Parent Artery Occlusion: A Well-Established Technique

“…Eighty of 82 petrous and cavernous aneurysms were obliterated with proximal occlusion, only 4 of which required trapping. In 1987, Fox et al 3 reported 58 patients with anterior circulation giant aneurysms, with all 37 aneurysms below the ophthalmic segment and 10 of 21 supraclinoid aneurysms obliterated with proximal occlusion alone without the need for trapping. We have been unable to find evidence in the literature demonstrating the inferiority of proximal occlusion as a first-line procedure.…”