Interventional treatment of coronary artery fistulas by using Guglielmi detachable coils：analysis of feasibility and safety with single center experience / 介入放射学杂志

Objective To summarize the experience in treating coronary artery fistula (CAF) by using Guglielmi detachable coils. Methods During the period from July 2009 to November 2014 at the Affiliated Changhai Hospital of Second Military Medical University, interventional treatment of CAF by using Guglielmi detachable coils was performed in 40 patients. The clinical data were retrospectively analyzed. The feasibility, safety and effectiveness of this technique were evaluated. Results Successful transcatheter closure of CAF with Guglielmi detachable coils was achieved in all 40 patients; the average Guglielmi detachable coils used in each patient was(2.33±1.38) coils. No procedure-related complications occurred. Intra-operative angiography showed that residual shunt completely disappeared in 12 patients (30%) and blood flow was significantly decreased in 28 patients (70%). All the patients were followed up for 1-65 months, neither complications such as recurrent bleeding and ischemia nor stenosis and occlusion of related arteries, or fistula cavity rupture occurred. Conclusion The use of Guglielmi detachable coil in interventional treatment of CAF is safe and effective, although its long-term effect needs to be further verified.

Thromboembolic Events Associated with Electrolytic Detachment of Guglielmi Detachable Coils and Target Coils : Comparison with Use of Diffusion-Weighted MR Imaging

OBJECTIVE: The purpose of this study was to retrospectively evaluate and compare the incidence of diffusion-weighted image (DWI) lesions between the Guglielmi detachable coil (GDC) and the Target coil for treating unruptured intracranial aneurysm. METHODS: From 2010 to 2011, consecutive 222 patients with an intracranial aneurysm underwent coil embolization. Inclusion criterias were : 1) unruptured intracranial aneurysm, 2) one or more GDC or Target coils used with or without other coils, 3) DWI examination within 24 hours after coiling, and 4) coiling performed without a balloon or stent. RESULTS: Ninety patients (92 cases) met the inclusion criteria. DWI lesions were detected in 55 (61.1%) of 90 patients. In the GDC group (n=44), DWI lesions were detected in 31 (70.5%). The average number of DWI lesions was 5.0+/-8.7 (mean+/-SD; range, 1-40) in aneurysm-related territory. In the Target coil group (n=48), DWI lesions were detected in 24 (50.0%). The number of DWI lesion was 2.1+/-5.4 (range, 1-32) in aneurysm-related territory. There was no significant correlation between a number of coils and DWI lesions. No significant differences were also observed in the number of DWI lesions in each group. CONCLUSION: The GDC and Target coils, which have an electrolytic detachable system, showed no differences in the incidence of DWI lesion.

Transcatheter closure of coronary artery fistula using Guglielmi detachable coil / 老年心脏病学杂志（英文版）

Background Coronary artery fistula (CAF) is a rare anomaly.Transcatheter CAF closure has been introduced using various materials,but only few data are available on the Guglielmi detachable coil (GDC).The advantage of using GDC for transcatheter CAF closure is more controllable,therefore much safer when compared to other coils.This report is about our experience in transcatheter closure of CAF using fibered GDC in our hospital.Methods & Results From 2002 to 2007,there were 10 patients with CAFs (age range:28 to 56 year-old,7 males) who underwent transcatheter CAF closure.There were a total of 19 CAFs which originated from right coronary (n =5),left circumflex (n =3),left anterior descending artery (n =10) and left main trunk (n =1).Median number of coil deployment for each fistula was 3 (range:1 to 6).The pulmonary artery was the most common site of the distal communication of CAFs (n =14),followed by right atrium (n =3),left atrium (n =1) and left ventricle (n =1).Immediate coronary angiography after GDC deployment revealed no residual shunt in 12 (63.2％) CAFs,significant reduction of the flow in 5 (26.3％),while 2 (10.5％) could not be closed due to small size.Nine (90％) patients underwent a repeated angiography within 3 to 8 months.Among 12 CAFs that were occluded immediately post-deployment,there were 2 CAFs with insignificant residual flow.Among 6 CAFs with significantly decreased flow immediately post-deployment,2 were occluded totally in the follow-up angiography.In total,12 (70.5％) CAFs were occluded completely and 5 (29.5％) CAFs still had insignificant residual flow,which did not need any additional coil deployment.During a mean follow up of 4.3 ± 0.7 year,all patients remained symptom and complication free.Conclusions The fibered GDC is a safe and effective method for percutaneous closure of the CAFs.

In Vitro Observation of Air Bubbles during Delivery of Various Detachable Aneurysm Embolization Coils

OBJECTIVE: Device- or technique-related air embolism is a drawback of various neuro-endovascular procedures. Detachable aneurysm embolization coils can be sources of such air bubbles. We therefore assessed the formation of air bubbles during in vitro delivery of various detachable coils. MATERIALS AND METHODS: A closed circuit simulating a typical endovascular coiling procedure was primed with saline solution degassed by a sonification device. Thirty commercially available detachable coils (7 Axium, 4 GDCs, 5 MicroPlex, 7 Target, and 7 Trufill coils) were tested by using the standard coil flushing and delivery techniques suggested by each manufacturer. The emergence of any air bubbles was monitored with a digital microscope and the images were captured to measure total volumes of air bubbles during coil insertion and detachment and after coil pusher removal. RESULTS: Air bubbles were seen during insertion or removal of 23 of 30 coils (76.7%), with volumes ranging from 0 to 23.42 mm3 (median: 0.16 mm3). Air bubbles were observed most frequently after removal of the coil pusher. Significantly larger amounts of air bubbles were observed in Target coils. CONCLUSION: Variable volumes of air bubbles are observed while delivering detachable embolization coils, particularly after removal of the coil pusher and especially with Target coils.

Giant High-Flow Type Pulmonary Arteriovenous Malformation: Coil Embolization with Flow Control by Balloon Occlusion and an Anchored Detachable Coil

Pulmonary arteriovenous malformations (PAVMs) are often treated by pushable fibered or non-fibered microcoils, using an anchor or scaffold technique or with an Amplatzer plug through a guiding sheath. When performing percutaneous transcatheter microcoil embolization, there is a risk of coil migration, particularly with high-flow type PAVMs. The authors report on a unique treatment in a patient with a giant high-flow PAVM whose nidus had a maximum diameter of 6 cm. A detachable coil, not detached from a delivery wire (an anchored detachable coil), was first placed in the feeding artery under flow control by balloon occlusion, and then multiple microcoils were packed proximally to the anchored detachable coil. After confirming the stability of the microcoils during a gradual deflation of the balloon, we finally released the first detachable coil. The nidus was reduced in size to 15 mm at one year postoperatively.

Risk factors and treatment experience of cerebral aneurysms rupture in the course of Gugliemi detachable coil embolization / 中国医师进修杂志

Objective To investigate the risk factors and treatment experience of cerebral aneurysms rupture in the course of Gugliemi detachable coil (GDC) embolization. Methods From August 2000 to June 2010,420 patients with aneurysmal subarachnoid hemorrhage (SAH) received GDC embolization and their clinical data were retrospectively reviewed to analyse the risk factors of cerebral aneurysms rupture in the course of treatment. Results Sixteen patients had intraoperative aneurysm rupture, the incidence rate was 3.8%(16/420),including 13 cases density filling,3 cases partial filling postoperative.Univariate analysis showed:SAH episodes ≥2 times,tumor size ≤4 mm,the presence of pseudoaneurysm,Hunt-Hess grade Ⅳ - Ⅴ as well as history of hypertension were the risk factors of cerebral aneurysms rupture in the course of GDC embolization. Logistic regression analysis showed:SAH episodes ≥2 times (P = 0.0424,OR =6.798)and the presence of pseudoaneurysm (P = 0.0069, OR = 4.423) were the independent risk factors of cerebral aneurysms rupture. Conclusions Rupture of intracranial aneurysm in the course of GDC embolization is mainly related to the multiple SAH and the presence of pseudoaneurysm. It should be alert to the risk factors and take active treatment as soon as the occurrence of rupture in clinic work, for this, most patients can get a good prognosis.

Combining Neuroform stents and Guglielmi detachable coils for treating acute ruptured giant intracranial aneurysms / 中国医师进修杂志

Objective To investigate the efficacy, technical tip, safety and complication prevention of combining Neuroform stents and Guglielmi detachable coils for treating acute ruptured giant intracranial aneurysms. Methods Among 10 cases who were diagnosed with giant intracranial aneurysms,Neuroform stents were released for supporting the neck of aneurysms, then micro-catheters were inserted into aneurysms through lumina of stents and coils were implanted. Results All the operations were completed successfully. There was no complication in these cases. The aneurysms were packed totally in 9 cases and partly in 1 case.Eight postoperative cases were followed up by 6 to 17 months. Neither bleeding nor thrombus was found, and all the patients recovered well. Conclusion Combining Neuroform stents and Guglielmi detachable coils for treating acute ruptured giant intracranial aneurysms is a safe and effective method.

Fusiform Intracanalicular Ophthalmic Artery Aneurysm; Case Report and Review of Literature

A 35-year-old man's vision had progressively deteriorated over a 3-month period. His left visual acuity was 5/20. Enhanced orbital computed tomographic (CT) scans revealed a fusiform dilatation of the ophthalmic artery in the left optic canal. Cerebral Angiography revealed a fusiform aneurysm on the left ophthalmic artery in the optic canal, measuring 6.2 x 4.6 mm in size. Four days after admission, visual acuity dropped to hand-motion. Endovascular treatment was chosen and a microcatheter was guided into the proximal segment of the ophthalmic artery. Using 4 detachable coils, parent artery occlusion was done. Three months after the intervention, the visual acuity in his left eye improved to 20/20. Dramatic recovery of visual acuity is exceptional with an ophthalmic artery trunk aneurysm. When an occlusion of the proximal ophthalmic artery is the only treatment option in such a situation, the endovascular occlusion of the proximal ophthalmic artery is quite feasible in the sense that it does not require any optic nerve manipulation.

Microcatheter-assisted Coil Embolization of Distal Vertebral Artery Wide-Necked Aneurysm: A Case Report / 신경중재치료의학

Endovascular treatment of wide-necked intracranial aneurysms remains challenging despite continuing instrumental and technical advances. A 67-year-old woman visited us for an asymptomatic unruptured aneurysm at the right distal vertebral artery and was planned to undergo endovascular coil embolization. During a second coil placement through a single microcatheter, the first coil frame was deformed and protruded into the parent artery. We decided to jack-up the protruded coil using an additional microcatheter because the tortuous vertebral artery path didn't allow a balloon or stent device to approach this aneurysm for parent artery protection. Using that microcatheter-assisted technique, the parent artery could be preserved and the aneurysm could, moreover, be excluded.

Comparison of three different endovascular approaches for the treatment of intracranial giant or large type aneurysms / 介入放射学杂志

Objective To evaluate the clinical efficacy of detachable balloons,detachable coils and intracranial covered stents in management of intracranial giant aneurysms.Methods From April 1998 to March 2006,20 patients with a giant or very large aneurysm were treated by parent artery occlusion(PAO), coils embolization and covered stent,in which 9 aneurysms were treated by PAO,8 by coils embolization and 3 by covered stent at initial management.Two recurrent aneurysms treated by coils embolization were performed by covered stent.Follow-up 9-83 months,mean 41.1?25.3 months.Immediate postprocedural angiographic outcomes were categorized as complete occlusion(100%),subtotal occlusion(95%-99%),and incomplete occlusion(＜95%)of the aneurysms;and follow-up angiographic outcomes were categorized as stable, thrombosis,and recanalization.Clinical outcomes were graded according to a modified Glasgow Outcome Scale (GOS).Results Endovascular treatment was technically feasible in all aneurysms without procedural-related complications.Immediate postprocedural angiograms showed complete occlusion was achieved in 11 aneurysms, subtotal occlusion in 7 and incomplete occlusion in 2.One patient with incomplete occlusion died on the seventh day with a rebleeding.The final angiographic findings in nineteen survival patients confirmed a complete occlusion in 15 aneurysms,subtotal occlusion in 3 and incomplete occlusion in 1,in which 10 parent arteries were successfully preserved.No rebleeding occurred during the follow-up period.The clinical evaluation performed at final follow-up in 19 patients revealed that the symptoms disappeared in 11 patients and improved in 8 in the modified GOS.Conclusions Treatment of giant intracranial aneurysms with coiling was associated with a low complete occlusion rate and a high recanalization rate.Treatment with endovascular parent artery occlusion remains practical,but this technique may result in damage to the parent artery and cause cerebral ischemic events.The use of an intracranial covered stent proved to be a relatively simple and safe procedure and maintained the pateney of the parent artery.

Rescue Balloon Reposition of the Protruding Coil Loops during Endovascular Treatment of An Anterior Communicating Artery Aneurysm: A Case Report / 신경중재치료의학

Protrusion of coil loop(s) and subsequent occlusion of the parent artery is one of the dreadful complications during endovascular coil embolization of cerebral aneurysm. Although protrusion of one or two coil loops may not cause adverse events and can be ignored in many instances, it can also compromise the parent artery in some cases with or without thrombus formation. We report a case of rescue balloon reposition of the protruding coil mass back into the aneurysm and recanalization of parent artery during embolization of the anterior communicating artery aneurysm.

Feasibility & Limitations of Endovascular Coil Embolization of Anterior Communicating Artery Aneurysms

OBJECTIVE: The purpose of this study is to analyze aneurysm morphology and define limitations and feasibility in endovascular Gugliemi detachable coil(GDC) embolization for anterior communicating artery (ACoA) aneurysms. METHODS: From January 2000 through October 2003, 123patients were treated with endovascular coil embolization for ACoA aneurysms. There were 75women and 48men, with a mean age of 63years. All ruptured aneurysms were treated within 15days of rupture. Aneurysm morphology was classified according to neck size and projection of aneurysm dome as follows - A: neck of aneurysm or =4mm) aneurysms are highly related to recanalization of aneurysms. CONCLUSION: Endovascular coil embolization of ACoA aneurysms shows good outcome in our study. Nevertheless, there is a limitation in the endovascular approach to ACoA, even though advanced modern techniques evolve rapidly. Compensatory surgical approach with the endovascular approach is required for successful treatment of ACoA aneurysms.

Double microcatheter technique for detachable coil treatment of wide-necked intracranial aneurysms / 介入放射学杂志

Objective To evaluate double microcatheter technique for detachable coil treatment of wide-necked intracranial aneurysms. Methods Routine endovascular coil occlusion was not achieved in 6 cases of wide-necked intracranial aneurysms. A second femoral arterial sheath was inserted on the opposite side . A second microcatheter was positioned within the aneurysm. The detachable coils were introduced via double microcatheter simultaneously or successively till the aneurysm were compactly embolized. The coils were detached after satisfactorily positioned. Results Total 6 cases of wide-necked aneurysms were successfully embolized with detachable coil. Aneurysmal sacs were 100% embolized in 2 cases, over 90% in 4 cases. 1 case suffered moderate disablement as a result of complication of. Angiographic follow-up in 5 cases revealed no recurrent or rerupture.Conclusions The double microcathter technique may be an optional method during embolization of some complicated wide-necked aneurysms.

Hemodynamic Infarction Associated with Coil Embolization of Intracranial Aneurysm / 대한뇌혈관외과학회지

We report a case of borderzone infarction which was developed after the coil embolization of unruptured internal carotid-posterior communicating artery aneurysm. Post-procedural angiography and brain computerized tomographic scan did not reveal any abnormality. However, brain magnetic resonance image (MRI) showed a wedge-shaped borderzone cerebral infarction between left middle cerebral artery and left anterior cerebral artery territory. It was suspected to be a manifestation of hypoperfusion in the internal carotid artery territory, caused by hemodynamic instability during the procedure. In order to prevent this unexpected serious complication, using the continuous hemodynamic monitoring during aneurysmal coil embolization, such as transcranial doppler ultrasonography, should be considered.

Failed GDC Embolization for Aneurysms Arising at the Fenestrated Anterior Communicating Artery

Fenestration of anterior communicating artery is one of relatively common anomalies. It is not always possible to check all of the anomalies in the anterior communicating artery by conventional angiogram. In case of coil embolization on aneurysm located in anterior communicating artery, the fenestration may cause unexpected complications. The evidential example taken here shows a 41-year-old patient with an anterior communicating artery aneurysm, on whom GDC embolization failed due to coil migration and ligation of aneurysm was given in a surgical treatment. The operative findings led to the discovery of the unexpected fenestration of anterior communicating artery and two separate aneurysms arising at each side of the fenestrated anterior communicating artery. A great concern should be given in coil embolization of aneurysms arising at the anterior communicating arteries.

Endovascular Treatment of Cerebral Aneurysms with Guglielmi Detachable Coils: Retrospective Review of a 4-Year Experience

OBJECTIVE: The authors evaluate the usefulness, results, and technical problem of endovascular treatment of cerebral aneurysms with Guglielmi detachable coil(GDC). METHODS: Forty patients with 31 ruptured and 11 unruptured aneurysms were treated with GDC embolization. Twenty-four aneurysms were located in the anterior circulation and 18 in the posterior circulation. Aneurysms size was categorized small(n=31) or large(n=11) and neck size was categorized narrow(n=30) or wide(n=12). We statistically analyzed occlusion rate according to the location, rupture, size, and neck size of aneurysms, and investigated the procedure-related complications and clinical outcomes. RESULTS: GDC treatment of aneursyms was successful in 40 aneurysms of 39 patients(95.2%). Total occlusion was achieved in 24(60.0%) cases, subtotal occlusion in 12(30%), and incomplete occlusion in 4(10.0%). Each total occlusion rate was 69.0% in small-sized, 36.4% in large-sized, 69.0% in narrow-necked, and 36.4% in wide-necked aneurysms. Location and rupture of aneurysms did not influence occlusion rate. The technical complications included 4 thromboembolisms, 3 parent artery occlusions, and 1 perforation of aneurysm. Procedure-related morbidity and mortality were 10.3% and 2.6%. 3 subtotally or incompletely embolized aneurysms in posterior circulation rebled during the follow-up period. CONCLUSION: The results of this study indicate that endovascular GDC treatment is an appropriate therapeutic alternative in cerebral aneurysms. However, the rebleeding by aneurysmal recanalization or regrowth is a major limitation of GDC treatment. Follow-up angiography and further technical improvement are mandatory to overcome rebleeding.

Embolization of Cerebral Aneurysms by Using the Guglielmi Detachable Coil

OBJECTIVE: The authors present the results of treatment and clinical outcome of intracranial aneurysm treated by Guglielmi detachable coil(GDC) embolization according to the location, size of the aneurysms and pre-operative state of patients. METHODS: We collected 222 patients who had 254 intracranial aneurysms and underwent endovascular treatment with GDC, which were treated at our institute during the 7-year period from 1995 to 2002. One hundred and forty-nine patients were females and 73 were males. Patient age ranged from 10 to 90 years(average: 54.1 years). One hundred and thirty-eight aneurysms were presented with ruptured aneurysm, 116 with unruptured aneurysm. Sixty aneurysms were located in the posterior circulation and 194 in the anterior circulation. Among the 138 ruptured aneurysms, fifteen patients were classified as Hunt-Hess Grade I, 64 Grade II, 25 Grade III, 20 Grade IV, and 14 Grade V. RESULTS: Among total of 254 aneurysms, we were achieved 90 to 100% obliteration of the aneurysm in 228 cases(89.8%) but failed in 6(2.4%) and partial obliteration(below 90%) in 20(7.9%). Overall mortality rate was 1.6%(4 cases) including 2 poor preoperative neurological status(Hunt-Hess Grade IV-V), 1 Hunt-Hess Grade III case with post-embolic rebleeding and one failed-embolic rebleeding. CONCLUSION: Embolization of intracranial aneurysms with GDC is safe, effective and reliable, and short-term clinical results of the endovascular treatment of cerebral aneurysm indicate that this procedure is a useful alternative approach in selected patients. Further follow-up review is necessary to establish durability in the long term outcomes, indication of GDC embolization and protection of rebleeding.

Neuroendovascular Therapy-Current Technical Advancement / 대한뇌혈관학회지

This article surveys current technical advancement in neuroendovascular therapy. The technical advancement happens not only in the field of products of microcatheter and guide wire but in the field of diagnosis. In the local intraarterial fibrinolysis, diffusion weighted MR imaging allows us more precise patient selection. In the atherosclerotic lesions, stent is clinically available. Some types of stent can be used in intracranial arteries. In the acutely ruptured aneurysm, intraanerysmal embolization using Guglielmi detachable coil followed by intratechal tissue-type plasminogen activator reduced occurring rate of vasospasm. In the wide neck aneurysm, neck plasty technique brings us better results. Neuroendovascular therapy is still evolving supported by such technical advancement.

A Case of Internal Carotid Artery Traumatic Pseudoaneurysm with Epistaxis: Treated with Detachable Balloon Occlusion (DBO) and Detachable Coil / 대한이비인후과학회지

Traumatic pseudoaneurysm of the intracavernous internal carotid artery (ICA) is rare, but it is life threatening because of massive epistaxis. Unfortunately, the prompt diagnosis and treatment of this desease are frequently delayed due to its rarity and latent period. Optimal therapy for this diseases is essential in order to minimize its morbidity and mortality. The authors present a case of male patient with traumatic pseudoaneurysm of ICA. This patient was a 24-year-old male with a multiple facial bone fracture, with unilateral blindness and recurrent massive epistaxis after suffering a head trauma. Computed tomography, MRI and carotid artery angiogram showed intracavernous pseudoaneurysm. The patient was effectively treated with occlusion of the ICA circulation by endovascular treatment utilizing detachable balloon occlusion (DBO) and mechanically detachable tungsten coils.

Controversies in the Coil Embolization of Intracranial Aneurysms

GDC embolization has been performed selectively since 1991 in patients with intracranial aneurysms and made remarkable technical and clinical advances in recent years. But until now, this procedure lacks an adequate long-term follow-up study. Also, clear mechanism and evidence of electrothrombosis and endothelialization of aneurysm neck, the incidence of vasospasm after GDC embolization are still controversial. Here we critically reviewed the published literatures pertaining to the GDC embolization in order to gain a comprehensive understanding and knowledge of forementioned controversies. Also from November 1997 to April 1999, we treated 12 patients of intracranial aneurysms with GDC embolization. In conclusion, although certain shortcomings and controversies are still remain, the GDC embolization can be an alternative, supportive and attractive therapeutic modality in the treatment of intracranial aneurysms. Not only to improve outcome of intracranial aneurysms but also fulfill the patient's requirement, we need cooperations and cross-training with the interventional neuroradiology and rigorous academic evaluation on anatomy of cerebral vasculature and pathophysiology of cerebrovascular disorders.