Intraaneurysmal Neck Plasty: Efficacy of a Super Compliant Double-Lumen Balloon Microcatheter

Abstract

Objective: While wide-neck aneurysms can be treated with several methods, we report the specific technique of intraaneurysmal neck plasty (IANP) with a super compliant double-lumen balloon microcatheter (Super-Masamune).

Methods: The Super-Masamune was inflated inside 18 aneurysms. Cases in which the tip of the Super-Masamune was located in the aneurysm were included. Embolization methods were the same as those used in the application of other balloons/stents. The use of the Super-Masamune for the performance of IANP followed two patterns: (1) the Super-Masamune was used not only as a balloon but also for coil insertion (simple IANP); (2) the Super-Masamune was used only as a balloon, and a microcatheter for coil insertion was separately introduced coaxially (coaxial IANP).

Results: The aneurysms were located in the anterior communicating artery (n = 6), middle cerebral artery (MCA; n = 4), anterior cerebral artery (n = 1), internal carotid artery (n = 5), basilar artery (n = 1), and vertebral artery (n = 1). Eight of the aneurysms were ruptured, while 10 were unruptured. Simple and coaxial IANP were both performed in seven cases. Embolization was not performed after inflating the Super-Masamune inside the aneurysm in four cases. Embolization grades following the procedure included eight neck remnants (NRs) and six body fillings (BFs). There was one complication of intraoperative rerupture; however, there was no rupture/rerupture in the follow-up period. Retreatment of the target aneurysm was performed in two cases. The embolization grade assessed in the follow-up period reached complete occlusion for one patient, NR for five, and BF for two patients.

Conclusion: IANP using the Super-Masamune is useful for the treatment of wide-neck aneurysms in which the introduction of a guidewire and/or microcatheter into the branching artery is difficult.

Keywords: balloon assist; embolization; intraaneurysmal neck plasty.

Fig. 1. External appearance of the Super-Masamune.

Fig. 2. Antero-posterior view of the right vertebral artery angiogram in Case 1. (A) An angiogram obtained just prior to embolization. Right PCA originates from the aneurysm dome. The Super-Masamune is already introduced. Note that the marker of the tip is inside the aneurysm, and the marker of the proximal end of the balloon indicates the distal portion of the basilar artery. (B) Skull X-p during coil insertion. The arrow shows the balloon inflated in the aneurysm. (C) An angiogram just after embolization showing the NR. (D) Follow-up angiogram performed 33 months after embolization shows CO with good patency of right PCA. CO: complete obliteration; NR: neck remnant; PCA: posterior cerebral artery

Fig. 3. Lateral oblique view of left internal carotid angiogram in Case 4 showing a large MCA aneurysm. (A) A 3D DSA just prior to embolization. The white arrow indicates a branching artery originating from the aneurysm dome with a hairpin curve. (B) Skull X-p during coil insertion. Note that the balloon is inflated in the aneurysm. (C) An angiogram just after insertion of the last coil. Both the MCA branches are completely preserved. MCA: middle cerebral artery

Fig. 4. Left (A, B, C) and right (D) anterior oblique view of the right internal carotid artery angiograms in Case 7. (A) A 3D DSA just prior to embolization showing an anterior communicating artery aneurysm. Note that the left A2 originates from the aneurysm dome (white arrow). (B) An angiogram performed just after the introduction of the Super-Masamune. The arrow indicates the inflated Super-Masamune inside the aneurysm. (C) An angiogram obtained just after coiling. The left A2 is completely preserved, though the embolization was graded as BF. (D) An angiogram performed just after stent assist coiling 4 months later. The black and white arrowheads indicate the distal and proximal ends, respectively, of an Enterprise stent. BF: body filling

Fig. 5. Left anterior oblique views in Case 14. (A) A 3D DSA obtained just prior to embolization showing an MCA aneurysm. The long white arrow indicates a branching artery originating from the aneurysm dome. (B) Skull Xp obtained just prior to embolization. The arrow indicates the Super-Masamune inflated inside the aneurysm, and an arrowhead indicates another microcatheter used for the insertion of the coils. (C) Screenshot of road mapping performed during the insertion of the coil. Note that the Super-Masamune is inflated inside the aneurysm (long arrow) to prevent the protrusion of the coils. (D) An angiogram obtained just after embolization shows BF with the preservation of the MCA branches. (E) An angiogram obtained 12 months later shows the NR with the preservation of the MCA branches. BF: body filling; MCA: middle carotid artery; NR: neck remnant