Introduction

Aneurysm coiling supported by balloon remodelling is a well known endovascular technique, especially for complex, wide-necked aneurysms. The efficacy and safety of this technique have been well established.2)

But, neck remodelling techniques across the aneurysm neck for the anterior communicating artery (ACoA) is not common due to its bilateral supply and near-midline localisation. Good visualisation and understanding of the entire H-complex prior to coil embolisation is the key to successful neurointervention of ACoA complex aneurysms. However, visibility of the target area can be limited due to many factors including bilateral arterial supply, flow competition and individual anatomical variations.

To overcome such limitations to visibility, we performed a bilateral femoral puncture and placed guiding catheters in both internal carotid arteries (ICA). We then performed simultaneous bilateral internal carotid angiography for balloon-assisted coil embolisation of AcoA aneurysms (ACoAA). The present report describes three such cases.

Materials and Methods

Patients

Three patients with a complex ACoAA identified on computed tomography angiography (CTA) and cerebral angiography were selected and embolised under bilateral carotid angiography. All patients presented with acute subarachnoid haemorrhage due to a ruptured aneurysm.

Endovascular Treatment

For all three patients, routine cerebral angiography was performed independently using a biplane angio-machine. Choice of which side would be used for the endovascular coil embolisation approach was based on anatomical details including aneurismal shape, dome direction and A1 segment dominancy.

Under the general anesthesia, a 6 French guiding catheter was placed in the working-side proximal ICA using a coaxial method. A 5 French guiding catheter was then positioned in the contralateral proximal ICA through another femoral route. During the whole procedure, continuous flushing with a heparin mixed saline solution was maintained bilaterally to prevent thromboembolic com- plications.

We then performed a simultaneous bilateral ICA angiography to obtain detailed anatomy of the entire H-complex and found that we could place the compliant balloon (HyperForm, ev3 Inc.) across the ACoA. Coil embolisation under balloon assistance was then undertaken in a usual manner. No additional antiplatelet medication was given during the peri-operative period.

In all cases, we achieved compact coil packing, and there were no complications related to bilateral angiography.

Discussion

ACoAA are complex due to frequent anatomical variations. Full visualisation of the major arterial trunks and perforating arteries in this area is critical for successful outcomes in both clipping and coiling procedures.

However, neurointerventionalists sometimes experience great procedural limitations when performing typical coil embolisation for ACoAA with unilateral ICA angiography. In addition, full visualisation of the H-complex is not always possible due to anatomical complexity arising from midline-localisation and occasional flow competition around the ACoA. Still, a complete aneurysm occlusion in endovascular treatment of ACoAA has been reported in 45.5%.1)

Song et al. documented simultaneous 3-D bilateral ICA rotational angiography in a patient with a ruptured ACoAA.3) In that report, the authors emphasised the effectiveness of simultaneous bilateral ICA angiography in ACoAA.

The present report describes a three-case series in which bilateral ICA angiography was used for balloon-assisted coil emboilisation of ACoAA. This approach allowed ACoA crossing, neck remodelling (Fig. 1, 3) or the use of additional devices through bilateral routes to the ACoA (Fig. 2).

However, this approach has some potential shortcomings, such as additional risks related to secondary femoral artery access or increased use of contrast. Usual adverse events following catheterisation of femoral artery were less than 4%, the most common being local bleeding with haematoma.4) And because bilateral angiographies are performed only as the situation demands, additional use of contrast is also very limited compared to typical coil embolisation procedures.

Conclusion

We suggest neck remodelling technique for selected complex ACoAA under bilateral ICA angiography as an alternative endovascular strategy.

REFERENCES

1)Guglielmi G, Viňuela F, Duckwiler G, Jahan R, Cotroneo E, Gigli R. Endovascular treatment of 306 anterior communicating artery aneurysms: overall, perioperative results. J Neurosurg 110:874-9, 2009

2)Shapiro M, Babb J, Becske T, Nelson PK. Safety and efficacy of adjunctive balloon remodeling during endovascular treatment of intracranial aneurysms: a literature review. AJNR Am J Neuroradiol 29:1777-81, 2008

3)Song JK, Nimi Y, Brisman JL, Berenstein A. Simultaneous bilateral internal carotid artery 3D rotational angiography. AJNR Am J Neuroradiol 25:1787-9, 2004

4)Tavris DR, Dey S, Albrecht-Gallauresi B, Brindis RG, Shaw R, Weintraub W et al. Risk of local adverse events following cardiac catheterization by hemostasis device use-Phase II. J Invasive Cardiol 17:644-50, 2005