Endovascular treatment of ophthalmic artery aneurysms: assessing balloon test occlusion and preservation of vision in coil embolization

Abstract

Background and purpose: ICA-ophthalmic artery aneurysms have unique configurations corresponding to relative risks of ophthalmologic morbidities. Presented herein are clinical and radiologic outcomes of coil embolization in ophthalmic artery aneurysms.

Materials and methods: From January 2003 to September 2013, endovascular coiling was performed in 43 consecutive patients with ophthalmic artery aneurysms, each classified by the degree to which the ophthalmic artery was incorporated by the aneurysm and the contiguity between the ophthalmic artery entry and parent ICA. Clinical and radiologic outcomes of this approach were investigated, including the technical aspects of treatment and the efficacy of balloon test occlusion.

Results: Among 14 patients (32.6%, all ophthalmic artery types) undergoing balloon test occlusion before endovascular coiling, patent collaterals between the external carotid artery and ophthalmic artery were demonstrated in 12 (85.7%) and complete compromise of the ophthalmic artery (without affecting vision) occurred in 4 patients during coiling. Steam-shaped S-configured (67.9%) or straight microcatheters (17.8%) facilitated aneurysm selection in most of the superiorly directed ophthalmic artery aneurysms (n = 28), and steam-shaped pigtail microcatheters (85.7%) were useful in medially directed aneurysms (n = 14). Balloon protection (n = 22) was generally used to facilitate coiling, or a stent (n = 9) was alternatively deployed. Satisfactory aneurysmal occlusion was achieved through coil embolization in 37 lesions (86.1%). During follow-up of 35 patients (mean interval, 12.9 ± 9.4 months), only 1 instance (2.9%) of major recanalization was observed.

Conclusions: If one tailors technical strategies, ophthalmic artery aneurysms are amenable to safe and effective endovascular coil embolization, which tends to be stable in follow-up. Balloon test occlusion may be helpful in devising treatment strategies to preserve vision when coiling ophthalmic artery aneurysms (especially those incorporating an ophthalmic artery origin) is done.

Fig 1.

Classification of OA aneurysms (ICA type versus OA type).

Fig 2.

A and B, Conventional angiography and 3D imaging of a medially directed OA aneurysm (OA originating from the aneurysmal neck and an aneurysm incorporating most of the OA entry). C, Balloon test occlusion performed after planned sacrifice of the OA orifice during coil embolization; the balloon catheter was placed at the ophthalmic segment (arrow) and inflated. D, With the balloon inflated, angiographic image of the common carotid artery reveals choroidal blush (arrow) and contrast filling (arrowhead) of the OA through the middle meningeal artery. E, Final angiographic view of the occluded aneurysm and OA orifice. F, Angiography of the external carotid artery confirms a patent choroidal blush (arrow) and contrast filling of the OA (arrowhead) after coiling.

Fig 3.

A, 3D imaging of a superiorly directed OA aneurysm; balloon test occlusion was not performed due to the aneurysm type (ICA) and a relatively well-demarcated margin between the OA orifice and the aneurysmal neck in the working projection. B, Simple technique via a steam-shaped S-configured microcatheter results in persistent herniation of coils into the parent artery. C, A Neuroform stent (arrows, stent markers) stabilizes the coil mass and secures the OA orifice. D, Completion angiography of successfully occluded aneurysm, with the OA preserved.

Fig 4.

Schematic depicting the treatment algorithm in the study population.

Fig 5.

A, 3D imaging of a superiorly directed OA aneurysm; balloon test occlusion was not performed due to the aneurysm type (ICA) and relatively well-demarcated margin, B, Completion angiography of a successfully occluded aneurysm with OA compromise (arrow). C, Angiography of the external carotid artery confirms no patent contrast filling of the OA. D, Restoration of OA flow after intra-arterial tirofiban infusion (0.75 mg).