Aneurysm coiling complication- rupture & thrombo-embolism

1. Vipul Gupta
Neurointerventional Surgery
Institute of Neurosciences
Medanta the Medicity, Gurgaon

2. Aneurysm rupture
INCIDENCE
 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

3. 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%

4. 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

5. 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.

6. 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

7. 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

8. 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,

9. 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

10. Issue- wire; control- protamine, coils

11. Issue- blister;
control- protamine,
coils

13. Issue- push
against resistance
control- balloon
protamine, coils

16. Lost cool !!!
Issue- aggression
in dissection;
control-
protamine, coils

19. Issue- tension in MC; control- protamine, coils

21. Issue- luck; control- balloon protamine, coils

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

25. 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%......

26.  THROMBOEMBOLISM DURING
ANEURYSM EMBOLIZATION

27.  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

28. 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 coils
Risk factors-
 wide necked aneurysms, the use of balloon remodeling
technique and prolapsed coils
Non-technical mechanisms
 SAH associated vasospasm
 SAH is a hypercoagulable state
 ? Diseased intima

29. 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

30. 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

31. 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

33. 48 YR, M; SAH
Issue- coil mass; control- heparin

35. 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

36. Issue- intima, ?
balloon; control-
reopro

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

39. 32 YR, M; SAH

40. Issue- GC
control-
heparin for time
being…

41. Post coiling- reopro

43. 48 year old
man with
SAH 5
days

44. Issue- dissection; control- stent

45. Post 1 week

48. Follow up
Issue- FMD- dissection; control- heparin ????

51.  COIL PROLAPSE

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

53. 3 D
Issue- coil tip MC withdrawl;
control- heparin, reopro, aspirin

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

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

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

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

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

60.  STENTS

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

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

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

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

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

69.  COAGULOPATHY /UNSUAL

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

72. • 47 F, SAH, allergy to multiple drugs .
Clot progressed,
ACT- 350s,
Reopro given- full
10 mg given

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

74. Issue- hypercoagulability, vasospasm ?Immune;
Control- reopro, suspect
 F/U –developes RA with severe Joint arthopathy

75.  54 M, LOC, cardiac arrest,
resuscitated
 Echo s/o LV enlargement, poor
cardiac output, PE

76. Issue- post coiling vasospasm & PRESS like syndrome
Control- ??? Avoid such patients

78. Issue- GC air embolism
Control- DNP, O2, wait

79. 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

83. A

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85. Thank you ….