Double-balloon remodeling of wide-necked aneurysms distal to the circle of Willis

Abstract

We describe a remodeling technique in which two compliant balloon catheters were used to treat large, wide-necked bifurcation aneurysms distal to the circle of Willis in two patients with subarachnoid hemorrhage. Although vasospasm and interaction between the constrained catheters in the small distal arteries added to the complexity of the procedure, placement of a balloon catheter in each side branch prevented coil encroachment and enabled embolization of these aneurysms.

Fig 1.

Case 1. A, Left internal carotid arteriogram (working projection) before bypass of the aneurysm shows that both of the trunks of middle cerebral artery arise from the aneurysm. Microcatheter in the middle cerebral artery and in the anterior communicating artery aneurysm are noted. B, Digital radiograph shows both catheters (HyperForm; Micro Therapeutics, Inc) in the superior and inferior trunks. Microcatheter tip is in the aneurysm. C, Left internal carotid arteriogram after embolization of the anterior communicating artery aneurysm shows satisfactory obliteration of both aneurysms.

Fig 2.

Case 2. A, Aneurysm viewed from its posterior aspect on a 3D angiogram, which shows involvement of the origins of both A2 segments. Small dashed arrow indicates left A1; large dashed arrow, left A2; small solid arrow, right A1; and large solid arrow, right A2. B, Live road-map image shows the crossed pattern of catheters extending from A1 segments to the contralateral A2 segments and the catheter tip in the aneurysm. C, Bilateral internal carotid arteriograms at the end of the procedure demonstrate a small neck remnant.