Intermediate catheter use is associated with intraprocedural rupture during coil embolization of ruptured intracranial aneurysms: a retrospective propensity score-matched study

Abstract

Introduction: An intermediate catheter (IMC) may pose a risk of intraprocedural rupture (IPR) during coil embolization of ruptured intracranial aneurysms (RIAs), because the pressure on the microcatheter and coil might be more direct. To verify this hypothesis, this study explored whether use of an IMC might correlate with an increased rate of IPR during coil embolization for RIAs.

Methods: We retrospectively reviewed 195 consecutive aneurysms in 192 patients who underwent initial coil embolization for saccular RIAs at our institution between January 2007 and December 2023. Patients were divided into two groups with aneurysms treated either with an IMC (IMC group) or without an IMC (non-IMC group). To investigate whether IMC use increased the rate of IPR, a propensity score-matched analysis was employed to control for age, sex, maximal aneurysm size, neck size, bleb formation, aneurysm location, proximal vessel tortuosity, balloon-assisted coiling, type of microcatheter, and type of framing coil.

Results: Ultimately, 43 (22%) coil embolization used IMC. In univariate analysis, the incidence of IPR was significantly higher in the IMC group compared with the non-IMC group (14.0 vs. 3.3%, p = 0.016). Propensity score matching was successful for pairs of 26 aneurysms in the IMC group and 52 aneurysms in the non-IMC group. The incidence of IPR was still significantly higher in the IMC group than in the non-IMC group (23.1 vs. 3.8%, p = 0.015). No significant differences in the incidences of ischemic complications and IMC-related parent artery dissection were observed between the two groups.

Discussion: When using IMC for coil embolization of RIAs, the surgeons should be more careful and delicate in manipulating the microcatheter and inserting the coils to avoid IPR.

Keywords: balloon guiding catheter; distal access catheter; endovascular treatment; hemorrhagic complication; intraoperative aneurysm rupture; intraoperative complication; intraoperative rupture; subarachnoid hemorrhage.

Figure 1

Flowchart for selection of saccular ruptured intracranial aneurysms for initial coil embolization and subsequent classification by use of IMC. A total of 243 consecutive initial endovascular treatments for ruptured cerebral aneurysms conducted at our institution between January 2007 and December 2023 were retrospectively reviewed. Patients with dissecting aneurysms (n = 38) and fusiform aneurysms (n = 5) were excluded. In addition, patients with extracranial aneurysm (n = 4) and aneurysms treated with parent artery occlusion (n = 1) were also excluded. Ultimately, 195 initial coil embolization of saccular ruptured intracranial aneurysms in 192 patients were included in the present study. Of the 195 saccular ruptured intracranial aneurysms, 43 patients were classified to the IMC group and 152 to the non-IMC group. IMC, Intermediate catheter.

Figure 2

Findings in a 33-year-old woman. (A) Left internal carotid arteriography. A 33-year-old woman presenting with severe headache revealed a ruptured anterior communicating artery aneurysm with a maximum diameter of 4.5 mm. (B) Fluoroscopic view demonstrating aneurysm embolization under a double-catheter technique with a 6-Fr Sophia catheter guided as an IMC to the supraclinoid segment of the left internal carotid artery. (C) Left internal carotid arteriography revealing perforation of the aneurysm sac during insertion of a framing coil into the aneurysm and extravasation of contrast medium. (D) Fluoroscopic view showing coil displacement beyond the boundaries of the aneurysmal sac. (E) Left internal carotid arteriography demonstrating that the coil was immediately filled into the aneurysm from the other unperforated catheter. The perforated coil was inserted in a dumbbell fashion from outside to inside the aneurysm to seal the perforation and stop the bleeding. (F) Fluoroscopic view indicating insertion of the perforated coil in a dumbbell fashion from outside to inside the aneurysm to seal the perforation. IMC, Intermediate catheter; Arrowhead, Tip of the microcatheter; Arrow, Tip of the IMC; and Double arrow, Perforated coil loop.