Balloon Test Occlusion Research Articles

Safety of Unilateral Endovascular Occlusion of the Cervical Segment of the Vertebral Artery without Antecedent Balloon Test Occlusion

Antecedent balloon test occlusion is often performed prior to vertebral artery sacrifice, but there is limited data to suggest this adds a significant clinical benefit, especially in the setting of trauma. Furthermore, balloon test occlusion can be time-consuming, add to the technical complexity of the procedure, and increase the overall cost of treatment. The purpose of this study was to determine the safety of unilateral vertebral artery occlusion without antecedent balloon test occlusion as part of the treatment regimen in patients with traumatic vertebral artery dissection, cervical tumor, or intracranial aneurysm. The medical records and imaging studies of 59 patients in whom unilateral endovascular cervical vertebral artery occlusion was performed were retrospectively reviewed. Procedure-related stroke was defined as imaging evidence of acute infarct in the vascular territories supplied by the occluded vertebral artery or new focal neurologic deficit developing in the first 30 days after vertebral artery occlusion attributable to infarction in the posterior circulation. Fifty-nine patients underwent unilateral endovascular cervical vertebral artery occlusion to prevent potential thromboembolic complications of vertebral artery injury, for treatment of intracranial aneurysms, or for presurgical embolization of a cervical vertebral tumor. Unilateral occlusion was performed when endovascular reconstruction was considered impossible or deemed more risky than deconstruction. Fifty-eight of the 59 patients underwent vertebral artery occlusion without antecedent balloon test occlusion. None of the 59 patients had clinical or imaging evidence of a postprocedural infarct. In this series, endovascular occlusion of a cervical segment of 1 vertebral artery was safely performed without antecedent balloon test occlusion. As long as both vertebral arteries were patent and converged at the vertebrobasilar junction, there was anatomic potential for retrograde filling of the distal intracranial vertebral artery to the level of the posterior inferior cerebellar artery origin, and there was no major vascular supply to the spinal cord arising from the target segment of the affected vessel. Dominant and nondominant vertebral arteries were safely occluded, and no infarcts were attributed to the treatment.

Management of Benign Head and Neck Tumors

: Endovascular procedures for benign head and neck tumors include embolization, stenting, and balloon test occlusion. A transarterial (or endovascular) approach forms the mainstay of treatment for head and neck bleeding as well as for transarterial chemotherapy for head and neck neoplasms. A combination of percutaneous and transarterial approaches may be needed in the embolization of high-flow craniofacial vascular malformations (VMs) and hypervascular tumors. This is a review of the current clinical applications of a variety of percutaneous and endovascular interventional procedures of the extracranial head and neck. The tumors that require embolization in the head and neck most commonly include glomus tumors, angiofibromas, and meningiomas. Many other types of tumors that may also require preoperative embolization include the following: hypervascular metastases, esthesioneuroblastomas, schwannomas, rhabdomyosarcomas, plasmacytomas, chordomas, and hemangiopericytomas. The goal of tumor embolization is to selectively occlude the external carotid artery (ECA) feeders through intratumoral deposition of embolic material. The embolic agents in common use are polyvinyl alcohol (PVA), Embospheres (BioSphere Medical, Rockland, Mass), liquid embolic agents (glue, ethylvinyl alcohol copolymer [EVOH], or Onyx [ev3, Irvine, Calif]), gelatin sponge (Gelfoam; Phadia, Uppsala, Sweden), and coils. The embolization is ideally performed 24-72 hours before surgical resection to allow maximal thrombosis of the occluded vessels and prevent recanalization of the occluded arteries or formation of collateral arterial channels. Preoperative embolization is cost-effective and tends to shorten operation time by reducing blood loss and the period of recovery.

Flow Diversion Is Not Yet the Complete Package

arsaut et al. prepared an article on their results after flow diversion in giant curved and bifurcation experiD ments with very low porosity flow diversion devices. This was done to improve on their prior experience to occlude aneurysms with flow diverters as a stand-alone therapy by progressively increasing the metal density of devices (1). They demonstrated that increasing the metal content of flow diversion devices (from 48 to 64 wire devices and then to double overlapping 64 wire devices) remained insufficient to reliably cause giant end wall bifurcation and curved sidewall aneurysm occlusion. Angiography at 3 months in most cases showed widely patent aneurysms and microscopic photography consistently revealed apertures through the neointima covering the devices, permitting blood flow to keep aneurysms, and branches, patent. As they point out, fundamental problems with devices deployed in a curved configuration include the incident angle of flow and the increased porosity found at the device convexity (2). They did note that the models they constructed were more challenging than previous animal models used as aneurysms were larger, and necks wider. This is an interesting article and many researchers would have argued, as Darsaut et al. did, that low porosity devices would occlude the aneurysm. The classic surgical treatment for giant aneurysms has been either microsurgical direct clip-reconstruction or occlusion followed by a cerebral bypass for those patients who fail in a balloon test occlusion. Nevertheless, the emergence of new endovascular techniques, especially flowdiverting devices, has promised to revolutionize the treatment of giant aneurysms, possibly avoiding major microsurgical operations. However, this article highlights the fact that endovascular therapy is not yet the standard for the treatment of all giant intracranial aneurysms, even in the controlled situation such as

Monitoring Balloon Test Occlusion of the Internal Carotid Artery with Transcranial Doppler

Angiographic balloon test occlusion (BTO) allows preoperative risk evaluation of patients undergoing permanent therapeutic occlusion of the internal carotid artery (ICA). The sensitivity of the BTO can be increased using different complementary techniques. Transcranial Doppler (TCD) stands out as a non-invasive, bedside method providing real-time monitoring of cerebral haemodynamics, therefore accurately identifying patients at risk of stroke. A case of a 30-year-old woman with a giant intracavernous aneurysm of the left ICA presenting with subacute left VI nerve palsy is described. A pre-operative TCD- and EEG-monitored BTO of the left ICA was performed. The 16.7% drop found in the middle cerebral artery's peak systolic velocity (PSVMCA) predicts clinical and haemodynamic tolerance to the permanent loss of that vessel. This case illustrates the potential of TCD monitoring during temporary BTO of the ICA. It highlights its ability to provide a complete preclinical evaluation of collateralization and autoregulatory adaptation to unilateral ICA occlusion. TCD may also decrease the time of occlusion required for the BTO.

An unusual cause of chronic otitis media with effusion

To describe an unusual cause for hearing loss in an adult. A 37-year-old man presented with a year's history of right-sided hearing loss. He had no history of trauma, or local or systemic infection. He was otherwise well, took no medication and had no allergies. He had a two-year history of low back pain. On examination, he had a retracted right tympanic membrane with no perforation, and a middle-ear effusion. Nasendoscopy was normal. Examination of other systems was unremarkable. Computed tomography of the temporal bones with contrast demonstrated a large, right, intra-cerebral internal carotid artery aneurysm compressing the eustachian tube. After a balloon occlusion test, he underwent endovascular occlusion of the parent vessel. He made a good post-operative recovery. A subsequent abdominal ultrasound excluded an abdominal aneurysm as a cause of his low back pain. His hearing had not improved three days post-operatively, and was to be formally assessed and monitored in the clinic. A carotid aneurysm is a rare cause of eustachian tube compression but must be considered in the differential diagnosis of conductive hearing loss. Aneurysms may have systemic causes, and their presence in other systems should be excluded as they may be multiple.

Balloon Occlusion Tests and Therapeutic Vessel Occlusions Revisited: When, When Not, and How

The concept of therapeutic occlusion of arteries to and in the brain is old, with Cooper describing a carotid artery ligation performed in 1805,[1][1] and Matas, a vertebral artery sacrifice in 1893.[2][2] The potentially deleterious effect of losing a carotid artery was even known in ancient Greece

Endovascular internal carotid artery trapping for ruptured blood blister-like aneurysms: long-term results from a single centre

Endovascular internal carotid artery (ICA) trapping was performed to treat ruptured blood blister-like aneurysms (BBAs). The aim of this study was to evaluate the procedural risks and long-term follow-up results. The records of 11 consecutive patients with BBAs who underwent endovascular ICA trapping between 2005 and 2010 were reviewed. Clinical outcomes were assessed with modified Rankin Scale (mRS) scores. Endovascular ICA trapping was performed in 11 patients as either the primary treatment (7 patients) or the secondary treatment (4 patients) after the patient underwent other treatments. Three patients underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass when balloon test occlusion (BTO) revealed inadequate collateral circulation. In the primary ICA trapping group (seven patients), six patients had good outcomes (mRS 0 in five, mRS 1 in one), and one patient had a poor outcome (mRS 6: dead). In the secondary ICA trapping group (four patients), two patients had good outcomes (mRS 0), and two patients had poor outcomes (mRS 4, 5). All ten of the surviving patients were clinically stable during the follow-up period (mean 39 months). A radiological follow-up of nine patients (mean 22 months) demonstrated stable occlusion, with the exception of one reopening of the ICA because of coil migration. Perfusion studies of nine patients (mean: 23 months) demonstrated no perfusion decrease. Endovascular ICA trapping is an effective and durable treatment for BBAs.

Cerebral Angiography Induced Prolonged Focal Seizure and Hemiparesis during Carotid Artery Balloon Test Occlusion

The frequency of neurologic complications of cerebral angiography is 0.3%-2.3%, and the frequency of the persistent neurologic deficits that remain over 7-10 days is 0.4%-0.5%. On the other hand, all neurologic complications of balloon test occlusion (BTO) have been reported in 0%-8.3% and especially in 1.6%-1.7% of symptomatic neurologic complications. There are a few reports concerning a seizure related to cerebral angiography and BTO. We report a case of prolonged seizures and left hemiparesis during and after BTO of the right internal carotid artery. The patient showed repeated focal seizures and prolonged left hemiparesis lasting for approximately 2 months. Computed tomography and magnetic resonance imaging demonstrated no abnormal findings. Suspected mechanisms of seizure were a cerebral blood flow change induced by BTO and neurotoxicity of accumulated contrast medium. A combination of prolonged focal seizures and subsequent hemiparesis is a rare complication of BTO, which should be taken into consideration during BTO.

Balloon test occlusion of internal carotid artery: Angiographic findings predictive of results.

To reveal angiographic findings to predict the result of balloon test occlusion (BTO). The cerebral angiograms of 42 consecutive patients who underwent cerebral angiography including both the Matas and Allcock maneuvers and BTO were retrospectively analyzed. Visualization of the anterior cerebral artery (ACA) and the middle cerebral artery (MCA) by the cross flow on the tested side during the Matas or Allcock maneuver was graded on a 5-point scale. Circle of Willis (COW) anatomy with respect to the presence/absence of a collateral path to reach the tested internal carotid artery (ICA) was classified into four categories. A univariate logistic analysis was used to analyze the associations between each angiographic finding and the BTO result. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for each finding were calculated. Five patients (12%) were BTO-positive and the remaining 37 patients (88%) were BTO-negative. Visualizations of the ACA and MCA as well as the COW anatomy were significantly associated with the BTO result (P = 0.0051 for ACA, P = 0.0002 for MCA, and P < 0.0001 for COW anatomy). In particular, good MCA visualization and the presence of an anterior connection (collateral path to the tested ICA from the contralateral ICA via the anterior communicating artery) in the COW were highly predictive for negative BTO (negative predictive value = 100% for both). A BTO result may be predicted by angiographic findings including ACA/MCA visualization and COW anatomy.

海綿静脈洞部大型・巨大内頚動脈瘤に対する頭蓋外内バイパス術とそのピットフォール

Our treatment modalities and techniques for intracavernous large or giant internal carotid artery (ICA) aneurysms have been changed based on past clinical experience. We report clinical results and pitfalls of bypass surgery for intracavernous ICA aneurysms. This study included unruptured symptomatic 37 intracavernous ICA aneurysms in 36 patients. Treatment methods were selected based on the anatomical features of the aneurysm and neurological/hemodynamic conditions during balloon test occlusion (BTO). Eleven aneurysms were treated without bypass surgery. Low flow bypass (STA-MCA anastomosis) was performed for 18 aneurysms, and eight aneurysms were treated with high flow bypass. A saphenous vein graft was originally used for high flow bypass, but it was changed with a radial artery because of the problem of long-term patency. ICA occlusion was accomplished by ligation of the cervical ICA alone in the early cases until we encountered a case with brain infarction due to emboli from the aneurysm after ICA ligation. Accordingly, ICA occlusion was performed by endovascular internal trapping two days after bypass surgery. There was, however, a case of graft thrombosis before ICA occlusion. We now occlude ICA by surgical trapping between the neck and the intracranial ICA immediately after revascularization. No patients had permanent ischemic neurological deficits due to cerebral hypoperfusion after ICA occlusion. Our treatment algorithm based on BTO was reliable. When the patients undergo bypass surgery, we perform ICA occlusion by surgical trapping between the neck and the intracranial portion.

Resolution of Symptoms after Parent Artery Occlusion Treatment for Giant Cavernous Carotid Artery Aneurysms

Background and Objective: Giant cavernous carotid artery aneurysms (CCAAs) often produce a variety of neurological deficits, primarily those related to ophthalmoplegia/paresis and headache. This study was designed to evaluate the resolution of symptoms after parent artery occlusion (PAO) treatment for giant CCAAs. Methods: We retrospectively reviewed a series of 17 consecutive giant CCAAs treated with PAO treatment. All patients were evaluated by balloon occlusion test (BOT) before treatment. Patients who could tolerate BOT were treated by PAO. The following outcomes were analyzed: angiographic assessment, evolution of symptoms and outcome at clinical follow-up using modified Rankin Scale (mRS). Results: A total number of 17 giant CCAAs were treated by PAO. The initial post-procedure and follow-up angiogram revealed complete occlusion in all patients, no new lesion was detected. Periprocedural infarcts occurred in 1 patient (5.9%). Procedure-related mortality and morbidity were 0% and 5.9%, respectively. At mean 31.8 months clinical follow-up, symptoms had disappeared in 7 (41.2%) of the patients, partially improved in 5 (29.4%), remained unchanged in 4 (23.5%) and worsened in 1 (5.9%) of cases. Sixteen (94.1%) patients presented a good clinical outcome (mRS 0 - 1). Conclusion: Most patients in our series improved or remained stable after PAO. The results of this study indicate that PAO can improve the outcome of those symptomatic giant CCAAs if BOT can be tolerated.

Clinical and Angiographic Outcome of Endovascular and Conservative Treatment for Giant Cavernous Carotid Artery Aneurysms

This study evaluated the outcome of endovascular and conservative treatment for giant cavernous carotid artery aneurysms (CCAAs). We retrospectively reviewed a series of 35 consecutive giant CCAAs treated with endovascular and conservative treatment. All patients were evaluated by balloon occlusion test (BOT) before treatment. Patients who could tolerate BOT were treated by parent artery occlusion (PAO), those who could not tolerate BOT were treated by stent/coil or conservative methods. Eight patients were treated conservatively, symptoms were worsened in four patients (50%), unchanged in three, and improved in one at 33.6±19.9 months (6~65 months) follow-up. In 27 aneurysms treated with endovascular methods, 17 aneurysms were treated by PAO, eight aneurysms were treated with stent-assisted coil embolization, and two aneurysms were embolized with coils. The initial post-procedure angiogram revealed complete occlusion, neck remnant, and incomplete occlusion in 81.5 %, 11.1 %, and 7.4 %, respectively. Procedure-related mortality and morbidity were 0 and 7.4 %, respectively. At 33.1±17.4 months (4~71 months) follow-up, a good clinical outcome (mRS 0-1) was observed in 25 (92.6%) patients, symptoms were resolved or improved in 20 (74.1%). Statistical analysis showed that risk factors for poor clinical outcome included age of 60 years and older (P=0.006), and conservative treatments (P=0.038). Risk factors for poor clinical outcome of giant CCAAs included conservative treatment and age older than 60 years. A symptomatic giant cavernous carotid aneurysm should be treated. The outcome of endovascular treatment of giant CCAAs is promising.

Surgical treatment of carotid body tumors

In this study, we report our clinical experience in a series of patients with carotid body tumors along with diagnosis, treatment and follow-up procedures in the light of related literature data. Between November 2001 and May 2012, 10 patients (5 males, 5 females; mean age 53.2 years; range 27 to 80 years) who underwent surgery due to a carotid body tumor in our clinic were included. Diagnosis was based on ultrasonography, computed tomography, magnetic resonance imaging, magnetic resonance angiography, selective carotid angiography, balloon occlusion test, biochemical tests and preoperative embolization. Complications were also recorded. Balloon occlusion test was performed in all patients preoperatively, while embolization was implemented in seven patients. All masses were dissected by carotid artery subadventitial approach. Carotid integrity was maintained in nine patients, while a vein graft was used in one patient. Neurological disorder was observed in one patient, whereas transient hypoglossal paresis was in one patient who underwent saphenous vein grafting. Our study results suggest that (i) carotid body tumors should be handled with multidisciplinary approach; (ii) balloon occlusion test should be performed in all patients undergoing surgery; (iii) a particular attention should be paid to cranial and phrenic nerves, if it is necessary to extend the surgical field while removing the tumor; and (iv) pathological examination should be carried out by an experienced team and in a multi-centered fashion, if necessary.

Percutaneous device closure of abernethy malformation—A treatable cause of hepatopulmonary syndrome

An eight-year-old girl was evaluated for unexplained cyanosis. A contrast echo was suggestive of pulmonary arteriovenous fistula. Further evaluation revealed Abernethy malformation (type 2) leading to hepatopulmonary syndrome. Percutaneous device closure of Abernethy malformation was done after anatomical and physiological evaluation of the portal circulation. Prior to closure, it is important to ensure adequate portal radicals into the liver and normal portal pressure after test balloon occlusion. Subcostal echocardiography can diagnose and guide device closure of Abernethy malformation, a treatable cause of hepatopulmonary syndrome.

Angiographic Circulation Time and Cerebral Blood Flow during Balloon Test Occlusion of the Internal Carotid Artery

Angiography-based balloon test occlusion (BTO) has been empirically used to predict tolerance to permanent carotid artery occlusion. We tested the hypothesis that the laterality of the hemispheric circulation time (HCT) of the contrast medium at cerebral angiography would reflect bilateral asymmetry of the cerebral blood flow (CBF) during BTO. Thirty-one consecutive patients who underwent BTO of the internal carotid artery were retrospectively analyzed. HCT was defined as the interval between the time-to-peak in the middle cerebral artery and the cortical veins calculated using time-density curve. The difference in HCT between the occluded and nonoccluded side was calculated at the carotid or dominant vertebral angiograms obtained during BTO. We estimated the correlation between the difference in HCT and bilateral asymmetry of the CBF, which was quantitatively determined by single-photon emission computed tomography. The HCT was 5.3±1.5 seconds and regional CBF was 41.3±11.3 mL/100 g per minute in the occluded side, compared with 3.6±0.9 seconds and 48.4±14.9 mL/100 g per minute in the nonoccluded side, respectively. The difference in HCT was strongly correlated with the asymmetry ratio of the CBF (r(2)=0.89, P<0.0001). Angiographically based measurement of the cerebral circulation time can provide valuable information concerning cerebral hemodynamics.

Balloon Test Occlusion in the Setting of Vessel Sacrifice: Procedural Refinements and Adjunct Assessment Measures

he ability to efficiently occlude the carotid artery with an endovascular approach represents a technical advanceT ment in the treatment of select cerebrovascular and intracranial pathologies. The Amplatzer Vascular Plug II is an occlusion device that can decrease time and limit cost associated with these procedures. Clinical indications, patient selection criteria, and anatomic considerations are of significant importance in the planning of vessel sacrifice. Here we review the modern techniques of balloon test occlusion (BTO) with a focus on adjunct techniques to enhance the sensitivity and specificity of this test.

Balloon Test Occlusion of the Internal Carotid Artery with Stump Pressure Ratio and Venous Phase Delay Technique

Balloon test occlusion (BTO) is crucial before sacrificing parent arteries. We proposed a simple paradigm combining clinical tolerance with venous phase technique and stump pressure ratio as a criterion for sufficient collateral flow. Internal carotid artery (ICA) occlusion was considered safe for asymptomatic patients who exhibited less than 2seconds of venous phase delay or had a stump pressure ratio greater than 60%. A total of 37 BTO procedures were performed on 31 patients. Twenty-three patients were monitored clinically and 3 were symptomatic. Venous phase comparison was performed on 27 patients, and 5 failed the test. The stump pressure was measured in all patients, and 7 patients failed the test. In summary, 7 patients failed the BTO, of which 6 received high-flow bypass and 1 of these 6 were symptomatic and exhibited stump pressure ratios less than 60% in the second BTO procedure. Occlusion of the ICA was performed on 29 patients. Only 1 patient developed delayed vasospasm and brain infarction. Adequate collateral flow may be indicated by a stump ratio of 60% or greater with or without a high-flow bypass. Combined with clinical assessment and venous phase technique, ICA occlusion may be a safe option that does not result in delayed ischemic complications.

Reporting standards for balloon test occlusion

Advances in skull base surgery have resulted in the ability to perform large scale en bloc resections of neoplasms of the clivus, sphenoid wings, sella, and other deep structures. Such...

Progressive Deconstruction

A variety of deconstructive and reconstructive therapies have been used to treat intracranial aneurysms. The Pipeline embolization device (PED) has become a quite successful option to treat aneurysms, while reconstructing and remodeling the parent vessel. We report a case of off-label PED use, where a flow diverter was placed across the parent vessel of a giant intracranial aneurysm in a novel deconstructive strategy. A 40-year-old man with a giant, slow-flow aneurysm of the distal middle cerebral artery (MCA) was treated with the placement of a PED across the vessel containing the aneurysm after superselective test balloon occlusion of that vessel failed. PED was successfully deployed in a competing MCA branch across the origin of the MCA branch supplying the giant aneurysm. The patient continued dual-antiplatelet therapy for 5 months and aspirin monotherapy thereafter. Follow-up angiography, performed 6 months after treatment, demonstrated complete and asymptomatic thrombosis of the aneurysm and its parent MCA branch. A collateral pial and leptomeningeal network developed, reconstructing the distal branches of the occluded MCA branch. After 18 months, the patient remains neurologically intact. This appears to be the first description of progressive deconstruction for aneurysm treatment by using PED. Despite not tolerating acute vessel occlusion with superselective test balloon occlusion, the patient was asymptomatic following long-term occlusion with PED secondary to the growth of pial and leptomeningeal collateral networks.

Intracranial Endovascular Balloon Test Occlusion

Abrupt interruption of the internal carotid artery without a balloon test occlusion (BTO) carries a 26% risk of cerebral infarction. BTO is a test used to decrease this risk by evaluating the efficacy of the collateral circulation. Clinical tolerance of parent vessel occlusion can be assessed by a BTO with several variables, including the clinical examination, angiographic assessment, stump pressure, induced hypotension, perfusion scanning, transcranial Doppler ultrasonography, and neurophysiologic monitoring. This review discusses the indications, methods, predictive value, and complications of BTO.