Balloon-assisted Embolization Research Articles

A Surgical Case of Delayed Coil Migration After Balloon-Assisted Embolization of an Intracranial Broad-Neck Aneurysm: Case Report

Balloon-assisted coil placement is an important technique for coil embolization of broad-neck aneurysms. With this technique, we can prevent coil migration into a parent artery during a procedure. Complications of intraprocedural coil migration have been reported in the literature. However, delayed coil migration is extremely rare. We present a case of delayed coil migration after balloon-assisted coil embolization and describe our management of this complication. A 59-year-old man presented with hypertension and a tension headache. Clinical evaluation incidentally discovered an unruptured broad-neck aneurysm at the left internal carotid bifurcation. Endovascular embolization of the aneurysm was performed with a balloon-assisted technique. The patient had a transient ischemic attack, and a skull radiograph showed coil migration 3 months after the procedure. We performed an operation to remove the coils and to clip the aneurysm with superficial temporal artery and middle cerebral artery bypass. The patient was discharged without neurological deficit. This is a rare case in which delayed coil migration into the parent artery occurred after balloon-assisted coil embolization, highlighting the importance of surgical management of delayed coil migration.

Endovascular treatment of congenital brain arteriovenous fistulas with combination of detachable coils and onyx liquid embolic agent

Congenital brain arteriovenous fistulas (BAVFs) are rare vascular lesions, and conservative management was associated with a high mortality rate. We report our experience in the treatment of congenital BAVFs using detachable coils and Onyx liquid embolic agent. Over the past 5 years, 15 patients with congenital BAVFs were treated endovascularly at our hospital using detachable coils and Onyx-34. All patients were clinically followed-up for 12-48 months. We retrospectively reviewed the medical records, cerebral angiograms, and endovascular reports for each patient. There were 15 patients with a total of 16 BAVFs (six men and nine women, with a mean age of 29.4 years). The clinical presentations were intracranial hemorrhage in six patients, headaches in four patients, and seizure in three patients, with two patients diagnosed incidentally. In all of the cases, transarterial microcatheterization was performed, 13 patients were treated with a combination of detachable coils and Onyx-34, and two with balloon-assisted coils and Onyx-34 embolization. There was no significant morbidity or mortality. All BAVF-related symptoms resolved immediately or gradually on clinical follow-up. Immediate angiographic obliteration was achieved in all patients. The fistulas remained closed in all patients, as ascertained by follow-up angiograms. No new neurological deficits related to the procedure were detected. In our experience, the endovascular treatment of BAVFs with combination of detachable coils and Onyx is feasible, safe, and effective. This technique affords more control in the Onyx injection and minimizes the risk of distal embolization.

Balloon-assisted embolization of skull base meningioma with liquid embolic agent

The authors report a novel technique of balloon-assisted embolization of a skull base meningioma supplied by a branch of the cavernous segment of the internal carotid artery using liquid embolic agent. A temporarily inflated balloon distal to the meningioma's feeding vessel may improve the access to this small branch and may reduce the chances of unintended reflux during delivery of the liquid embolic agent.

Wide-necked Intracranial Aneurysms: Treatment with Stent-assisted Coil Embolization during Acute (<72 Hours) Subarachnoid Hemorrhage—Experience in 61 Consecutive Patients

To evaluate the safety and efficacy of stent-assisted embolization of ruptured wide-necked intracranial aneurysms during acute subarachnoid hemorrhage (SAH). Institutional review board approval for this retrospective study was obtained; the need to obtain informed consent was waived. Results in 61 consecutive patients (20 men, 41 women; mean age, 55.1 years; range, 26-83 years) with acutely ruptured wide-necked intracranial aneurysms who were treated with stent-assisted coil embolization were evaluated. The mean length of angiographic follow-up was 12.1 months (range, 0-52 months). Statistical analysis was performed to determine whether the features of the patient and the ruptured aneurysm affected the primary angiographic result or the patient's clinical outcome. Categoric and dichotomous variables were examined with the chi(2) test or the Fisher exact test; the Mann-Whitney U test and Kruskal-Wallis one-way analysis were used to compare continuous-scale data for non-normally distributed variables. The technical success rate was 72% (44 of 61). The technique-related complication rate was 21% (13 of 61), and the 30-day mortality rate was 20% (12 of 61). There was only one case of rebleeding, and clinical outcome was good for the majority of the patients (69% [42 of 61] had Glasgow Outcome Scale scores of 4 or 5 at the end of the study period). Stent-assisted coil embolization is a feasible method for the endovascular treatment of wide-necked intracranial aneurysms that are difficult to treat surgically or with balloon-assisted embolization during acute SAH. The risk of subsequent rerupture of the aneurysm seems to be reduced for aneurysms treated early compared with that for nonsecured aneurysms.

Endovascular repair of subclavian artery complex pseudoaneurysm and arteriovenous fistula with coils and Onyx

Treatment of subclavian artery pseudoaneurysm and arteriovenous fistula (AVF) can be challenging and carries a high risk of complications. Rare cases described in the literature have been managed with major surgery or endovascular treatment with stent graft placement. We present a patient with a large lobulated pseudoaneurysm of the subclavian artery and associated high-flow AVF near the left vertebral artery origin. Surgery was considered too risky and stent graft placement would have required occlusion of the vertebral artery. Successful endovascular repair was achieved with balloon-assisted selective embolization of the fistula with a combination of coils and Onyx.

Endovascular Treatment of a Superior Mesenteric Artery Aneurysm Secondary to Behcet’s Disease with Onyx (Ethylene Vinyl Alcohol Copolymer)

Behcet's disease is a complex multisystemic chronic inflammatory disease that is characterized by oral and genital aphtous ulcers and vasculitis. Aneurysms of major arteries are the most important cause of mortality in Behcet's disease. Four patients with superior mesenteric artery (SMA) aneurysms related to Behcet's disease have been reported in the literature. We report here the first successful endovascular treatment of a giant, wide-necked SMA aneurysm secondary to Behcet's disease. We performed a balloon-assisted embolization technique using ethylene vinyl alcohol copolymer (Onyx, ev3, Irvine, CA, USA). There were no signs of recurrence during 2-year follow-up.

Transarterial balloon-assisted glue embolization of high-flow arteriovenous fistulas

We report here our experience in treating high-flow arteriovenous fistulas (AVFs) of the brain and spine using balloon-assisted glue injection. During a 3-year period (2003-2005) five patients with high-flow AVFs were treated at our hospital using transarterial balloon-assisted glue injection. There were two pial AVFs, one dural AVF, one vein of Galen malformation and one perimedullary AVF of the cervical spine. All patients were clinically followed-up for 12-48 months. Immediate angiographic obliteration was achieved in all patients. The fistulas remained closed in all patients, as ascertained by follow up-angiograms. No new neurological deficits related to the procedure were detected. Clinically, one patient with severe pre-treatment neurological deficit experienced excellent recovery. Transarterial balloon-assisted glue embolization of high-flow AVFs is a feasible and efficient treatment. This technique affords more control in the glue injection and minimizes the risk of distal embolization.

Embolization of High-Flow Craniofacial Vascular Malformations with Onyx

Various techniques and materials have been used for the endovascular treatment of craniofacial high-flow arteriovenous vascular malformations, because their rarity precludes standardization of their treatment. The aim of this retrospective review is to assess Onyx as the primary embolic agent in the treatment of these vascular malformations. Six patients with arteriovenous fistulas and 3 with arteriovenous malformations (AVMs) of the head and neck region were treated with intra-arterial (IA)/direct percutaneous injections of Onyx. Adjunctive maneuvers used during embolization included external compression of the arterial feeders or venous outflow (6 patients), balloon assist (4 patients), and direct embolization of the draining vein remote to the fistula site (1 patient). n-butyl-2-cyanoacrylate (n-BCA) was used in addition to Onyx for rapid induction of thrombosis in a large venous pouch (1 patient) and for cost containment purposes (1 patient). Four patients were treated surgically after the embolization. There were no neurologic complications secondary to the embolization procedure. The arteriovenous shunt was eliminated in all of the fistulous lesions and 2 of the 3 AVMs. The embolization was incomplete in 1 patient with a large AVM who declined further endovascular or surgical procedures. Untoward events included 2 instances of catheter entrapment (of 9 IA injections), blackish skin discoloration necessitating surgical revision in 1 patient, and difficulty of balloon deflation/wire withdrawal during a balloon-assisted embolization. Onyx appears to be a safe and effective liquid embolic agent for use in the treatment of craniofacial high-flow vascular malformations with distinct advantages and disadvantages compared with n-BCA.

Alcohol Embolization of Carotid-Cavernous Indirect Fistulae

Abstract OBJECTIVE Carotid-cavernous fistulae (CCFs) are abnormal communications between the carotid artery and cavernous sinus that may present with rapid visual deterioration and extraocular paresis as a result of increasing intraocular pressure requiring emergent treatment to preserve vision. We present a technique of balloon-assisted ethanol embolization of the cavernous carotid artery supply to indirect CCFs providing immediate reduction in intraocular pressure with symptomatic improvement. METHODS We reviewed clinical and angiographic data and present a retrospective case series illustrating six patients who underwent endovascular embolization because of worsening visual acuity and extraocular motility disorder caused by CCFs. Cerebral angiography revealed significant blood supply from the cavernous carotid artery to these CCFs. We performed ethanol embolization of these branches with distal balloon protection. RESULTS Five of the six patients experienced immediate and sustained (mean follow-up, 21 mo) decreases in intraocular pressure, with significant symptom improvement. One patient experienced cavernous sinus thrombosis after conclusion of embolization, which caused a temporary worsening of symptoms that improved gradually over time. CONCLUSION Many surgical and endovascular options are available to treat indirect CCFs. Absolute ethanol is a liquid agent that causes immediate vessel sclerosis and occlusion, which makes it a dangerous but potent liquid embolic agent. With distal temporary balloon protection to prevent migration of ethanol, we achieved excellent clinical and angiographic results using absolute ethanol to embolize the cavernous carotid supply to indirect CCFs. This represents a safe and effective method of endovascular management of this complex vascular anomaly.

Alcohol Embolization of Carotid-Cavernous Indirect Fistulae

Carotid-cavernous fistulae (CCFs) are abnormal communications between the carotid artery and cavernous sinus that may present with rapid visual deterioration and extraocular paresis as a result of increasing intraocular pressure requiring emergent treatment to preserve vision. We present a technique of balloon-assisted ethanol embolization of the cavernous carotid artery supply to indirect CCFs providing immediate reduction in intraocular pressure with symptomatic improvement. We reviewed clinical and angiographic data and present a retrospective case series illustrating six patients who underwent endovascular embolization because of worsening visual acuity and extraocular motility disorder caused by CCFs. Cerebral angiography revealed significant blood supply from the cavernous carotid artery to these CCFs. We performed ethanol embolization of these branches with distal balloon protection. Five of the six patients experienced immediate and sustained (mean follow-up, 21 mo) decreases in intraocular pressure, with significant symptom improvement. One patient experienced cavernous sinus thrombosis after conclusion of embolization, which caused a temporary worsening of symptoms that improved gradually over time. Many surgical and endovascular options are available to treat indirect CCFs. Absolute ethanol is a liquid agent that causes immediate vessel sclerosis and occlusion, which makes it a dangerous but potent liquid embolic agent. With distal temporary balloon protection to prevent migration of ethanol, we achieved excellent clinical and angiographic results using absolute ethanol to embolize the cavernous carotid supply to indirect CCFs. This represents a safe and effective method of endovascular management of this complex vascular anomaly.

Post-TIPS Hepatic Encephalopathy Treated by Occlusion Balloon-Assisted Retrograde Embolization of a Coexisting Spontaneous Splenorenal Shunt

Post-TIPS Hepatic Encephalopathy Treated by Occlusion Balloon-Assisted Retrograde Embolization of a Coexisting Spontaneous Splenorenal Shunt