Elsevier

World Neurosurgery

Volume 91, July 2016, Pages 483-489
World Neurosurgery

Original Article
Complications Associated with Cerebral Aneurysm Morphology in Balloon-Assisted Coil Embolization of Ruptured and Unruptured Aneurysms—a Single-Center Analysis of 116 Consecutive Cases

https://doi.org/10.1016/j.wneu.2016.04.091Get rights and content

Background

We investigated the complication rates of balloon-assisted coil embolization of ruptured and unruptured cerebral aneurysms dependent on their morphologic characteristics in angiography.

Methods

The study was a single-center retrospective analysis of all consecutive endovascular balloon-assisted coiling interventions performed between April 2008 and December 2013. Data were extracted from a prospective database on an intention-to-treat basis. We described the clinical (Hunt & Hess score, modified Rankin scale) and technical results (Raymond Roy aneurysm occlusion scale) and analyzed the rate of periprocedural complications with regard to aneurysm subgroups of bifurcation aneurysms versus sidewall aneurysms.

Results

There were 116 interventions performed on 108 patients (mean age: 51.7 ± 11.1 years), with 70/116 emergency procedures (60%), 36/116 elective procedures (31%), and 10/116 elective procedures on recurrent aneurysms (9%). The balloon was used in 108/116 cases (93%). Among the cases, 76/116 were bifurcation aneurysms and 40/116 were sidewall aneurysms. Periprocedural complications, such as rerupture, thrombus formation, distal embolism, coil-loop protrusion, and coil migration, occurred in 26/116 cases (22%). Complications occurred significantly more often in ruptured than unruptured bifurcation aneurysms (23 vs. 3 events, P < 0.05). There was a significantly higher rate of complications in bifurcation aneurysms compared with sidewall aneurysms (17% vs. 3%, P = 0.03). Six periprocedural complications were associated with a permanent neurologic deficit (6% of cases), all of which occurred in the subgroup of acutely ruptured aneurysms.

Conclusion

The risk of periprocedural complications in balloon-assisted coil embolization of ruptured and unruptured cerebral aneurysms is linked to the morphologic presentation of the aneurysm; the complication rate was significantly higher in bifurcation aneurysms.

Introduction

The endovascular treatment of intracranial aneurysms can be technically challenging in cases of wide necks or unfavorable anatomic conditions (e.g., access- or parent-vessel tortuosity or vessel angulation). Coils deployed without supporting devices may herniate from the aneurysm sac into the parent artery, causing thromboembolic complications or vessel occlusion. Therefore alternative strategies for managing wide-necked aneurysms have been introduced, such as stent-assisted coil embolization, balloon-assisted coil embolization (BACE), and double-catheter coil embolization. BACE, as it has been initially described by Moret et al.,1 allows for optimal coil packing in the aneurysm fundus and neck. Thus BACE of intracranial aneurysms is associated with a reduction of residual or recurrent aneurysms compared with conventional coiling.2

Setting technical advantages aside, there is a debate whether BACE might be associated with a higher periprocedural complication rate (CR) in comparison with conventional coiling or not. Some retrospective studies have reported an increased incidence of death associated with BACE3, 4, 5 or a trend toward an increased incidence of thromboembolism,6 giving the warning that on the basis of the personal experience of the authors, the procedure should only be performed if no other option existed to coil the aneurysm.5 However, several larger studies1, 7, 8 and a meta-analysis performed by Shapiro et al.9 could not reproduce these concerns, although they observed a discrete but nonsignificant increase of the CR.

Except for thromboembolism, potential alternative causes for an increased rate of complications in BACE have not been studied in detail yet.6 Therefore we focused on the question of whether there are considerable differences of BACE complications dependent on the anatomic presentation of the aneurysms and further between electively treated patients and patients presenting with acute subarachnoid hemorrhage (SAH). BACE is technically more challenging in bifurcation aneurysms (BAs) than sidewall aneurysms. Reasons for this observation are morphologic characteristics, which influence the accessibility of the aneurysm and the technical complexity of placing and inflating the balloon correctly. Further, the complication rate might be higher in the acute setting. We hypothesized that there might be differences of complication rates depending on these cofactors, which would be relevant to the discussion of BACE-related complications.

Section snippets

Patient Data

We conducted a retrospective single-center analysis of all BACE interventions that were performed at a high-volume endovascular center in the period between April 2008 and December 2013 by a team of 3 experienced board-certified neuroradiologists. The datasets were pooled in a prospective database and analyzed on an intention-to-treat basis, documenting the intervention, as well as the clinical and technical outcome of the procedures. Informed consent was obtained from the patients or their

Overview

The mean patient age was 51.7 years (standard deviation [SD] ± 11.1 years, range of 20–79 years). The patient data included a majority of women (79 women, 29 men). The data on clinical presentation of the patients and the overall and subgroup distribution pattern of the aneurysms according to their localization in the vasculature are given in Tables 2 and 3.

In the study period, 1014 aneurysms were treated in the institution. Of these, 752 were treated with angiographically guided interventions.

Discussion

BACE of intracranial aneurysms allows dense packing of the lesion with the benefit of increased safety of coil placement and reduction of reperfusion rates.1, 7, 8, 9 However, there is an ongoing debate if there is generally a higher rate of complications associated with the procedure.3, 4, 5, 9 With the hypothesis that the localization of an aneurysm at a vessel bifurcation results in an increase of complications due to the more challenging anatomy and that acute SAH cases are associated with

Conclusion

The results of 108 BACE treatments proved that the method is a reliable procedure allowing a high rate of primary aneurysm occlusion. Although the overall complication rates appear to be comparable with other coiling procedures, we found a trend toward an increased rate of thromboembolism in patients with acute subarachnoid hemorrhage and in patients with BAs. The aneurysm morphology should therefore be taken into account in the interdisciplinary decision-making process of endovascular aneurysm

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    Ethical Standards and Patient Consent: The German National Institutional Guidelines and the Guidelines of the Local Ethics Commission of the University of Bochum, Germany, state that monocentric retrospective studies in Germany generally do not have to and also cannot apply for approval by the local ethics commission. Thus we declare that our retrospective study on human patient data is approved by the local ethics commission based on the institutional guidelines, as well as the national institutional guidelines, and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. We declare that all patients gave informed consent before inclusion in this study at hospital admission.

    Conflict of interest statement: The authors do not have conflicts of interest to declare.

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