Utilization of the Ballast Long Guiding Sheath for Neuroendovascular Procedures: Institutional Experience in 68 Cases

Abstract

Background: The rise of neurointerventional devices has created a demand for guide systems capable of navigating to the carotid artery consistently regardless of tortuosity. The shift toward large distal access catheters (DACs) and desire for greater trackability have inspired the creation of flexible, supportive, large-lumen long guiding sheaths. Recently, the Ballast long guiding sheath was introduced to provide stability and flexibility while navigating neurointerventional devices through tortuous intracranial anatomy. Objective: To report our experience using the Ballast long guiding sheath in a series of patients undergoing a variety of neuroendovascular procedures. Methods: We retrospectively identified all patients who underwent neuroendovascular treatment with a long guiding sheath were selected from a prospectively maintained endovascular database from January 2019 to November 2019. Baseline clinical characteristics and procedural details were collected. Results: A total of 68 patients were included, mean patient age 67.6 ± 13.6 years. Of the patients treated, 52.9% (36/68) presented with stenosis, 25% (17/68) with aneurysms, 13.2% (9/68) with stroke or emboli, 1.5% (1/68) with a tumor, 1.5% (1/68) with an arteriovenous fistula (AVF), and 4.4% (3/68) with a carotid web. Of the patients with stenosis, 20/36 (55.6%) were extracranial, and 16/36 (44.4%) were intracranial. The Ballast long guiding sheath was used to deliver treatment devices for stenting (37/68, 54.4%), flow diversion (12/68, 17.6%), mechanical thrombectomy (8/68, 11.8%), endovascular coiling (5/68, 7.4%), liquid embolization (3/68, 4.4%), balloon angioplasty (2/68, 2.9%), and balloon angioplasty with stenting (1/68, 1.5%). No Ballast-related complications or adverse events were encountered. Conclusions: We demonstrate the feasibility of the Ballast long guiding sheath to successfully deliver modern neurointerventional treatment devices through tortuous anatomy.

Keywords: aneurysm; endovascular therapy; long guiding sheath; stent; stroke.

Figure 1

Right middle cerebral artery stenosis. (A) Pre-procedure angiogram demonstrating intracranial stenosis of the right M1-MCA segment. (B) Ballast position in the ICA petrous segment. (C) Post-balloon mounted stent deployment. (D) Final angiography showing no evidence of vasospasm or dissection.

Figure 2

Right carotid stenting—radial approach. (A,B) Pre-procedure angiogram demonstrating a right carotid web. (C) Radial artery. (D) Ballast position post-stenting (outlined).

Figure 3

Balloon-assisted coiling of a posterior communicating artery aneurysm. (A) Pre-procedure angiogram demonstrating a large PCA aneurysm. (B) Proximal anatomy. (C) Peri-coiling. (D) Post-coiling angiogram demonstrating no residual filling.

Figure 4

Flow diverter deployment for right middle cerebral artery aneurysm. (A) Pre-procedure angiogram demonstrating right MCA aneurysm. (B) WEB flow diverter deployment, demonstrating successful deployment with conformity to the aneurysm walls. (C) Post-procedure angiogram demonstrating successful occlusion.

Figure 5

Aspiration thrombectomy for right middle cerebral artery occlusion. (A) Pre-procedure angiogram demonstrating occlusion of the right M1 segment (TICI 0). (B) Post-thrombectomy angiogram demonstrating TICI 3 reperfusion.