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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 8
| Issue : 2 | Page : 87-90 |
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Dual microcatheter technique for coil embolisation of irregular and wide-necked intracranial aneurysms: A case series
Amit Kumar Sharma, Anita Jagetia, Arvind Kumar Srivastava, Daljit Singh
Department of Neurosurgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi, India
| Date of Submission | 03-Jan-2021 |
| Date of Decision | 10-Jan-2021 |
| Date of Acceptance | 17-Jan-2021 |
| Date of Web Publication | 3-Feb-2021 |
Correspondence Address:
Dr. Amit Kumar Sharma
Department of Neurosurgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jcvs.jcvs_2_21
Background: The endovascular coiling of ruptured aneurysms with complicated geometry presents a significant treatment challenge, especially with the non-availability of adequate sized coils and balloon/stent. The dual microcatheter technique is an alternative treatment for stent-assisted coiling in acutely ruptured wide-necked aneurysms because of no antiplatelet therapy.
Objective: We report our initial experience with the use of a dual microcatheter technique in seven patients. The technique provided an efficient strategy for treating aneurysms with complicated configurations and high risks.
Patients and Methods: We describe a technique used to treat seven patients with irregular shaped and wide-necked aneurysms. In the initial attempts at embolisation, coil instability within the aneurysm or significant impingement of coil loops on the parent artery was observed. The advancement of a second microcatheter into the aneurysm allowed two coils to be braced across the aneurysmal neck before the detachment of either coil. This technique permitted successful coil treatment.
Conclusion: The dual microcatheter technique is a safe and effective treatment for acutely ruptured wide-necked aneurysms due to few treatment-related complications and mortality rate.
Keywords: Coil embolization, dual microcatheter, wide-neck aneurysm
How to cite this article:
Sharma AK, Jagetia A, Srivastava AK, Singh D. Dual microcatheter technique for coil embolisation of irregular and wide-necked intracranial aneurysms: A case series. J Cerebrovasc Sci 2020;8:87-90 |
How to cite this URL:
Sharma AK, Jagetia A, Srivastava AK, Singh D. Dual microcatheter technique for coil embolisation of irregular and wide-necked intracranial aneurysms: A case series. J Cerebrovasc Sci [serial online] 2020 [cited 2021 Sep 17];8:87-90. Available from: http://www.jcvs.com/text.asp?2020/8/2/87/308627 |
| Introduction | |  |
Embolisation of wide necked and irregular-shaped aneurysms is a great challenge. An attempt to occlude an aneurysm with an unfavourable dome-to-neck ratio carries a risk of coil herniation or coil impingement on the parent vessel.[1] Therefore, to overcome these complications in endovascular treatment, methods such as intracranial stents, balloon remodelling, the double microcatheter, the microcatheter protective technique and flow diverters have been developed.[1],[2],[3],[4],[5],[6],[7],[8],[9] This article aims to show coiling of an aneurysmal sac by dual catheter technique when dealing with wide necked and irregularly shaped aneurysms, which could be an alternative to the balloon stent remodelling method when conventional coiling fails. In all the mentioned rescue, two microcatheters can be used. One catheter coil and another catheter are used to deploy a balloon or stent at the desired site. We can deploy this second catheter inside the aneurysm sac for coil placement, i.e., dual microcatheter technique for coil embolisation.
| Patients and Methods | | |
General data
Based on a definitive diagnosis using digital subtraction angiography, we performed endovascular coil embolisation using the double microcatheter technique on seven cases of ruptured irregular intracranial aneurysms with wide neck and non-availability of the adequate size of coils.
Treatment protocol
The right femoral artery was catheterised with a 6F or 7F catheter sheath using the Seldinger technique. According to an aneurysm position, a guiding catheter (Envoy 6 F) was placed at the appropriate position. Using haemostatic valves, two microcatheters (0.014 and 0.010) under the guidance of a/0.0100.014 micro-guide wire were taken into the aneurysmal sac and placed in different locations in sac of aneurysm, heading in different directions. The two microcatheters contain heads in different shapes and angles that vary with irregular aneurysms. The available coils were to embolise the aneurysm according to its size and shape. The first coil was woven into a basket based on a pre-set microcatheter varying with the aneurysm's size and shape. The second coil required the double microcatheter technique for alternate embolisation based on the coil shape inside the aneurysm until it was compactly embolised. The two coils are deployed in the sequence through each microcatheter. If the first coil cannot be pushed entirely into the sac due to the coil mesh's shape change during the coil deployment, some part of the coil protrudes into the parent artery. Only part of the first coil is deployed in these cases, and then, part of the additional coil through the second microcatheter is introduced. When the second coil could fix the first coil into the aneurysm sac, alternately deploy the two coils. After a stable frame is achieved, the aneurysms are coiled regularly [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]. | Figure 1: (a-c) Schematic diagram showing dual microcatheter coil embolisation
Click here to view |
 | Figure 2: (a) Right internal carotid artery angiogram, lateral view, shows a wide-neck, bilobed, dumble shaped, aneurysm of cavernous segment. (b) Right internal carotid artery angiogram with two microcatheter and coils positioned but not detached. (c and d) Post procedural angiogram, with two microcatheter removed and coils deposited, shows satisfactory aneurysmal occlusion with slight residual neck (Raymond class-2)
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 | Figure 3: (a) Right internal carotid artery lateral angiogram shows wide neck aneurysm of paraclinoid segment. (b) Shows two microcatheters with coils basket in aneurysm sac. (c) Angiogram showing two microcatheters before detachment with coiled sac. (d) Postprocedural angiogram shows adequate packing of aneurysmal sac (Raymond class-2)
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 | Figure 4: (a) Left internal carotid artery angiogram shows bilobed paraclinoid internal carotid artery aneurysm with the wall of internal carotid artery making neck of sac. (b) Angiogram shows two microcatheter and coils being deposited simultaneously with basket formation. (c) Shows microcatheter removed and coils detached with dense coil pack. (d) Post-procedural angiogram showing complete obliteration of aneurysmal sac (Raymond class-1)
Click here to view |
 | Figure 5: Showing bilobed supraclinoid internal carotid artery aneurysm coiling (a) Left internal carotid artery angiogram shows supraclinoid bilobed, medially directing aneurysm. (b) Shows coils being deposited simultaneously with basket formation. (c) Angiogram shows two microcatheters and coil well-formed basket. (d) Postprocedural angiogram showing complete obliteration of aneurysmal sac (Raymond class-1)
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 | Figure 6: Showing wide-neck, bilobed aneurysm being coiled with dual microcatheter to make initial good basket even with small sized coils
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 | Figure 7: (a-d) Shows giant aneurysm being coiled with dual microcatheter and forming good basket even with inadequate sized coils
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 | Figure 8: Posterior circulation angiogram with basilar top aneurysm coil embolisation with neck remodelling using simultaneous coil deployment using the dual catheter technique
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| Discussion | | |
In 1998, Baxter et al.[1] first reported double microcatheter use to embolise intracranial wide-necked aneurysms with satisfactory results. Despite intervention with double microcatheter for irregular and complicated aneurysms, few published studies are available. It is based on the concept of securely bracing coils beside one another to achieve a stable configuration. With coil loops bridging but not herniating through the aneurysmal neck, a lattice is formed for the safe deposition of subsequent coils. In this method, the two microcatheters did not interfere with one another when passing through the sheath. Double microcatheters have advantages such as a single 6 F introducer can be used for simultaneous control of two microcatheters. Second, the rate of compact embolism of an aneurysm is significantly increased by the simultaneous resting of the two microcatheters in different positions inside the aneurysm sac, the duration of the operation and procedural complications are dramatically reduced. This technique may avoid long-term anticoagulation and complications, especially in younger patients. The final result is comparable to balloon/stent-assisted coiling in a wide neck/sidewall and terminal saccular aneurysm and cost-effectiveness.
| Conclusion | | |
A variety of endovascular options are available for the treatment of irregular and wide-necked aneurysms. The majority of the time, these techniques, which often involve devices such as three-dimensional complex coils, stents and balloons, are efficacious. However, there are situations when either the device is unavailable, or available, but inappropriate for a specific case. It is in these situations that the dual catheter method may be considered as a viable method in the management aneurysms with unfavourable architecture.
Financial support and sponsorship
Nil
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Baxter BW, Rosso D, Lownie SP. Double microcatheter technique for detachable coil treatment of large, wide-necked intracranial aneurysms. AJNR Am J Neuroradiol 1998;19:1176-8.  |
| 2. | Akpek S, Arat A, Morsi H, Klucznick RP, Strother CM, Mawad ME. Self-expandable stent-assisted coiling of wide-necked intracranial aneurysms: A single-center experience. AJNR Am J Neuroradiol 2005;26:1223-31. |
| 3. | Kwon OK, Kim SH, Kwon BJ, Kang HS, Kim JH, Oh CW, et al. Endovascular treatment of wide-necked aneurysms by using two microcatheters: Techniques and outcomes in 25 patients. AJNR Am J Neuroradiol 2005;26:894-900. |
| 4. | Lee JY, Seo JH, Cho YD, Kang HS, Han MH. Endovascular treatment of wide-neck intracranial aneurysms using a microcatheter protective technique: Results and outcomes in 75 aneurysms. AJNR Am J Neuroradiol 2011;32:917-22. |
| 5. | Kim JW, Park YS. Endovascular treatment of wide-necked intracranial aneurysms: Techniques and outcomes in 15 patients. J Korean Neurosurg Soc 2011;49:97-101. |
| 6. | Kwon SC, Shin YS, Kim HS, Kim SY. A double catheter technique for elongated middle cerebral artery bifurcation aneurysm. A case report. Interv Neuroradiol 2006;12:41-4. |
| 7. | Cho YD, Lee WJ, Kim KM, Kang HS, Kim JE, Han MH. Endovascular coil embolization of middle cerebral artery aneurysms of the proximal (M1) segment. Neuroradiology 2013;55:1097-102. |
| 8. | Hwang JH, Roh HG, Chun YI, Kang HS, Choi JW, Moon WJ, et al. Endovascular coil embolization of very small intracranial aneurysms. Neuroradiology 2011;53:349-57. |
| 9. | Kwon OK, Kim SH, Oh CW, Han MH, Kang HS, Kwon BJ, et al. Embolization of wide-necked aneurysms with using three or more microcatheters. Acta Neurochir (Wien) 2006;148:1139-45. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
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