Case Sharing: Perdenser® Coil Embolization for Treatment of Multiple Aneurysms in Posterior Communicating Artery, Cavernous Sinus and Anterior Choroidal Artery

Customer Story

Patient Information

• Female, 57 years old, admitted to the hospital due to SAH and intracranial aneurysm.

Pre-operative imaging

• Preoperative angiography showed an aneurysm (ruptured) of the posterior communicating segment of the left internal carotid artery, an aneurysm of the cavernous sinus segment of the left internal carotid artery, and an aneurysm located at the proximal anterior choroidal artery on the right. The three-dimensional image showed that the size of the aneurysm in the posterior communicating segment of the left internal carotid artery was about 3.35 mm×3.18 mm, the aneurysm neck about 2.43 mm; the size of the aneurysm in the cavernous sinus segment of the left internal carotid artery was about 14.12 mm×7.29 mm, and the aneurysm neck was about 5.56 mm; the size of the aneurysm located at the right proximal anterior choroidal artery was about 1.51 mm×1.79 mm.

Procedure

• First, the aneurysm at the right proximal anterior choroidal artery was subject to the embolization. Under the guidance of the intraoperative working position road map, TJWY Frepass® microcatheter was inserted smoothly to the site, and then TJWY Perdenser® 1.5 mm×2 cm-3D coil was used to form a single embolus.

• Next, the ruptured aneurysm in the posterior communicating segment of the left internal carotid artery was embolized. Under the guidance of the intraoperative working position road map, TJWY Frepass® embolization microcatheter and stent catheter were smoothly placed, and TJWY Perdenser ®3 mmx6 cm-3D coil was used to form a frame with the assistance of stents. Then the frame was filled with Perdenser®2 mm×4 cm-3D, 1.5 mm×3 cm-2D coils, and finally closed with 1.5 mm×2 cm-2D coil.

• Finally, cavernous carotid aneurysms in the left internal carotid artery was embolized. Under the guidance of the intraoperative working position road map, the embolization microcatheter and stent catheter were smoothly placed, and TJWY Perdenser®14 mm×30 cm-3D coils was placed to form a frame with the assistance of the stents, and the frame was filled with Perdenser®12 mm×30 cm-3D coil, 10 mm×20 cm-3D coil, 8 mm×15 cm-3D coil, 6 mm×20 cm-3D coil, 5 mm×20 cm-3D coil, 5 mm×15 cm-3D coil, 4 mm×10 cm-2D coil, three 3 mm×10 cm-2D coils, two 3 mm×8 cm-2D coils, and two 2 mm×8 cm-2D coils. The frame was completed with 2 mm×6 cm-2D coil.

After Operation

• The postoperative angiography immediately after surgery showed that the aneurysm was densely embolized, no contrast agent was residual in the aneurysm cavity, and the blood flow in the parent artery and branch vessels was unobstructed. The operation ended perfectly.

This case refers to an embolization therapy of multiple aneurysms. The aneurysm at the right proximal anterior choroidal artery that was first embolized during the operation is a small aneurysm. Due to the high risk of rupture during the operation, the selected coil needs to be soft and the pressure on the aneurysm wall needs to be small during the release process. The TJWY Perdenser® coil adopts a design of 360° open loop, which allows it to release its own tension during the implantation process and reduces the pressure on the aneurysm wall. A full range of product models and super soft coils can meet the choice of clinical small and medium-sized aneurysms. In this case, the aneurysm in the posterior communicating segment of the left internal carotid artery had ruptured before the operation. The Perdenser® coil has better conformability on the basis of stably adhering to the wall and forming a basket. At the same time, the second-level detachable method is more stable and convenient, saving operation time. In the embolization treatment of cavernous carotid aneurysms in the left internal carotid artery, the Perdenser® strengthening coils perfectly formed a frame, which had excellent support and compression resistance, and at the same time provided a suitable space for the subsequent filling of the coils, and finally densely embolized the aneurysm body and aneurysm neck.

There are two types of Perdenser® coils independently developed and produced by Lepu Medical TJWY Medical owns: complex and helical. And the product models are complete, with more half-size designs, providing more and more comprehensive solutions for clinical needs and suitable for the whole process of framing, filling and closing in the process of embolization of aneurysms. Perdenser® coils have three different hardness options: Extra soft, soft, and strengthening. Multiple options ensure that the filling can not only achieve a dense effect, but also avoid overfilling that will cause aneurysm rupture.

Intracranial aneurysm is the third most common cerebrovascular accidents, after cerebral thrombosis and hypertensive cerebral hemorrhage [1]. The results [1] showed that the incidence of posterior communicating aneurysms was the highest among intracranial aneurysms. Rupture and bleeding of posterior communicating artery aneurysm is the main cause of spontaneous subarachnoid hemorrhage (SAH), and its mortality and disability rate is gradually decreasing with the improvement of medical technology. The mortality rate of intracranial aneurysm rupture SAH is 30% to 40%. SAH patients who are fortunate enough to survive the first hemorrhage immediately face the risk of rebleeding. Patients may rupture again at any time, and the fatality rate of rebleeding is getting higher (40% – 75%)[2]

With the development of interventional materials and technologies, most IAs can be treated with coil embolization alone or with stent-assisted coil embolization to achieve satisfactory outcomes[3-5]. As epidural intracranial aneurysms, cavernous carotid aneurysms (CCAs) can still cause subarachnoid hemorrhage (SAH) after their growth breaks through the dura despite low risk of disability or death; in addition, the space-occupying effect of the CCAs can also cause cranial nerve defects such as oculomotor nerve palsy. Currently, the therapeutic indications of CCAs are mainly[6-9]: (1) Symptomatic CCAs caused by space-occupying effect (oculomotor nerve palsy, refractory retroorbital pain) or acute thrombosis in the aneurysm cavity; (2) Symptomatic or asymptomatic CCAs have the following conditions: rupture, bone destruction around the aneurysm, and imaging examinations suggest that the aneurysm has entered the subarachnoid space or suggest that the aneurysm is growing, larger in size (diameter> 10mm), or coagulation dysfunction.

The coil diameter-based differentiated flexibility design can meet the requirements of filling different sizes of aneurysms, and support the operations of framing, filling and finishing throughout the whole process. TJWY ultra-soft coil has good flexibility, which not only can be used for framing and filling in the treatment of small aneurysms, but also can be used for finishing for the treatment of medium and large aneurysms. The performance in either is safe and reliable.

TJWY Frepass® microcatheter is China’s first microcatheter product for intracranial blood vessels. It adopts a design of three-layer composite structure. The outer layer adopts thermoplastic resin, which provides excellent shaping ability and holding ability after shaping. The intermediate layer is supported by metal, which can make the microcatheter have a thinner lumen thickness, provide a smaller outer diameter and a larger lumen diameter. The inner layer is made of polytetrafluoroethylene (PTFE) that effectively reduces friction and ensures smoother pushing of other instruments in the microcatheter. As China’s first detachable coil system in one second, it is featured with stable and fast detachment method, which can effectively reduce the operation time. Especially in the treatment of aneurysm rupture, it can race against time and reduce the risk of patients.

The proximal end of the metal support layer in the Frepass® microcatheter adopts a stainless steel braided structure to provide good support and force transmission. The distal end adopts a platinum-tungsten alloy winding structure to improve the flexibility and anti-elliptic properties, making the microcatheter easier to pass through tortuous blood vessels. At the same time, platinum-tungsten alloy has good developability, ensuring clear visualization under intraoperative fluoroscopy.

References:

[1] Wang Zhongcheng. Neurosurgery [M]. Nanjing: Jiangsu Science and Technology Press, 2005: 585.

[2] Wu Chen, Xu Bainan, Li Baomin, et al. Analysis of the efficacy of surgical treatment of intracranial aneurysms [J]. Chinese Journal of Neurosurgery, 2010, 48 (19): 1496-1499.

[3] Won YS, R ho MH, Kim BM, et al. Various techniques of stent-assisted coil embolization of wide-necked or fusiform middle cerebral artery aneurysms: initial and midterm results [J]. J Korean Neurosurg Soc, 2013, 53 (5): 274-280.

[4] R ho MH, Park HJ, Chung EC, et al. Various techniques of stent-assisted coil embolization of wide-necked or fusiform artherosclerotic and dissecting unruptured vertebrobasilar artery aneurysms for reducing recanalization: mid-term results [J] . Acta Neurochir (Wien), 2013,155 (11): 2009-2017.

[5] Spiotta AM, Wheeler AM, Smithason S, et al. Comparison of techniques for stent assisted coil embolization of aneurysms [J]. J Neurointerv Surg, 2012, 4(5): 339-344.

[6] ter Brugge KG. Cavernous sinus segment internal carotid artery aneurysms: whether and how to treat [J]. AJNR Am J Neuroradiol, 2012, 33 (2): 327-328.

[7] Eddleman CS, Hurley MC, Bendok B R, et al. Cavernous carotid aneurysms: to treat or not to treat? [J]. Neurosurg Focus, 2009, 26(5): E4.

[8] Kupersmith MJ, Stiebel-Kalish H, Huna-Baron R , et al. Cavernous carotid aneurysms rarely cause subarachnoid hemorrhage or major neurologic morbidity [ J ] J Stroke Cerebrovasc Dis, 2002, 11 (1): 9-14.

[9] Stiebel-Kalish H, Kalish Y, Baron RH, et al. Presentation, natural history, and management of carotid cavernous aneurysms [J]. Neurosurgery, 2005, 57(5): 850-857.