Balloon Test Occlusion Research Articles

Carotid and vertebral artery sacrifice with a combination of Onyx and coils: technical note and case series

Permanent vessel sacrifice has become a routine for the management of aneurysms, pseudoaneurysms, tumors, and carotid blowouts. The purpose of this study is to describe a new technique for carotid and vertebral artery sacrifice using a combination of Onyx and coils and to assess its feasibility, safety, and efficacy. The technique consists of deploying a few coils in the parent vessel under proximal flow arrest followed by Onyx embolization directly into the coil mass. A total of 41 patients underwent carotid/vertebral artery sacrifice using this technique in our institution. A total of 26 internal carotid arteries and 15 vertebral arteries were treated. In all but one patient, a balloon test occlusion was performed prior to permanent arterial sacrifice. The mean number of coils used was 6.8 (range, 2-19). The total volume of Onyx used was 1.3 ml on average (range, 0.2-5.2 ml). All 41 (100%) parent arteries were successfully occluded. No distal migration of Onyx or coils was noted. Periprocedural complications occurred in 14.6% (6/41) of cases causing permanent morbidity in 7.3% (3/41). No patient developed a recurrence during the follow-up period (mean, 14 months). Parent vessel sacrifice with a combination of Onyx and coils appears to be feasible, safe, and effective and may be an alternative to the traditional deconstruction technique with coils alone. The risk of thromboembolism exists with this technique, but there were no instances of Onyx migration.

Treatment of Severe Pulmonary Hypertension in the Setting of the Large Patent Ductus Arteriosus

Treatment of the large patent ductus arteriosus (PDA) in the setting of pulmonary hypertension (PH) is challenging. Left patent, the large PDA can result in irreversible pulmonary vascular disease. Occlusion, however, may lead to right ventricular failure for certain patients with severe PH. Our center has adopted a staged management strategy using medical management, noninvasive imaging, and invasive cardiac catheterization to treat PH in the presence of a large PDA. This approach determines the safety of ductal closure but also leverages medical therapy to create an opportunity for safe PDA occlusion. We reviewed our experience with this approach. Patients with both severe PH and PDAs were studied. PH treatment history and hemodynamic data obtained during catheterizations were reviewed. Repeat catheterizations, echocardiograms, and clinical status at latest follow-up were also reviewed. Seven patients had both PH and large, unrestrictive PDAs. At baseline, all patients had near-systemic right ventricular pressures. Nine catheterizations were performed. Two patients underwent 2 catheterizations each due to poor initial response to balloon test occlusion. Six of 7 patients exhibited subsystemic pulmonary pressures during test occlusion and underwent successful PDA occlusion. One patient did not undergo PDA occlusion. In follow-up, 2 additional catheterizations were performed after successful PDA occlusion for subsequent hemodynamic assessment. At the latest follow-up, the 6 patients who underwent PDA occlusion are well, with continued improvement in PH. Five patients remain on PH treatment. A staged approach to PDA closure for patients with severe PH is an effective treatment paradigm. Aggressive treatment of PH creates a window of opportunity for PDA occlusion, echocardiography assists in identifying the timing for closure, and balloon test occlusion during cardiac catheterization is critical in determining safety of closure. By safely eliminating the large PDA, this treatment algorithm can halt the perilous combination of the large shunting from the PDA and PH in a population at high risk of morbidity and mortality.

Is flow diversion the death of cerebral bypass and coiling/stent-assisted coiling for giant cavernous aneurysms? A critical review on comparative outcomes and ongoing clinical trials

The classic surgical treatment for symptomatic giant aneurysms originating from the cavernous segment of the carotid artery has been either microsurgical direct clip-reconstruction or carotid occlusion followed by additional cerebral bypass for those patients who fail in a balloon test occlusion. Nevertheless the emergence of new endovascular techniques, especially flow-diverting devices, has promised to revolutionize the treatment of giant cavernous aneurysms, possibly avoiding major microsurgical operations. In this review the authors summarize the current "state-of-art" of treatment of giant cavernous aneurysms, comparing the overall outcomes, complications, morbidity and mortality rates of new flow-diverting devices in relation to traditional microsurgical series.

Endovascular treatment of a symptomatic extracranial vertebral artery aneurysm

Aneurysms of the extracranial vertebral artery are uncommon, with most cases attributed to penetrating head and neck trauma. We report a 29-year-old man with a symptomatic proximal extracranial vertebral artery aneurysm of unclear etiology. This patient's aneurysm was definitively treated after a successful balloon occlusion test of his affected vertebral artery. An endovascular approach was used combining coil embolization of the distal vertebral artery and a covered stent graft in the subclavian. Although aneurysms of this size and location are traditionally repaired with open aneurysmectomy, we show that endovascular approaches can be a safe and effective alternative.

Monitoring of Balloon Test Occlusion of the Internal Carotid Artery by Parametric Color Coding and Perfusion Imaging Within the Angio Suite: First Results

Temporary balloon test occlusion (BTO) might be performed prior to procedures in which occlusion of the internal carotid artery (ICA) might be necessary. We tested the hypothesis that parametric color coding (PCC) of angiographic series (digital subtraction angiography (DSA)) along with the assessment of cerebral blood volume (CBV) in the angiography suite would simplify and enhance the identification of candidates who are most likely to tolerate occlusion. Fifteen patients underwent angiographic series (DSA) and perfusion imaging before and during BTO. Pre- and postocclusion DSA acquisitions were evaluated for venous delay by conventional methods ("eye balling") and by PCC measurements. Comparison of CBV values between the left and right hemisphere in 6 defined regions was performed. Values of venous delay by eye balling and PCC showed a high correlation (r = 0.87, p < 0.01). Bland-Altman plot indicated slightly lower values (-0.05 s) by the PCC method. One of the 15 patients developed an asymmetrical CBV map with an increase in CBV of more than one standard deviation in 3 of the 6 regions of interest (ROIs). Acquisition of angiographic series and perfusion imaging did not prolong the test occlusion time. PCC and CBV mapping are feasible during BTO. The use of PCC seems to simplify the ability to measure changes in venous filling delay. Perfusion imaging may show an increase in CBV in patients reaching the limits of cerebral autoregulation. These patients may be at risk for delayed infarction, even though they seem to tolerate temporary occlusion, and could be unsuitable candidates for permanent ICA occlusion.

Abstract WMP26: Endovascular Arterial Deconstruction with a Combination of Onyx and Coils: Technique, Feasibility, and Complications

Object: Permanent vessel deconstruction has become routine for the management of aneurysms, pseudoaneurysms, tumors, and carotid blowouts. We describe a new technique for carotid and vertebral artery deconstruction using a combination of Onyx and coils, and assess its feasibility, safety, and efficacy. Methods: Between 2008 and 2012, a total of 41 patients underwent carotid or vertebral artery deconstruction with a combination of Onyx and coils in our institution. A few coils were initially deployed in the parent vessel under proximal flow arrest followed by Onyx embolization directly into the coil mass. Results: A total of 26 internal carotid arteries and 15 vertebral arteries were treated. In all but one patient, a balloon test occlusion was performed prior to permanent arterial occlusion. The mean number of coils used was only 6.8 (range, 2-19). The total volume of Onyx used was 1.3 ml on average (range, 0.2-5.2 ml). All 41 (100%) parent arteries were successfully occluded. No distal migration of Onyx or coils was noted. Periprocedural complications occurred in 14.6% (6/41) of cases causing permanent morbidity in 7.3% (3/41). All were the result of delayed ischemic events after vessel deconstruction; none were related to the occlusion technique. No patient developed a recurrence during the follow-up period (mean, 14 months). Conclusions: Parent vessel occlusion with a combination of Onyx and coils is feasible, safe, and effective and results in significant savings in terms of cost, operative time, and fluoroscopy time. Importantly, no complications related to the technique itself were encountered in the series. This new technique should replace the traditional deconstruction technique with coils alone.

Image fusion for hybrid repair of dislocated superior mesenteric branch of a branched endovascular aortic graft

Recent advances in imaging technology allow the projection of volumetric imaging data from the preacquired computed tomography angiography over live fluoroscopy during interventions. This "fusion" technology is currently underused, although its application carries distinct advantages. We introduce a case in which fusion technology was used for the placement of two thoracic and one branched abdominal aortic endograft and to treat late dislocation of its side branch using a hybrid technique.

Balloon-assisted coil embolization of the celiac trunk before endovascular aortic repair of thoracoabdominal aortic aneurysm

Celiac trunk coil embolization before thoracic endovascular aneurysm repair (TEVAR) of a thoracoabdominal aortic aneurysm involving the celiac trunk can prevent type II endoleaks. One disadvantage of conventional coil embolization is the risk of coil displacement. We performed coil embolization under balloon occlusion of the celiac trunk to address this issue. Between December 2008 and January 2011, 5 patients (3 men and 2 women, mean age 76 years) were included in this study. For all patients, after confirming the collateral blood flow from the superior mesenteric artery via the pancreaticoduodenal arcades by using the balloon occlusion test, celiac trunk coil embolization proceeded under balloon occlusion of the proximal part of the celiac trunk. Balloon-assisted coil embolization of the celiac trunk was completed for all patients without any complications. All coils were deployed as planned in the short segment of the celiac trunk without displacement. Coil migration, ischemic complications, and endoleaks via the celiac trunk did not arise in any of the patients over a follow-up period of 77-637 (mean 258) days. Balloon-assisted coil embolization of the celiac trunk before TEVAR could be a feasible treatment option for suitable patients.

Transcatheter Closure of Secundum Atrial Septal Defect in Patients Over 60 Years Old

Transcatheter Closure of Secundum Atrial Septal Defect in Patients Over 60 Years Old

Fusiform Aneurysm on the Basilar Artery Trunk Treated with Intra-Aneurysmal Embolization with Parent Vessel Occlusion after Complete Preoperative Occlusion Test

Fusiform aneurysms on the basilar artery (BA) trunk are rare. The microsurgical management of these aneurysms is difficult because of their deep location, dense collection of vital cranial nerves, and perforating arteries to the brain stem. Endovascular treatment is relatively easier and safer compared with microsurgical treatment. Selective occlusion of the aneurysmal sac with preservation of the parent artery is the endovascular treatment of choice. But, some cases, particularly giant or fusiform aneurysms, are unsuitable for selective sac occlusion. Therefore, endovascular coiling of the aneurysm with parent vessel occlusion is an alternative treatment option. In this situation, it is important to determine whether a patient can tolerate parent vessel occlusion without developing neurological deficits. We report a rare case of fusiform aneurysms in the BA trunk. An 18-year-old female suffered a headache for 2 weeks. Computed tomography and magnetic resonance image revealed a fusiform aneurysm of the lower basilar artery trunk. Digital subtraction angiography revealed a 7.1×11.0 mm-sized fusiform aneurysm located between vertebrovasilar junction and the anterior inferior cerebellar arteries. We had good clinical result using endovascular coiling of unruptured fusiform aneurysm on the lower BA trunk with parent vessel occlusion after confirming the tolerance of the patient by balloon test occlusion with induced hypotension and accompanied by neurophysiologic monitoring, transcranial Doppler and single photon emission computed tomography. In this study, we discuss the importance of preoperative meticulous studies for avoidance of delayed neurological deficit in the patient with fusiform aneurysm on lower basilar trunk.

293: Transcatheter closure of ASD in infancy with the Amplatzer septal occluder

Many devices are available for atrial septal defect (ASD) usually in adults and children. We report here one center experience in transcatheter closure of ASD in infancy, using the Amplatzer septal occluder. From January 2003 to March 2010, 10 males and 5 female, mean age 10.9±6.4 months, with weight 6.7±2.5 kg underwent transcatheter closure of atrial septal defect. The patients had significant left-to-right shunting (n=12), right-to-left shunting with hypoxemia (n=3). For the left-to-right shunting, the ASD was closed for pulmonary hypertension (n=10), for recurrent chest infection and bronchiolitis (n=5). The ASD was associated with other congenital heart defect (n=5), prematurity and bronchopulmonary dysplasia (n=6), foetopathy (n=1) and encephalopathy (n=1). The ASD was evaluated by transthoracic echocardiography (TEE) before the procedure. Percutaneous closure was realized with TEE for all patients. They received intravenous heparin. For 4 patients implantation was performed after a balloon test occlusion (mean 11±3.4 mm diameter). The ASO device size was 10.4±3.9 mm. The fluoroscopy time was 7.9±3.9 minutes and the time of the procedure 55.6±21.8 minutes. No per procedural complications were observed for all but for two (one anomalous device deployment and one insufficient rim). These two patients were subsequently surgically repaired. Patients left the hospital with a low dose of aspirin for 6 months. During follow-up, four patients had a minimal residual shunt on TEE performed up to one year after the implantation. No later cardiac complication was observed. To conclude, transcatheter closure of atrial septal defect in infant with the ASO is feasible and a possible alternative to surgical closure. In addition, ASD occlusion improves the respiratory status and reduces the level of pulmonary hypertension. Additional long-term results and a large study are both necessary to establish the future of this population

Percutaneous device closure of persistent ductus venosus presenting with hemoptysis

An eight-year-old boy was evaluated for unexplained hemoptysis and cyanosis. A contrast echocardiogram was suggestive of pulmonary arteriovenous fistula. Further evaluation revealed persistent ductus venosus (PDV) and aortopulmonary collaterals. Both the PDV and aortopulmonary collaterals were closed percutaneously. PDV is amenable for device closure after detailed anatomical evaluation. Prior to closure, it is important to ensure adequate portal vein arborization into the liver and normal portal pressure after test balloon occlusion.

Successful laparoscopic division of a patent ductus venosus: report of a case

Patent ductus venosus (PDV) is a rare condition of a congenital portosystemic shunt from the umbilical vein to the inferior vena cava. This report presents the case of an adult patient with PDV, who was successfully treated with laparoscopic shunt division. A 69-year-old male was referred with hepatic encephalopathy. Contrast-enhanced CT revealed a large connection between the left portal vein and the inferior vena cava, which was diagnosed as PDV. The safety of a shunt disconnection was confirmed using a temporary balloon occlusion test for the shunt, and the shunt division was performed laparoscopically. The shunt was carefully separated from the liver parenchyma with relative ease, and then divided using a vascular stapler. Portal flow was markedly increased after the operation, and the liver function of the patient improved over the 3-month period after surgery. Although careful interventional evaluation for portal flow is absolutely imperative prior to surgery, a minimally invasive laparoscopic approach can be safely used for treating PDV.

Cerebral Blood Flow and Metabolism Measurement Using Positron Emission Tomography before and during Internal Carotid Artery Test Occlusions: Feasibility of Rapid Quantitative Measurement of CBF and OEF/CMRO2

Balloon test occlusion (BTO) of the internal carotid artery (ICA) combined with cerebral blood flow (CBF) study is a sensitive test for predicting the outcome of permanent ICA occlusion. However, false negative results sometimes occur using single photon emission tomography (SPECT). We have recently developed a rapid positron emission tomography (PET) protocol that measures not only the CBF but also the cerebral oxygen metabolism before and during BTO in succession. We measured acute changes in regional CBF and OEF/CMRO(2) before and during BTO in three cases with large or giant cerebral aneurysms using the rapid PET protocol. Although no patients showed ischemic symptoms during BTO, PET studies exhibited mildly to moderately decreased CBF (9∼34%) compared to the values obtained before BTO in all cases. The average OEF during BTO was significantly increased (21% and 43%) than that of before BTO in two cases. The two cases were considered to be non-tolerant for permanent ICA occlusion and treated without ICA sacrifice. Measurement of the CBF and OEF/CMRO(2) using a rapid PET protocol before and during BTO is feasible and can be used for accurate assessment of tolerance prediction in ICA occlusion.

Giant Extracranial Aneurysm of the Internal Carotid Artery in Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by cutaneous pigmentations, neurofibromas, Lisch nodules and neuroectodermal tumors. Supra-aortic vessel aneurysms may affect patients with NF-1 and can be associated with rupture, ischemic complications and compression symptoms. We describe a 48-year-old woman with NF-1 and an extracranial 3×5 cm right internal carotid artery aneurysm. After balloon test occlusion the patient was treated with parent artery sacrifice which led to significant shrinkage on follow-up MR and reduction of compression symptoms. The literature concerning internal carotid artery aneurysms associated with NF-1 is reviewed evaluating the possible therapeutic options.

E-054 Endovascular treatment for traumatic dissection of the carotid and vertebral arteries

PurposeFor patients with acute and subacute (30 days after onset) traumatic dissection of the carotid (CD) and vertebral (VD) arteries, causing progressive or fluctuating neurologic deficit in the presence of...

E-027 Stent graft repair of carotid pseudoaneurysm in a young child with short-term follow-up

IntroductionTraumatic pseudoaneurysm of the carotid artery is a dangerous complication of penetrating trauma. Stent grafting is an accepted treatment; however the youngest reported patient so treated at the time was...

E-058 The ultimate sacrifice of a recalcitrant common carotid pseudoaneurysm after carotid endarterectomy

Common Carotid Artery (CCA) pseudoaneurysms are uncommon vascular lesions. They are most likely to occur as a sequelae of previous neck surgery (CEA incidence <1%), blunt or penetrating injuries to...

Quantifying Increased Hepatic Arterial Flow With Test Balloon Occlusion of the Splenic Artery in Liver Transplant Recipients With Suspected Splenic Steal Syndrome

The purpose of this study is to quantify hepatic arterial flow (HAF) in liver transplants with splenic steal syndrome (SSS) pre- and post-test balloon occlusion of the splenic artery utilizing Doppler ultrasound (DUS) and quantitative digitally subtracted angiography (Q-DSA). A total of 193 liver transplants were evaluated retrospectively. Hepatic arterial velocity (HAV) and HAF were calculated utilizing DUS and Q-DSA (i-flow prototype, Siemens) pre- and post-splenic artery balloon occlusion. The rate of HAF increase, total HAF, and peak contrast density (PKD) by Q-DSA were compared with HAF by DUS. Of all, 4 suspected SSS cases underwent test-balloon occlusion with DUS and Q-DSA. Using DUS, HAV and HAF increased by 1.6- to 1.8-fold and 1.7- to 2.6-fold, respectively. Using Q-DSA, the HAF rate, total HAF, and PKD increased by 1.1 to 12.8, 1.5 to 7.6, and 1.3 to 5.3, respectively. Occlusion of the splenic artery in liver transplants with SSS doubles the HAF (+1.7- to 2.6-fold). The Q-DSA parameters correlate qualitatively but overestimate the resultant increased HAF.

Epistaxis in the Presence of a Petrous Internal Carotid Artery Pseudoaneurysm: An Unusual Complication of Malignant Otitis Externa

Patient: A 65-year-old patient with a background of refractory malignant otitis externa and diabetes was admitted with recurrent epistaxis. He was diagnosed with adenocarcinoma and treated with parotidectomy and radiotherapy in 1972. The malignant otitis externa was treated with a mastoidectomy and antibiotic therapy in 2007. He was discharged on intravenous Tazocin and metronidazole for 1 month and converted to oral metronidazole and ciprofloxacin. In 2008, he developed epistaxis that required mucosal cauterization and sphenopalatine artery ligation. Before discharge, he had brisk epistaxis from his left nostril. Subsequently he underwent an MRI that suggested the presence of a pseudoaneurysm. He was transferred to neurosurgery, where a formal cerebral angiogram confirmed the presence of an internal carotid pseudoaneurysm. The next day he passed a balloon occlusion test and had his left internal carotid artery occluded. He was given 2 months of oral ciprofloxacin and intravenous meropenem in hospital and oral ciprofloxacin with Augmentin for 7 months after discharge.