Parent Vessel Sacrifice

Parent vessel occlusion is still an acceptable treatment for aneurysms that are not amenable to endovascular coiling or surgical clipping. Broad-necked and fusiform aneurysms are often not amenable to endovascular treatment unless parent vessel sacrifice is an option. This procedure is mainly reserved for large or giant aneurysms that lack a definable neck.

Balloon test occlusion of the parent vessel to assess tolerance to the occlusion should always precede balloon detachment. If the test is not tolerated, an extracranial-intracranial bypass procedure can be considered. Following a successful balloon occlusion test, detachable balloons are placed proximal to or at the aneurysm neck. Fox et al. (78) reported a 0% mortality in a series of 65 patients with cerebral aneurysms treated with proximal artery occlusion with detachable latex balloons. Of the treated patients, 37 had aneurysms in the cavernous or petrous ICA, 21 had aneurysms in the supraclinoid ICA, 6 had aneurysms of the proximal basilar artery, and 1 had an aneurysm of the vertebral artery. Delayed ischemic symptoms developed in 13.2% of the patients, with a 1.5% permanent morbidity. In a large series of 87 patients with cavernous carotid artery aneurysms treated with detachable silicone balloons, proximal occlusion was performed in 68 patients, and intraaneurysmal balloon placement in 19 patients, followed by filling of the balloon with liquid polymerizing permanent embolic material to ensure lasting results (79). The permanent morbidity in this series was 4.6%. Three of the 68 patients (4.4%) with a proxi-

bosed, with no residual inflow after 4 d on oral antiplatelet therapy. There is a small neck remnant above the left P1. An additional stent from the distal basilar artery to the left P1 could be considered to help support coil reconstruction of this remnant if indicated.

mal occlusion and 1 of 19 patients (5%) with direct balloon occlusion of the aneurysms developed a stroke. The physical properties of silicone balloons are more favorable for endovascular use compared with the latex balloons. Sili-cone balloons are more pliable and are thought to carry a lower risk of vessel rupture (80,81). Moreover, the silicone shell does not degrade over time as latex does (81,82). These results compare favorably with those of surgical ligation of the common carotid artery or the proximal ICA, which carry a high procedural morbidity and mortality and are associated with a substantial permanent neurologic deficits (83).

Occlusion of the parent vessel can also be performed with coils (84,85) (Fig. 6). The procedure can be combined with temporary proximal flow arrest with a nondetachable balloon in cases in which the arterial anatomy or disease process precludes the safe delivery and deployment of detachable balloons (86). Hughes et al. (87) showed in an experimental canine model that the use of proximal flow arrest during coil placement eliminated the risk of distal embolic events and reduced the risk of distal coil migration. The precise coil placement was facilitated with this technique.

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