Procedure Complications

Aneurysm Rupture During Coiling

Vinuela et al. (41) reported a rupture rate of 2% in a series of 700 aneurysms treated with GDCs. This complication was more common in small aneurysms. In a reported series of 128 aneurysms, Valavanis et al. (42) observed aneurysmal perforation only in previously ruptured small aneurysms. The most common cause is forward migration of the micocatheter. Therefore, tension within the microcatheter has to be minimized (43). The guidewire should be removed very slowly under fluoroscopic visualization (44). Perforations also commonly occur during the first coil placement (45). The strategy for managing this serious and potentially fatal complication includes immediate reversal of heparin anticoag-

ulation with protamine sulfate. The coil delivery should be completed in an attempt to achieve dense packing and sealing of the perforation site. Some neu-rointerventionalists suggest leaving the initial microcatheter in place across the perforation and using a second microcatheter to access the aneurysm and coil its lumen (46). The blood pressure should be pharmacologically reduced. Emergency ventriculostomy placement in the angiography suite should also be considered to decrease the intracranial pressure.

Thromboembolic Complications

Thromboembolic events are the commonest complication of endovascular treatment of aneurysms. A rate of up to 28% clinically evident thromboembolic events has been reported, with a 3.4% rate of permanent neurologic deficit (47). The anticoagulation regimen, the aneurysm size, location, and neck morphology, the number of guiding catheters and microcatheters, the patient's clinical status, and the operator's experience are important determining variables of the frequency of these events (48). Intraarterial fibrinolysis or mechanical clot fragmentation can be used to restore vascular patency (49). In cases of ruptured aneurysms, the administration of fibrinolytic drugs should be avoided. The platelet glycogen receptor IIb/IIIa antagonist abciximab has been used successfully in the treatment of acute arterial intracranial thrombosis, resulting in prompt clot dissolution (50). The shorter half-life platelet glycogen receptor IIb/IIIa antagonists eptifibatide and tirofiban may be a better choice in this setting.

Coil Herniation into the Parent Vessel

Coil protrusion into the parent artery is more common in aneurysms with a wide neck, which is less likely to contain the coil loops, and in aneurysms located at complex branching points incorporating outflow arteries into the aneurysm base or walls such as the MCA bifurcation. It can potentially lead to occlusion of the parent vessel or serve as a source of distal emboli. These are more common in small arteries, such as the M1 segments of the MCA, the P1 segments of the posterior cerebral arteries and the anterior communicating arteries (41). Attempts can be made to push the herniated coil part back into the aneurysm lumen with a microwire or by inflating a balloon at the ostium of the aneurysm. If these prove unsuccessful, we elect to use long-term antithrombotic therapy with aspirin. 3DA delineates the exact relationship of the aneurysmal sac to the parent vessel and helps to minimize the risk of parent vessel occlusion. 3D imaging is particularly useful in MCA and anterior communicating artery aneurysms. In a study of the added value of 3DA in the endovascular management of cerebral aneurysms, it was found that 3DA facilitated coiling, modified treatment, eliminated the need for treatment, and predicted potential complications by providing additional morphological information (51) (Fig. 1).

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