Balloon assisted coiling-Are we over doing stent assisted coiling?

1. BALLOON ASSISTED COILING-
ARE WE OVER DOING STENT ASSITED
COILING
Vipul Gupta
Interventional Neuroradiology/
Neurointerventional Surgery
Institute of Neurosciences
Medanta the Medicity

4. Major changes
 Length of balloon
 Double lumen
 14 wire, easy to reshape,
stability, exchange
 Placement of stents
 Distal infusion
Historical
 One of the major issues for coiling – broad neck
 Prof J Moret – “Remodeling technique”
Interventional Neuroradiology 1997

5. Uses of balloon
 Broad neck aneurysm
 Remodelling – J Moret
 Packing density
 Control of rupture
 Test occlusion

6. Remodeling- broad neck

7. Balloon assisted coiling

8.  Intra-operative rupture

9. Test
occlusion

10. ANATOMICAL RESULTS
IMMEDIATE TOTAL
OCCLUSION
SUBTOTAL
OCCLUSION
INCOMPLET
E
OCCLUSION
BRT 73% 22% 5%
COILING
ALONE
49% 39% 13%
FOLLOW UP TOTAL
OCCLUSION
SUBTOTAL
OCCLUSION
INCOMPLET
E
OCCLUSION
BRT 72% 17% 10%
COILING
ALONE
54% 34% 11%
Shapiro et al AJNR 2008

11. BAC – complications
M Piotin et al , Frontiers in Neurology, 2014

12. Remodeling technique for endovascular treatment of ruptured
intracranial aneurysms had a higher rate of adequate
postoperative occlusion than did conventional coil
embolization with comparable safety.
Pierot L Cognard C, Anxionnat R, Ricolfi F; CLARITY Investigators.
CONCLUSION –REMODELING
TECHSAFE AND MORE EFFICACIOUS IN
TERMS OF POSt OP OCCLUSIONTHANTHE
CONVENTIONALCOILINGTECH
Radiology. 2011 Feb;258(2):546-53.
POSTOP ANATOMICAL RESULTS

13. Technique
 Sidewall- compliant balloon, if overinflation
needed and aneurysm not large supercompliant
 Bifurcation- Supercompliant
 Usually balloon with 014 wire
 Wire – usually choice, Synchro
 6 F (.70) Guiding catheter , long sheath (Raphe,
Cook)
 Choose the right branch (even if takes time,
effort…)- more involved, lobule near neck

14.  Usually check after first coil placement
 Thereafter – multiple coils in single inflation –
5min (may be more)
 Increase heparinization, BP maintenance
 If unruptured- anti-platelet beforehand
 Overall – 70-80% of cases (our practise- 90%
ruptured, 80% small)- trend towards balloon
coiling in all broad neck aneurysms

15. Choice of artery …

18. Placement angle….

21. A B C

22. STENTASSISTED COILINGTECH VS STANDALONE COILING
ADVANTAGES –
Scaffolding, haemodynamic effect, straightening of vessels
DRAWBACKS WITH SACT:
• looser aneurysm packing, lesser immmediate angiographic occlusions
rate than the stand alone coiling
• DUAL ANTIPLATELET – RISK OF HEMORRHAGICCOMPLICATION
• MORETHROMBOEMBOLIC RISKS
AT FOLLOW UP COMPLETE OCCLUSION RATE WITH SACT
INCREASEDTO 73.4% IN SACTVS 54% IN SAC

23. MORBI-MORTALITY
WITH STAND ALONE
COILING OR BRT
MORBI-MORTALITY
WITH STENT ASSISTED
COILING
Nishido et al.(AJNR 2014)
unruptured and ruptured
aneurysms
5.6% 9.4%
Shapiro et al. (AJNR
2012) review, unruptured
and ruptured aneurysms
NA 12.2%
GeyIk at al (AJNR 2013) NA 6.4%
Stent assisted coiling .. Complication rate
M Piotin et al , Frontiers in Neurology, 2014

24. Balloon – specific situations
 Branchfromaneurysm–overinflationtech.
 Near the neck rupture – catheter reposition tech.
 Unstable catheter coils- Single inflation
 Circumferential involvement- end hole technique
 Verysmallaneurysm–partialinflationtech
 Displaced coil loop – balloon reposition
 Balloon assisted MC placement

25. Branch from aneurysm- Overinflation technique

26. A B

28.  Near the neck rupture

29. Multi-lobulated aneurysms-
Catheter reposition

31.  Single inflation technique

32.  Circumferential involvement-End hole

33. Follow-up

36. Very small aneurysm-
partial inflation technique

37.  Displaced coil loop(s)- Balloon repositioning

41. Stents in acute SAH
• 548 aneurysms ; 35 aneurysms in 33 patients
 Loading dose of double antiplatelets (Ecospirin -300 mg
and Clopidogrel -450mg/Prasugrel -50mg)
• Wide Neck aneurysms - 16 ; Dissecting /blister aneurysms - 19
• Single (28) or double overlapping (5) stents with additional coil
placement in 26 aneurysms.
28
2 3
0
5
10
15
20
25
30
mrs 0-2 mrs 3-5 mrs 6
Good outcome -
28/33 (84.9%)
Management Morbidity -
2/33 (6.1%)
Management Mortality -
3/33 (9.0%)
TE – 5, Rupture – 1, ICH/IVH at EVD site - 2

42. Review of literature
Neurosurgery. 2012 Jun;70(6):1415-29; discussion 1429. doi: 10.1227/NEU.0b013e318246a4b1.
Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: experience in 65 patients.
Neurosurgery. 2013 Jun;72(6):953-9. doi: 10.1227/NEU.0b013e31828ecf69.
Treatment of ruptured intracranial aneurysms: comparison of stenting and balloon remodeling.
AJNR Am J Neuroradiol. 2011
Aug;32(7):1232-6. doi: 10.3174/ajnr.A2478.
Epub 2011 May 5.
Stent-assisted coiling in acutely ruptured
intracranial aneurysms: a qualitative,
systematic review of the literature.

43. Recurrences and neck
• Small aneurysm with small neck – very low need
of retreatment – 3% (T Ries et al, AJNR 2007)
• Increased risk >10mm and >4mm neck
• Raymond et al Stroke 2003, did not find increased
risk when neck > 4mm
• Small reccurences (2mm) amd residual necks –
very low risk of rebleeding – (T Ries et al, AJNR
2007, Hayakawa M J Neurosurg 2000
• Repeat treatment is low risk (Henkes h et al
Neurosurg 2006;Tries et al AJNR 2007)

44. When stent ?
• Large and giant aneurysms
• Blister
• Fusiform and dissecting aneurysms
• Recurrent

45. Points to ponder …..
• Relevance of small neck
• Significance of small residual in unruptured ??
• Are we behaving like clipping surgeons – cure at
a higher complication rate
• If there is a trial in small aneurysms?
• Controlling a disease vis a vis killing a disease
• Let us learn from experiences in other diseases –
AVM and carotid trials …..

46. Balloon assisted coiling
 Extremely versatile technique
 Almost essential in treating difficult
ruptured aneurysms
 Modern balloons – easier, better
 Overall doesn't increase complication
rate
 Stent when needed
 Personal balance

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48. Thank you