Balloon Protection Research Articles

Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus.

Combined transarterial balloon-assisted endovascular embolization with double-lumen balloon microcatheters and concomitant transvenous balloon protection was described as a promising treatment technique for dural arteriovenous fistulae of the transverse and sigmoid sinus. The purpose of this study was to evaluate the technical efficacy and safety of this combined treatment technique. Nine consecutive patients presenting with dural arteriovenous fistulas of the transverse and sigmoid sinuses underwent combined transarterial and transvenous balloon-assisted endovascular embolization. Prospectively collected data were reviewed to assess the technical success rate, complication rate, and clinical outcome. Six patients presented with clinically symptomatic Borden type I, and 3 patients, with Borden type II dural arteriovenous fistulas of the transverse and sigmoid sinuses (3 men, 6 women; mean age, 50.4 years). Transarterial embolization was performed with a double-lumen balloon with Onyx and concomitant transvenous sinus protection with a dedicated venous remodeling balloon. Complete angiographic occlusion at the latest follow-up (mean, 4.8 months) was achieved in 6 patients, and near-complete occlusion, in 2 patients. Clinical cure or remission of symptoms was obtained in 6 and 2 patients, respectively. One patient with a residual fistula underwent further treatment in which the dural arteriovenous fistula was cured by sinus occlusion. Complete occlusion of the dural arteriovenous fistula was visible on the follow-up angiography after final treatment in 8 patients. One patient refused follow-up angiography but was free of symptoms. There were no immediate or delayed postinterventional complications. Transarterial balloon-assisted embolization of dural arteriovenous fistulas of the transverse and sigmoid sinuses with combined transvenous balloon protection is safe and offers a high rate of complete dural arteriovenous fistula occlusion and remission of clinical symptoms.

Transvenous retrograde AVM embolization: Indications, techniques, complications and outcomes.

Objective Transvenous retrograde arteriovenous malformation (AVM) embolization (TRAE) has been proposed. The present study was to review the techniques, their conjunctions and effectiveness. Methods Eligible related articles were identified by searching the PubMed and Web of Science databases using "transvenous" and "arteriovenous malformation." Results A total of 16 eligible studies, with 60 cases of AVM treated with TRAE, were analyzed. Prior to TRAE procedure, transarterial Onyx 18 was performed in 23 (38.3%), cyanoacrylate in three (5%) and coiling in two (3.3%), neurosurgery in one (1.7%) and radiosurgery in three (5%). These prior treatments were used to reduce the size of the nidus to <3 cm and TRAE was performed. One anterior choroidal artery aneurysm was coiled before TRAE. Systemic hypotension (blood pressure<100 mmHg) occurred in six (10%) patients and local hypotension (proximal arterial temporary balloon protection) in five (8.3%) patients. Complete obliteration was achieved in 56 (93.3%) AVMs, four (6.7%) with residual, of which one was supplemented with radiosurgery. During mean one-year follow-up (1 month to 3.2 years), there were five cases (8.3%) of permanent disability and one (1.7%) mortality resulting from initial hemorrhage. Fifty-four (90%) patients were independent (mRS ≤ 2) at follow-up. Ruptured AVMs and Spetzler-Martin I-III were associated with a high cure rate. Conclusion According to previous reports, selected AVMs could undergo TRAE. TRAE is safe and curative with Onyx after the nidus size is reduced sufficiently by transarterial embolization, neurosurgery or radiosurgery, with or without the aid of proximal arterial temporary balloon protection.

TCTAP A-055 Possible Mechanism of Jailed Balloon Technique for a Side Branch Protection at Stenting in Main Vessel: An Experimental Study

Jailed balloon protection (JBP) is a technique used when placing a stent in the main branch (MB) with a bifurcation that needs to be protected, accomplished by inflating a balloon in the side branch (SB). This technique has gained traction as a simple and quick way to avoid occlusion of the SB. In

経上腕動脈の頚動脈ステント留置術で応用できる protection 法の工夫〜7Fr ガイディングシースを用いて proximal balloon protection から total distal balloon protection へ切り替える方法〜

経上腕動脈の頚動脈ステント留置術で応用できる protection 法の工夫〜7Fr ガイディングシースを用いて proximal balloon protection から total distal balloon protection へ切り替える方法〜

近赤外線スペクトロスコピーを用いて頚動脈ステント留置術後過灌流現象を評価する妥当性についての検証

Hyperperfusion syndrome is a complication of carotid artery stenting (CAS) that leads to a poor outcome. Therefore, prevention of hyperperfusion syndrome is important in the perioperative management of CAS. We performed CAS under general anesthesia with both proximal balloon protection and distal filter protection. We used the Invos system to monitor regional cerebral oxygen saturation (rSO2) for 2 days after CAS. Although the Invos system provides continuous and less-invasive monitoring, rSO2 values may be influenced by the patient's respiratory or circulatory conditions. In this study, we compared perioperative rSO2 monitoring and single-photon emission computed tomography (SPECT) imaging, and report the efficacy of rSO2 monitoring in predicting hyperperfusion syndrome.Methods: SPECT was performed before and one day after CAS; rSO2 monitoring was continuously performed from immediately before induction of general anesthesia until two days after CAS.Results: In total, 44 patients underwent 49 CAS operations at our institution between January 2012 and December 2013. One patient who did not undergo SPECT imaging 1 day after CAS was excluded. The median age of all patients was 74 years and 88% patients were male. One patient experienced asymptomatic subarachnoid hemorrhage after CAS. According to the SPECT imaging results, hyperperfusion phenomenon was diagnosed in 4 patients, in 3 of whom the increase in the ratio of rSO2 on balloon deflation was above 0.2 and the decrease in ratio of rSO2 on balloon inflation was below 0.15. In one of these 4 patients, compared to the preoperative status, the difference between ipsilateral rSO2 and contralateral rSO2 increased by more than 5% after CAS.Conclusion: A change in the rSO2 ratio by proximal balloon protection could be one of the indices of hyperperfusion phenomenon. In some cases, rSO2 monitoring alone may not detect hyperperfusion. Therefore, another method such as SPECT imaging may be used in combination with rSO2 to detect hyperperfusion syndrome after CAS.

Transfemoral Stenting of Stenoses at the Common Carotid Artery Origin Using an Anchoring Technique With a Balloon Protection Device.

Transfemoral stenting of stenoses at the common carotid artery (CCA) origin is technically difficult because of poor stability of the guiding catheter. To describe an anchoring technique using a balloon protection device that provides excellent stability of the guiding catheter. Four patients (5 stenotic lesions) with stenosis of the CCA origin underwent transfemoral stenting with a balloon protection device (PercuSurge GuardWire; Medtronic, Santa Rosa, California). These 5 stenotic lesions of the CCA origin included 1 on the right side and 4 on the left side. Two of the stenoses were symptomatic, and 3 were asymptomatic. A balloon-expandable stent (Express LD stent; Boston Scientific, Natick, Massachusetts) was used in all patients. All stenoses were successfully dilated. With the balloon protection device as an anchor in all patients, the guiding catheter was highly stable during the procedure. There were no intraprocedural or periprocedural ischemic complications in any patients. None of the patients developed a stroke during a mean follow-up period of 8.4 months. The anchoring technique using a balloon protection device is useful for transfemoral stenting of stenoses at the CCA origin. CCA, common carotid arteryECA, external carotid arteryICA, internal carotid arteryPTA, percutaneous transluminal angioplasty.

Transfemoral Stenting of Stenoses at the Common Carotid Artery Origin Using an Anchoring Technique With a Balloon Protection Device

BACKGROUND: Transfemoral stenting of stenoses at the common carotid artery (CCA) origin is technically difficult because of poor stability of the guiding catheter. OBJECTIVE: To describe an anchoring technique using a balloon protection device that provides excellent stability of the guiding catheter. METHODS: Four patients (5 stenotic lesions) with stenosis of the CCA origin underwent transfemoral stenting with a balloon protection device (PercuSurge GuardWire; Medtronic, Santa Rosa, California). These 5 stenotic lesions of the CCA origin included 1 on the right side and 4 on the left side. Two of the stenoses were symptomatic, and 3 were asymptomatic. A balloon-expandable stent (Express LD stent; Boston Scientific, Natick, Massachusetts) was used in all patients. RESULTS: All stenoses were successfully dilated. With the balloon protection device as an anchor in all patients, the guiding catheter was highly stable during the procedure. There were no intraprocedural or periprocedural ischemic complications in any patients. None of the patients developed a stroke during a mean follow-up period of 8.4 months. CONCLUSION: The anchoring technique using a balloon protection device is useful for transfemoral stenting of stenoses at the CCA origin. ABBREVIATIONS: CCA, common carotid artery ECA, external carotid artery ICA, internal carotid artery PTA, percutaneous transluminal angioplasty

Transfemoral Carotid Artery Stenting Using Proximal Balloon Protection for Patients with Severe Elongation of the Aortic Arch: Inner-catheter Exchange with the Balloon Guide Catheter Anchored (“BGA Exchange”)

Transfemoral Carotid Artery Stenting Using Proximal Balloon Protection for Patients with Severe Elongation of the Aortic Arch: Inner-catheter Exchange with the Balloon Guide Catheter Anchored (“BGA Exchange”)

The Lurking Catastrophic Complication of an Equally Catastrophic Disease

Abstract BACKGROUND Medullary-bridging vein dural arteriovenous fistula (DAVF) is an uncommon type of DAVF with an aggressive clinical course due to direct fistulous shunting into medullary and brainstem veins. Important considerations need to be given to retrograde embolic migration or perforator involvement while treating these fistulas endovascularly with a liquid embolic agent. We report a lateral spinal artery feeding the DAVF, the recognition of which is important to avoid potential catastrophic complications during definitive therapy, and which has not been described before. OBJECTIVE To discuss the anatomy of the lateral spinal artery (LSA) and its communications with pial arteries such as the posterior inferior cerebellar artery (PICA) that may have important implications in the management of neurovascular diseases in and around the foramen magnum. METHODS A retrospective analysis of cerebral angiograms and 3-dimensional rotational angiograms of a patient with medullary-bridging vein DAVF treated by transarterial embolization under balloon protection was performed after the patient developed lateral medullary syndrome in the postoperative period. RESULTS Detailed analysis revealed a dural branch from the LSA feeding the DAVF which anastomosed with rudimentary PICA. CONCLUSION LSA has important anastomoses with perforating arteries of the medulla and cervical cord and, hence, it is important to recognize and identify LSA prospectively in the vascular pathologies of the foramen magnum to avoid fatal neurological complications during endovascular therapy. This is especially important while treating neurovascular pathologies using liquid embolic agents such as Onyx or SQUID, because they can percolate retrogradely through the anastomoses into PICA or other vertebrobasilar perforators.

Modified Balloon Protection Technique for Preoperative Embolization of Feeder Arteries from Internal Carotid Artery Branches to Skull-Base Tumor: Technical Note

To improve bleeding management during brain tumor surgery, feeder arteries supplying the tumor are often embolized presurgically. However, access to feeder arteries can be limited, and embolization of feeders from internal carotid artery (ICA) branches often causes complications. We evaluated the PercuSurge GuardWire (Medtronic, Minneapolis, Minnesota, United States) system (PGWS) with aspiration catheter as a modification of the embolization technique used to block tumor-supplying branches of the ICA. Two skull-base tumors were treated with preoperative embolization. One was a meningioma; the other was a hemangiopericytoma. In each case, the microcatheter could not be threaded into the ICA feeder arteries. Therefore, particulate embolic material was injected near the ICA branch while maintaining ICA balloon protection by the PGWS at the orifice of the ophthalmic artery. After embolization, we removed the remaining embolic material in the ICA using an aspiration catheter. In both cases, there were no postembolization complications and no high-intensity areas in the diffusion-weighted magnetic resonance image, and the tumorectomy proceeded as scheduled. This modified technique may be a promising alternative for reducing embolic complications and improving the success rate, although case accumulation is needed to confirm this result.

Jailed balloon protection and rescue balloon jailing techniques set the field for safer bifurcation provisional stenting

Jailed balloon protection and rescue balloon jailing techniques set the field for safer bifurcation provisional stenting

TCTAP C-228 Physical Intervention, FFR Guided PCI in Two Bifurcation Lesions with Jailed Balloon Protection

### Patient initials or identifier number 10481479 ### Relevant clinical history and physical exam The 68 year-old female had history of CAD, SVD and one stent was deployed in Ostium-LCX 7 years before admission. She had progressive chest pain and unstable angina. Therefore, she was admitted for

バルーン付きガイディングカテーテルを用いた経上腕動脈アプローチによるproximal balloon protection 下の頚動脈ステント留置術：9Fr Optimo を用いたシースレス法

バルーン付きガイディングカテーテルを用いた経上腕動脈アプローチによるproximal balloon protection 下の頚動脈ステント留置術：9Fr Optimo を用いたシースレス法

Microcatheter Looping to Facilitate Aneurysm Selection in Coil Embolization of Paraclinoid Aneurysms.

ObjectiveDescribed herein is a microcatheter looping technique to facilitate aneurysm selection in paraclinoid aneurysms, which remains to be technically challenging due to the inherent complexity of regional anatomy.Materials and MethodsThis retrospective study was approved by our Institutional Review Board, and informed consent was waived. Microcatheter looping method was employed in 59 patients with paraclinoid aneurysms between January 2012 and December 2013. In the described technique, construction of a microcatheter loop, which is steam-shaped or pre-shaped, based on the direction of aneurysms, is mandatory. The looped tip of microcatheter was advanced into distal internal carotid artery and positioned atop the target aneurysm. By steering the loop (via inner microguidewire) into the dome of aneurysm and easing tension on the microcatheter, the aneurysm was selected. Clinical and morphologic outcomes were assessed with emphasis on technical aspects of the treatment.ResultsThrough this looping technique, a total of 59 paraclinoid aneurysms were successfully treated. After aneurysm selection as described, single microcatheter technique (n = 25) was most commonly used to facilitate coiling, followed by balloon protection (n = 21), stent protection (n = 7), multiple microcatheters (n = 3), and stent/balloon combination (n = 3). Satisfactory aneurysmal occlusion was achieved through coil embolization in 44 lesions (74.6%). During follow-up of 53 patients (mean interval, 10.9 ± 5.9 months), only one instance (1.9%) of major recanalization was observed. There were no complications related to microcatheter looping.ConclusionThis microcatheter looping method facilitates safe and effective positioning of microcatheter into domes of paraclinoid aneurysms during coil embolization when other traditional microcatheter selection methods otherwise fail.

血流遮断による虚血症状が遷延した頸部内頸動脈狭窄症の1 治療例

要旨：症例は78 歳男性で，左中心前回の皮質梗塞による右上肢の単麻痺で発症．頸部MRA で左頸部内頸動脈狭窄を指摘．狭窄部は内出血を伴う脆弱性プラークが示唆された．発症約2 カ月後に頸動脈ステント留置術を施行．バルーンによる遠位プロテクションを選択．左内頸動脈を遮断すると直後より右片麻痺，失語，意識障害が出現．鎮静下に速やかにステントを留置し，遮断時間は8分50 秒．血流再開後の撮影で末梢塞栓はみられなかったが，遮断解除後も虚血症状は改善しなかった．治療3 時間後には右片麻痺は改善したが失語が続き，完全に改善したのが治療翌々日であった．バルーン遠位プロテクションでは虚血耐性が問題となるが，血流再開後虚血症状は多くは速やかに改善するとされる．本症例は片麻痺が約3 時間，失語が30 時間程度遷延したが，新たな脳梗塞はみられず，その後完全回復し，純粋に虚血不耐性による症状が遷延したものと考えられた．

Multiple device時代の頚動脈ステント治療の変遷と吸引血自己輸血の導入

Multiple device時代の頚動脈ステント治療の変遷と吸引血自己輸血の導入

Emergency endovascular treatment of petrous carotid artery false aneurysm

Abstract Introduction The management of ruptured intracranial false aneurysms (IFAs) might be tricky as any kind of treatment modality, surgical or endovascular, is burdened with significant challenges. A case report of the endovascular treatment of IFA in emergency setting is presented to provide more understanding of its pathophysiology as well as of the best operative work-up for petrous carotid artery reconstruction. Methods Technical notes from a left sided skull base abscess, involving and eroding the carotid canal and petrous carotid artery (PCA) resulting in an IFA are shown and analyzed. Results Balloon-assisted low viscosity Onyx embolization seems an effective method for the emergency treatment of IFA. Indications, technical nuances, and peri- and post-procedural complications are thoroughly discussed. A flow chart for the management of IFA is also proposed. Conclusions The combination of parent artery balloon protection and low viscosity Onyx embolization can provide an effective occlusion of the IFA while maintaining parent artery patency. Normal distal filling of the parent artery, and optimal obliteration of the IFA are easily achievable.

Acute subarachnoid hemorrhage in posterior condylar canal dural arteriovenous fistula: imaging features with endovascular management

A 43-year-old man presented with acute subarachnoid hemorrhage. He was investigated and found to have a rare posterior condylar canal dural arteriovenous fistula (DAVF). DAVFs of the posterior condylar canal...

Endovascular treatment of ophthalmic artery aneurysms: assessing balloon test occlusion and preservation of vision in coil embolization.

ICA-ophthalmic artery aneurysms have unique configurations corresponding to relative risks of ophthalmologic morbidities. Presented herein are clinical and radiologic outcomes of coil embolization in ophthalmic artery aneurysms. From January 2003 to September 2013, endovascular coiling was performed in 43 consecutive patients with ophthalmic artery aneurysms, each classified by the degree to which the ophthalmic artery was incorporated by the aneurysm and the contiguity between the ophthalmic artery entry and parent ICA. Clinical and radiologic outcomes of this approach were investigated, including the technical aspects of treatment and the efficacy of balloon test occlusion. Among 14 patients (32.6%, all ophthalmic artery types) undergoing balloon test occlusion before endovascular coiling, patent collaterals between the external carotid artery and ophthalmic artery were demonstrated in 12 (85.7%) and complete compromise of the ophthalmic artery (without affecting vision) occurred in 4 patients during coiling. Steam-shaped S-configured (67.9%) or straight microcatheters (17.8%) facilitated aneurysm selection in most of the superiorly directed ophthalmic artery aneurysms (n = 28), and steam-shaped pigtail microcatheters (85.7%) were useful in medially directed aneurysms (n = 14). Balloon protection (n = 22) was generally used to facilitate coiling, or a stent (n = 9) was alternatively deployed. Satisfactory aneurysmal occlusion was achieved through coil embolization in 37 lesions (86.1%). During follow-up of 35 patients (mean interval, 12.9 ± 9.4 months), only 1 instance (2.9%) of major recanalization was observed. If one tailors technical strategies, ophthalmic artery aneurysms are amenable to safe and effective endovascular coil embolization, which tends to be stable in follow-up. Balloon test occlusion may be helpful in devising treatment strategies to preserve vision when coiling ophthalmic artery aneurysms (especially those incorporating an ophthalmic artery origin) is done.

Triple Balloon Protection Technique Using the Mo.Ma Ultra with the Carotid GuardWire for Carotid Stenting: Technical Note

We describe the "triple balloon protection technique" (TBPT) using the Mo.Ma Ultra in combination with the Carotid GuardWire during carotid artery stenting (CAS). This technique is expected to prevent distal embolism to the internal and external carotid arteries, and is suitable for East Asians in whom the origin of the superior thyroid artery is lower than that in Caucasians. From December 2012 to May 2013, 11 patients underwent CAS using TBPT in our center. Procedural success was achieved in all patients. Complete flow blockade by angiography could not be obtained in 8 patients (72.7%) by proximal occlusion using the Mo.Ma Ultra only. Complete angiographic flow blockade was obtained in all patients by TBPT. No major adverse cardiovascular events, including stroke, myocardial infarction, or death because of any cause, occurred within 30days. The use of TBPT for CAS maybe effective for preventing distal embolisms, especially for East Asians.