Procedure

Anticoagulation

For endovascular procedures in unruptured aneurysms, systemic anticoagulation with heparin should be administered during the procedure to minimize thromboembolic complications. Intravenous aspirin is also administered. Some groups elect to give heparin to patients with ruptured aneurysms from the start of the procedure. Our approach with regard to coiling of ruptured aneurysms is to withhold the administration of heparin until the first coil is placed. Heparin is sometimes continued for 1-2 d after the procedure.

The GDC System

The GDC system consists of a platinum coil attached to a stainless steel delivery wire. The coil has a circular memory, which it assumes once it is advanced past the microcatheter tip. Application of electric current results in dissolution of the solder joint between the delivery wire and the platinum coil. Several sizes, shapes, and softness grades are available to conform to the diverse aneurysm morphology.

Fig. 3. Sequential coiling of a right internal carotid artery (ICA) giant aneurysm. Angiograms in 2D (top) and/or 3D (bottom) are performed after a coil has been positioned but not detached. From left to right are angiograms after 1 coil, 3 coils, and 22 coils have been placed. The pushwire within the microcatheter is also visible in the right ICA. The angiogram is evaluated for coil position, residual aneurysm, and patency of parent and daughter arteries. The coil can then be detached, repositioned, or removed.

Fig. 3. Sequential coiling of a right internal carotid artery (ICA) giant aneurysm. Angiograms in 2D (top) and/or 3D (bottom) are performed after a coil has been positioned but not detached. From left to right are angiograms after 1 coil, 3 coils, and 22 coils have been placed. The pushwire within the microcatheter is also visible in the right ICA. The angiogram is evaluated for coil position, residual aneurysm, and patency of parent and daughter arteries. The coil can then be detached, repositioned, or removed.

Technique

The microcatheter is advanced into the aneurysm lumen over the microgu-idewire. The microguidewire is then removed, and the coil is then introduced into the aneurysm (Fig. 3). The largest coil is used first, to form the initial basket. Subsequently, smaller coils are used to increase the packing density. The sequential coil placement continues until resistance is felt. The goal should be to achieve as dense a packing as possible (see Aneurysm Remnant section following). During the coil delivery, proximal and distal radiopaque markers on the microcatheter are used to maintain its position. It is crucial to avoid forward migration of the microcatheter and impingement on the thin aneurysm wall. Control angiography is performed prior to each coil detachment to assess patency of the parent vessel and coil position stability. The microcatheter can be repositioned within the aneurysm if it is felt that there are loosely filled or unfilled regions of its lumen, and further coils can be delivered.

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