Which factor increases procedural thromboembolic events in patients with unruptured paraclinoid...
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![Page 1: Which factor increases procedural thromboembolic events in patients with unruptured paraclinoid internal carotid artery aneurysm treated by coil embolization?](https://reader035.fdocuments.us/reader035/viewer/2022062413/5a4d1ba77f8b9ab0599c9929/html5/thumbnails/1.jpg)
Which factor increases procedural thromboembolic events in patients with unruptured paraclinoid internal carotid artery aneurysm treated by coil embolization?
Morio Nagahata, Rei Kondo*, Shinjiro Saito*, Atsuhito Takemura**, Toru Hatayama**
Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine, Japan
* Department of Neurosurgery, Yamagata City Hospital SAISEIKAN, Japan**Department of Neurosurgery, Aomori City Hospital, Japan
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Introduction
paraclinoid internal carotid artery aneurysm
Coil embolization is not always easy due to its anatomical location
or shape of the aneurysm.
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• Simple technique?• Combination with adjunctive technique?
such as balloon / stent assistance• Selection of the microcatheter• How about the steam shaping of the catheter tip?
Interventional neuroradiologists often worry about the appropriate coiling procedure
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Does the maneuver of
– exchanging microcatheter / coils
– combined adjunctive technique (assist balloon) lead to more frequent ischemic complication?
60F, unruptured left ICA aneurysm diameter: 6mm
coiling with balloon assistance
silent infarction
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Purpose
To analyze the factors
which increase the frequency of thromboembolic events
during the coil embolization of the unruptured
paraclinoid internal carotid artery aneurysms.
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Materials and Methods• December 2007 – April 2010• 14 consecutive patients with unruptured paraclinoid
internal carotid aneurysms– Treated with GDCs.– 1 male, 13 females– Aged 40-71, mean 58.6 y.o.– Max. diameter of aneurysm: 3.4-8.5, mean 5.5mm– Simple coiling in 7 patients– Balloon assisted technique in 7 patients
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All patients
• Received dual antiplatelet agents preoperatively.
• Systemic heparinization during the procedure.
• Posttreatment DWI was performed within 4 days.
• A neuroradiologist and a neurosurgeon evaluated the DWI.
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Analysis
Existence of the hyperintense lesion on postoperative DWI (within 4 days).
– Patients’ age, sex.– Maximum diameter of the aneurismal dome.– Coil packing density.– Use of assistant balloon.– Exchange of microcatheter.– Withdrawal of undetached coil.
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Results• Neurologically symptomatic complications did not
occur in our series. • Silent procedure-related infarction was detected on
postoperative DWI in 6 cases (35.7%).
49 F, left ICA aneurysmaneurysm diameter: 4.0mmballoon assistance (+)
exchange of microcatheter (+)withdrawal of undetached coil (+)
packing density: 29.5%
silent infarcts (++)
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n.s. n.s. n.s. n.s.
Sex M/F
Age (mean)
y.o.
max. diameter of aneurysm
(mean)mm
Coil packing density (VER)
(mean)%
ischemiccomplication
+
0 / 6 49-68(58.8)
3.4-6.0(4.72)
18.9-32.0(26.3)
ischemiccomplication
-
1 / 7 40-71(65.5)
4.1-8.5(6.10)
15.6-47.8(29.7)
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withballoon
assistance
withoutballoon
assistance
ischemiccomplication
+3 3
ischemiccomplication
-4 4
Assist balloon (HyperGlide)
n.s.
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Exchange of microcatheter
+
Exchange of microcatheter
-ischemic
complication
+3 3
ischemiccomplication
-1 7
Exchange of microcatheter during the procedure
n.s.
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Withdrawalof coil
+
Withdrawalof coil
-ischemic
complication
+6 0
ischemiccomplication
-3 5
Withdrawal of undetached coilduring the procedure
P=0.031
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• Silent infarcts found in 35.7% of our cases – 66.7% cases in which we needed to withdraw the
undetached coil during the procedure – versus 0% in patients without intraprocedural coil
withdrawal. (P=0.03)
• Patient’s age, sex• Aneurysm diameter• Packing density• Balloon-assisted technique• Exchanging maneuver of microcatheter
did not increase the frequency of silent infarcts.
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Discussion
Previous reports (cerebral aneurysms treated by coils)– Symptomatic thromboembolic complication: 1-31%– Silent infarcts observed on postoperative DWI: 20-61%– Perioperative antiplatelet management reduce the risk
Our complication rate (IC paraclinoid aneurysm): 35.7%– Asymptomatic infarcts observed on DWI– Using dual antiplatelet agents.– May be acceptable rate!
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Thromboembolic complication can occur more frequently – large or wide-neck aneurysms,– balloon-assisted technique
Soeda M, et al. AJNR 24: 127-132, 2003
Risky maneuvers during the balloon-assisted coiling– microcatheter repositioning, – coil removal and repositioning
Albayram S, et al. AJNR 25: 1768-1777, 2004
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In the present study,
• Withdrawal of the unreleased coil the only factor increasing the rate of silent
infarcts.
• Aneurismal size, • Use of the assist balloon,
• Exchange of microcatheter during the procedure did not increase the frequency of silent infarcts.
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• It has not been known which maneuver during the procedure may be responsible for most thromboembolic events.
• We should make an appropriate selection of the coil to avoid the coil withdrawal which may lead to thromboembolic complication.
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Conclusion
Coil embolization of unruptured IC paraclinoid aneurysms
• Only the withdrawal of undetached coil from the aneurysm increased the frequency of the postoperative DWI abnormalities in our series.
• Appropriate coil selection, which may reduce the necessity of coil withdrawal, is important to perform safer embolization.