Vipul GuptaNeurointerventional SurgeryInstitute of Neurosciences

Medanta the Medicity, Gurgaon

Aneurysm ruptureINCIDENCE ISAT- 5.4% and 19% for coiling and clipping, respectively,   Rupture rate- between 2% and 5%; 10 years ago  Cerebral Aneurysm Rerupture After Treatment (CARAT) trial

1010 aneurysms - coiling (5%) or clipping (19%) increased the risk of periprocedural death/disability fourfold and twofold

A Dutch study Of 31 procedural ruptures five died and three developed disability (74%) did not develop clinical sequelae  

A meta analysis (Cloft HJ et al, 2002) 4.1% - 1248 ruptured aneurysms; 0.7% - 760 unruptured 66 ruptured aneurysms 22 (33%) died; 3 (5%)

haddisability

CAUSES  sudden rise in BP during contrast hand

injection direct perforation of the aneurysm wall -

microguidewire, microcatheter , coils Microguidewire perforations tend to be the

smallest; Microcatheter and/or coil perforations tend to lead to larger perforations

Meta-analysis - morbidity and mortality coil 33% microcatheter perforations 39% microguidewire perforations – 0%

Several risk factors- Previously ruptured aneurysms Smaller diameter The surface area of the initial rupture is

proportionally; that coils in the 2-3 mm diameter ? balloon remodeling raises the risk for both

periprocedural rupture and thromboemboli , issue of microcatheter being fixed

A more recent meta-analysis (AJNR 2008) comparable complication rates between aneurysms treated with or without balloon remodeling

Detection  Device that breaches the outlines on a digital Gentle guide catheter angiogram with a

minimum amount of contrast can allow for true perforation

Blood pressure, intracranial pressure (ICP) and a simultaneous increase in the pulse rate.

Rupture…Intervention Resist the impulse to pull back on the

perforating device If balloon, inflate rapidly place coils in the aneurysm (soft, small) another microcatheter/ n-butyl cyanoacrylate

(NBCA) / balloon Iatrogenic rupture of small, <3 mm, aneurysms

may lead to a breach that, proportionally, comprises much of the original wall

If the rupture has occurred close to the aneurysm neck, balloon occlusion to induce hemostasis followed by possible surgical intervention

ICP Management Transit time Degree of mydriasis and/or the rise in systemic arterial pressure.  ICP warrants emergent ventriculostomy, or an additional

ventriculostomy  Posterior fossa is even less tolerant to elevations in ICP.Heparin reversal  1 mg of protamine, intravenously, per 100 units of heparin CP- include hypotension, anaphylaxis and pulmonary hypertension. Max rate - 50 mg over 10 min. Aspirin and clopidogrel Desmopressin- 0.3 mg/kg is recommended; pharmacy.  Transfusion of five random donor platelet units (5 single units) is

recommended

Anesthetist Ventilated at 100% O2.  Blood pressure needs to be more aggressively

controlled  Mannitol 0.5 g/kg  NPM is available, then burst suppression should be

obtained to decrease cerebral metabolic activity.  Thiopental can be given as a loading dose of 5

mg/kg over 10 min intravenously, then at 2 mg/kg/ 10 min until the Bispectral Index Monitor shows suppression ratio >80% of BIS index <20.19 

EVD, call NS An external ventricular drain is present,

Technologist- Remind the physician to minimize contrast runs. Be prepared to open coils in rapid fashion.  compliant balloon

Post op  Possible DynaCT scan. Regular CT Ventilate – control BP We usually extubate the next day

Issue- wire; control- protamine, coils

Issue- blister; control- protamine, coils

Issue- push against resistance control- balloon protamine, coils

Lost cool !!!

Issue- aggression in dissection; control- protamine, coils

Issue- tension in MC; control- protamine, coils

Issue- luck; control- balloon protamine, coils

Issue- near neck small lobule; control- nature, protamine, coils

Rupture……Avoidance High stable guiding catheter Catheterization- shape, slow, may be

we need not wire in many cases Coiling- be sure of catheter position,

tension, do not be overenthusiastic Beware of blister/dissecting If it happens- keep calm-follow the rules May be 1%......

THROMBOEMBOLISM DURING ANEURYSM EMBOLIZATION

Thromboembolic complications occur more frequently and are associated with higher morbidity.

Van Rooj et al -681 consecutive 32 patients (4.7%) with 13 of these 32 cases leading to mortality

 Brooks et al -155 patients asymptomatic cerebral infarcts, overall 24% rate8.4% rate of clinically detectable

DWI  MRI in ruptured (40%) as opposed to unruptured aneurysm (13%) embolizations

Chen - 218 aneurysm six (2.7%), Of these six, two (1%) developed significant morbidity

Causes  The guide catheter  Platelet rich thrombi may develop on catheters,

wires or balloons and then embolize  Interface and interaction of coils and arterial blood  Prolapse of coilsRisk factors- wide necked aneurysms, the use of balloon

remodeling technique and prolapsed coilsNon-technical mechanisms  SAH associated vasospasm SAH is a hypercoagulable state ? Diseased intima

Management Heparin (ACT) Reopro (IA, IV) BP, volume

Mechanical tPA- never in

ruptured

Amount of clot Cause of clot- coil

out? Diameter and flow

in artery Aneurysm secure

or not Arterial supply

Glycoprotein IIB-IIIA  can actually disaggregate newly formed platelet

clusters in vitro, even when their potential fibrinolytic activity is ruled out.

 achieved within 10 min after intravenous infusion of abciximab.

 An intra-arterial Preferred, Although less desirable, an intravenous dose may be given as 0.25 mg/kg intravenous rapid bolus followed by 125 mg/kg/min infusion to a maximum of 10 mg/min for 12 hrs

 overall successful recanalization rate of abciximab to be estimated at 114/132 bleeding complications in 7/147 cases

 mechanical thrombolysis may be

Post op LMWH IV heparin Volume expanders Anti-platelet drugs single/double Ryles tube/after extubation loading  or not duration 3 weeks to

forever

Amount of clot Cause of clot- coil out? Tip vs loops Diameter and flow in

artery Aneurysm secure or

not Resistance to drugs Arterial supply

48 YR, M; SAH

Issue- coil mass; control- heparin

Immediate 5 min 8 min-Reopro

25 min Post reopro 7 mg

35 min Post reopro 10 mg

Post reopro 10 mg- after 50 min

Issue- intima, ?balloon; control- reopro

Issue- coil mass, spasm; control- heparin, IAVD

32 YR, M; SAH

Issue- GC control- heparin for time being…

Post coiling- reopro

48 year old man with SAH 5 days

Issue- dissection; control- stent

Post 1 week

Follow up

Issue- FMD- dissection; control- heparin ????

COIL PROLAPSE

Issue- coil tip at detachment; control- heparin, aspirin

3 D

Issue- coil tip MC withdrawl; control- heparin, reopro, aspirin

Issue- coil tip at detachment; control- heparin….

Issue- delayed thrombus with embolism; control- reopro, heparin, aspirin

Issue- coil migration; control- retrieval (Stent retriever ?)

Issue- coil mass prolapse ? Inflow related; control- reopro, loaded with 2 anti-platelet, luck!)

Left ICA

Issue- coil mass prolapse ? Inflow related; control- collateral flow, luck!)

STENTS

Issue- stent thrombosis ?resistance; control- reopro, heaprin, 3rd anti-platelet)

Issue- stent thrombosis ?resistance/kinking; control- reopro, heparin)- rebled after 2-weeks

Issue- stent thrombosis ?resistance; control- reopro IA & infusion, Plavix BD)- repro induced thrombocytopenia

Issue- stent thrombosis ?resistance, incomplete opening; control- ; PTA, MC, reopro, Pasugrel)- MRI DWI positive

Issue- stent thrombosis on pasugrel ? too much metal, flow change opening; control- ???, ? staged

COAGULOPATHY /UNSUAL

Issue- HIT (drop in platelet counts, antibody positive); control- suspect, no more heaprin

• 47 F, SAH, allergy to multiple drugs .

Clot progressed, ACT- 350s, Reopro given- full 10 mg given

Post procedure- severe abdominal pain , Develops left hemiparesis, M5, rise in TLC

Issue- hypercoagulability, vasospasm ?Immune;Control- reopro, suspect

F/U –developes RA with severe Joint arthopathy

54 M, LOC, cardiac arrest, resuscitated

Echo s/o LV enlargement, poor cardiac output, PE

Issue- post coiling vasospasm & PRESS like syndromeControl- ??? Avoid such patients

Issue- GC air embolismControl- DNP, O2, wait

Conclusion Complications can be predictable

and unpredictable- be on look out With early detection and mgt.,

technical complication may not lead to clinical complication

Have team protocol and check lists

A

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Dr Vipul Gupta

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