MR evaluation of neurovascular lesions after endovascular occlusion with detachable balloons

Three patients with surgically inaccessible giant carotid aneurysms/pseudoaneurysms and one patient with carotid cavernous fistula had endovascular occlusion with detachable silicone balloons filled with Cholografin. MR was performed before the procedures in three cases and again 18 hr to 44 days after embolization in all four cases. The age-related changes of arterial thrombi, as well as the optimal timing and value of different pulse sequences in the noninvasive follow-up, were evaluated. Arterial thrombi have some characteristics in common with intracerebral hematomas, being isointense on T1-weighted spin-echo images during acute phase and subsequently acquiring hyperintense signals on both T1- and T2-weighted spin-echo images during the subacute and chronic phases. Additional observations are that (1) hyperacute (less than 24 hr old) thrombus is hyperintense on T2-weighted spin-echo sequences; (2) hemosiderin is less conspicuous in chronic intraluminal thrombi than in intracerebral hematomas of comparable size; and (3) thrombosis is initiated at a site remote from the apex of the aneurysm and then progresses centripetally. The Cholografin-filled balloon is hypointense to gray matter on T1-weighted spin-echo images and isointense to both hyperacute and chronic thrombus on T2-weighted spin-echo images. The optimal timing and sequence for MR follow-up of a thrombosed aneurysm with conventional spin-echo technique is beyond 7 days on T1-weighted spin-echo images. The in vivo appearance of Cholografin-filled silicone balloons does not change appreciably on T1- and T2-weighted spin-echo sequences up to 6 weeks if filled according to the manufacturer's specification.     

Therapeutic embolization with detachable balloons

In our first 18 months' clinical experience with embolization in the chest and abdomen using detachable ballons, successful results were obtained in 34 of 38 patients. One and 2-mm detachable silicone balloons, which can occlude vessels 4–8 mm in diameter, were employed. Prolonged balloon inflation was routinely achieved using iso-osmotic iodipamide meglumine as the filler and limiting inflation volumes to experimentally determined maximums. Improvements in introducer catheter design simplified delivery of the balloon into a variety of circulations. Detachable balloons are not suitable for all embolization purposes, and they are frequently used in conjunction with other agents. When used properly, balloons produce a permanent occlusion that is extremely selective and potentially reversible up to a certain point in the procedure. The balloon technique enables the angiographer to occlude vessels at distances of 2–10 mm beyond the introducer catheter, thus avoiding the need for subselective catheterization and minimizing the dangers of inadvertent embolization. Biomedical Engineer, Becton-Dickinson Corporation, Rutherford, New Jersey 07070, USA Supported in part by a grant from Becton-Dickinson Corporation, Rutherford, New Jersey 07070, USA     

A 5-F needle-sheath system for translumbar catheter angiography

A 5-F needle-sheath catheter delivery system allows translumbar introduction and interchange of 4-F-catheters with various lengths and shapes. The system was used in 236 patients. In 227 cases, a pigtail catheter was introduced for outflow studies of the lower extremities or visualization of the aortic arch. In 9 cases a selective catheter (sidewinder, headhunter, cobra) for angiography of a total of 19 vessels (carotid arteries, visceral arteries, renal arteries) was used. No major complications related to aortic puncture or catheter manipulation occured, no relevant retroperitoneal hematomas were observed. The 5-F needle-sheath system is a safe and simple alternative to the more precarious transbrachial technique. Offprint requests to: Edgar A. Rinast     

Slippery coaxial catheter system

A slippery coaxial, 3-F catheter device was developed for selective angiography, embolization, and infusion of chemotherapeutic agents. The device comprises three parts: an 0.018-inch, plastic-coated guide wire; a 3-F coaxial catheter; and a 6.5-F guiding catheter. Both the guide wire and coaxial catheter are coated with hydrophilic polymer, which becomes slippery when immersed in water. Experience with four patients indicates the new coaxial catheter device is capable of traversing tortuous vessels smoothly and safely, and it permits infusion of chemotherapeutic agents and 1-mm gelatin particles.     

Permanent inflation of detachable balloons with a low-viscosity, hydrophilic polymerizing system

A polymer system was developed for use in permanent inflation of detachable balloons, to avoid long-term reliance on the integrity of balloon shells or valve mechanisms. This system is based on 2-hydroxy-ethyl methacrylate (HEMA) as the monomer, in combination with a cross-linking agent and a water-soluble curing system. The low-viscosity, hydrophilic mixture can be exchanged through a small-bore catheter into a detachable balloon and polymerizes in 40-60 minutes at body temperature. Partially polymerized HEMA can cause vascular occlusion; hence, careful timing of balloon detachment is required. The evolution of the radiographic appearance of HEMA-filled balloons is predictable. The balloons remain radiopaque on plain radiographs as long as the balloon shell and valve mechanisms are competent. After rupture of the shell or failure of the valve mechanism, the balloons become invisible on plain radiographs but remain hyperattenuating on computed tomography scans.     

Carotid-cavernous fistula: closure with detachable silicone balloons

Detachable silicone rubber balloons, which do not require an outer catheter to effect detachment, were used to close carotid-cavernous fistulas in 10 patients. Closure was effective in nine of 10 patients. The internal carotid artery was intentionally occluded in two patients. The procedure resulted in inadvertent occlusion of the internal carotid artery in three patients. Follow-up studies showed no recurrence of the fistula; nor did any permanent neurologic deficits develop as a result of the procedure. The balloon catheter system and techniques of introduction are discussed in detail. The system is compared with other silicone and latex balloon systems that require a coaxial catheter for detachment. Technical and clinical problems are illustrated.     

Endovascular occlusion of direct carotid cavernous fistula with detachable balloons: usefulness of 3D angiography

The objective of this study is to show rotational 3D angiography findings and their usefulness in the occlusion of carotid cavernous fistulas (CCFs) using detachable balloons. Five patients with direct CCF were retrospectively reviewed for details of interventional procedures and 2D and 3D angiography findings. Pretherapeutic 2D and 3D angiograms (n=2) were compared to evaluate the size of the fistula and the relative size of the cavernous sinus with respect to the fistula. Postinflation-predetachment (n=3) and postdetachment (n=4) 2D and 3D angiograms were compared in each stage to evaluate the relative location of the balloon to the internal carotid artery (ICA), presence of a pseudoaneurysm, and relative size of the balloon to the fistula. Pretherapeutic 2D and 3D angiograms were equally effective in showing the fistula and relative size of the cavernous sinus. But, 3D angiography with cut images at arbitrary viewing angles clearly visualized the 3D relations between the ICA, fistula, and cavernous sinus. Both postinflation-predetachment 2D and 3D images in two patients equally showed a contrast-filled pseudoaneurysm outside the ICA and intraluminal location of the balloon. However, only the 3D images showed no difference in size of the balloon compared with the fistula, which was relevant to traction-induced instability in the remaining one patient. Both postdetachment 2D and 3D angiograms were equal in terms of showing ICA compromise (60%) in one patient and an extraluminal balloon location with complete fistular occlusion in two patients. In the remainder, a small pseudoaneurysm was identified only on 3D images. Three-dimensional angiography is a useful imaging tool for capturing the complex perifistular anatomy in the pretherapeutic stage, and for providing detailed information about the degree of balloon inflation and its location, the presence of a pseudoaneurysm, and the expected traction-induced instability in the predetachment stage. Postinflation-predetachment 3D angiography may therefore offer a chance to correct an erroneous manipulation that would otherwise lead to an incomplete procedural outcome and disastrous balloon migration.     

Treatment of direct carotid-cavernous fistulas with detachable balloons

Experience with transarterial treatment of 14 direct carotid-cavernous fistulas using the Debrun technique with detachable balloons manually tied to the catheter is reported. Ten of the fistulas were occluded by balloons with concomitant occlusion of the internal carotid in one case. Another fistula closed spontaneously in connection with the embolization procedure. Three fistulas were treated with surgical trapping after recurrence. The transvenous approach was attempted in three cases but failed. Four complications occurred, two with clinical consequences as the patients developed neurologic deficits. Except in four cases with persistent or slowly regressing orbital palsies all signs and symptoms of the fistula disappeared after successful occlusion. The use of detachable balloons for selective occlusion is in experienced hands a rather safe and simple method with good results. Large fistulas offer most problems, and to avoid progression in fistula size the treatment should be undertaken as soon as possible after diagnosis.     

Embolic control of lumbar artery hemorrhage complicating percutaneous renal biopsy with a 3-F coaxial catheter system: Case report

A case is presented in which massive retroperitoneal hemorrhage from the left first lumbar artery complicating a percutaneous renal biopsy was successfully controlled by superselective embolization with microcoils. An anterior radiculomedullary artery (artery of Adamkiewicz) orginated from the lumbar artery. To minimize the risk of ischemic damage to the spinal cord from embolization, the extravasating branch of the lumbar artery had to be superselectively catheterized using a 3-F coaxial catheter system. Computed tomography (CT) scan localized the hematoma within the left posterior pararenal space in the retroperitoneal space.     

Clinical usefulness of reservoir system with a coaxial catheter

We have developed a new implantable catheter and port system (reservoir) with a 2.9 Fr coaxial catheter. This study was undertaken to evaluate the initial results of the new reservoir system. Fifty-three patients with liver neoplasms underwent implantation of this reservoir owing to tortuousity, angulation, and stenosis of the hepatic arteries, and received repeated arterial infusion chemotherapy. Implantation was technically successful in all patients. Hepatic arterial occlusion occurred at rates of 13.7% at six months and 35.3% at one year. There were no major complications apart from port infection in two patients. This reservoir with a 2.9 Fr catheter expands the indications of hepatic arterial infusion chemotherapy.     

A new balloon catheter for coaxial embolization

Summary A new design for double lumen catheters which increases the size of the injection lumen by 30% is described.