Balloon-assisted guide catheter positioning to overcome extreme cervical carotid tortuosity: technique and case experience

Abstract

Background and significance: We describe a method by which to efficiently and atraumatically achieve distal positioning of a flexible guiding catheter beyond extreme cervical tortuosity using a hypercompliant temporary occlusion balloon.

Methods: A retrospective review of a prospective neuroendovascular database was used to identify cases in which a hypercompliant balloon catheter (Hyperform or Hyperglide, ev3/Covidien, Irvine, California, USA; Scepter or Scepter XC, Alisa Viejo, California, USA) was used to achieve distal positioning of a flexible guiding catheter (Navion, ev3/Covidien, Irvine, California, USA; Neuron, Penumbra Inc, Alameda, California, USA). After achieving a stable guiding sheath position within the proximal cervical carotid artery, a hypercompliant balloon catheter was manipulated beyond the tortuous cervical internal carotid segment into the distal carotid artery. The balloon was then inflated to anchor it distally within an intracranial (cavernous or petrous) segment of the internal carotid artery. The guiding catheter was then advanced beyond the tortuous cervical segment, over the balloon catheter, as gentle counter traction was applied to the balloon.

Results: Balloon-assisted guiding catheter placement was used to perform endovascular treatments of 12 anterior circulation aneurysms. One patient underwent coiling alone. Five patients underwent balloon-assisted coiling. One patient underwent balloon and stent assisted coil embolization. Four patients with five carotid aneurysms (one with bilateral carotid aneurysms) underwent vascular reconstruction with the pipeline embolization device. All patients had severe tortuosity of the extracranial carotid system. Three patients had findings consistent with cervical carotid fibromuscular dysplasia. The technique was successful each time it was attempted. No parent artery dissections or catheter induced vasospam were noted in any case.

Discussion: Hypercompliant balloon catheters can be reliably used to facilitate safe and rapid distal positioning of flexible guiding catheters beyond severe cervical tortuosity.

Keywords: Aneurysm; Balloon; Catheter; Navigation; Technique.

Figure 1

Female patient with a large, multilobulated left internal carotid artery (ICA) aneurysm (A). Left common carotid angiogram demonstrates challenging arch anatomy, with a backwards facing common origin of the left common carotid artery from the innominate (ie, ‘bovine’ arch anatomy) (B). Left internal carotid angiogram demonstrates marked tortuosity of the extracranial ICA with irregularity of the proximal vessel wall (arrows), compatible with fibromuscular dysplasia (C). A 7×7 mm Hyperform balloon was navigated past the tortuosity and inflated in the distal cavernous segment of the ICA over a 0.010 inch Xpedion microwire (D, E). Then, while applying counter tension to the balloon catheter, a Navien 058 guiding catheter was manipulated to the proximal cavernous segment of the ICA (F–H). Note that as the catheter passes through the regions of abrupt tortuosity, the balloon counter traction centers the catheter, moving it away from the outer curvature (arrows, F–G). Throughout the positioning of the guiding catheter, there is little, if any, distortion of the native carotid anatomy (D–H). This catheter position supported reconstruction of the left ICA with the pipeline embolization device (I–J).

Figure 2

Female with a ruptured left carotid–ophthalmic segment aneurysm and marked fibromuscular dysplasia of the entire mid cervical carotid artery with numerous serial webs and diffuse luminal irregularity (A). A Scepter 4×15 mm balloon catheter was navigated over an Avigo 0.014 inch microwire (ev3/Covidien, Irvine, California, USA) into the cavernous segment of the internal carotid artery (ICA)  (B). Using the distal anchoring technique, a 072 Navien guiding catheter was then manipulated into the vertical petrous segment of the ICA (C, D). From this guiding catheter position, the Scepter 4×15 mm balloon was used to perform balloon-assisted coil embolization of the aneurysm (F). Following treatment, angiography performed from the proximal cervical ICA demonstrated no evidence of carotid dissection or injury (F).

Figure 3

Young male patient with sickle cell disease, bilateral paraclinoid segment aneurysms and a remote history of subarachnoid hemorrhage. The proximal cervical segment of the right carotid artery takes serial abrupt 180° turns (A). A 7×20 mm Hyperglide balloon was manipulated over a 0.010 inch Xpedion microwire into the proximal cavernous segment of the internal carotid artery (ICA) (B). A Navien 058 guiding catheter was then atraumatically manipulated over the Hyperglide balloon into the proximal cavernous segment of the ICA (C–E). Counter tension applied to the balloon catheter drew the guiding catheter away from the outer curvature of the vessel at the apex of both abrupt turns (C, D, arrows). Throughout the positioning of the guiding catheter, there is little, if any, distortion of the native carotid anatomy (B–D). Injection of contrast in the working angle for coil embolization demonstrates no flow limitation, vascular injury, or vasospasm (F). The aneurysm treatment was successfully completed with deployment of a pipeline embolization device across the lesion (G).

Figure 4

Elderly female with a ruptured anterior communicating artery aneurysm. Initial angiography demonstrated marked tortuosity of the left common carotid artery as it arose from the aortic arch (not shown). Left internal carotid artery (ICA) angiography demonstrates marked tortuosity of the proximal cervical ICA (A). An Avigo 0.014 inch microwire (A) and then a Scepter XC 4×11 mm balloon catheter (B) were easily navigated beyond the tortuous segment. The Scepter balloon was inflated (C) and while applying counter tension to the balloon, the Navion 058 guiding catheter was advanced over the balloon catheter (D–G). The counter tension applied to the balloon catheter functioned to center the guiding catheter in the parent artery, pulling the catheter tip away from the outer curvature of the vessel wall (D–E, arrows). In the final guide catheter position, there is minimal distortion of the native carotid anatomy (G).