This document discusses balloon-assisted coiling techniques for treating ruptured cerebral aneurysms. It begins by outlining the historical use of balloons to treat broad-neck aneurysms using the "remodeling technique." It then provides details on techniques such as balloon selection and placement, aneurysm types best suited for different techniques, and potential complications. The conclusion is that balloon-assisted coiling is a versatile technique that does not increase complications compared to standalone coiling and can achieve better aneurysm occlusion, especially for difficult ruptured aneurysm cases.

1. BALLOON ASSISTED COILING IN
RUPTURED CEREBRAL ANEURYSMS
Vipul Gupta
Neurointerventional Surgery
Artemis Hospital, Gurgaon

4. Major changes
 Length of balloon
 Double lumen
 14 wire, easy to reshape,
stability, exchange
 Placement of stents
 Distal infusion
Historical
 One of the major issues for coiling – broad neck
 Prof J Moret – “Remodeling technique”
Interventional Neuroradiology 1997

5. Uses of balloon
 Broad neck aneurysm
 Remodelling – J Moret
 Packing density
 Control of rupture
 Test occlusion

6. Remodeling- broad neck

7. Balloon assisted coiling

8.  Intra-operative rupture

9. Test
occlusion

10. Remodeling technique for endovascular treatment of ruptured
intracranial aneurysms had a higher rate of adequate
postoperative occlusion than did conventional coil
embolization with comparable safety.
Pierot L Cognard C, Anxionnat R, Ricolfi F; CLARITY Investigators.
CONCLUSION –REMODELING
TECHSAFE AND MORE EFFICACIOUS IN
TERMS OF POSt OP OCCLUSIONTHANTHE
CONVENTIONALCOILINGTECH
Radiology. 2011 Feb;258(2):546-53.
POSTOP ANATOMICAL RESULTS

11. Technique
 Sidewall- compliant balloon, if overinflation
needed and aneurysm not large supercompliant
 Bifurcation- Supercompliant
 Usually balloon with 014 wire
 Wire – usually choice, Synchro
 6 F (.70) Guiding catheter , long sheath (Raphe,
Cook)
 Choose the right branch (even if takes time,
effort…)- more involved, lobule near neck

12.  Usually check after first coil placement
 Thereafter – multiple coils in single inflation –
5min (may be more)
 Increase heparinization, BP maintenance
 If unruptured- anti-platelet beforehand
 Overall – 70-80% of cases (our practise- 90%
ruptured, 80% small)- trend towards balloon
coiling in all broad neck aneurysms

13. Choice of artery …

16. Placement angle….

19. A B C

20. STENTASSISTED COILINGTECH VS STANDALONE COILING
ADVANTAGES –
Scaffolding, haemodynamic effect, straightening of vessels
DRAWBACKS WITH SACT:
• looser aneurysm packing, lesser immmediate angiographic occlusions
rate than the stand alone coiling
• DUAL ANTIPLATELET – RISK OF HEMORRHAGICCOMPLICATION
• MORETHROMBOEMBOLIC RISKS
AT FOLLOW UP COMPLETE OCCLUSION RATE WITH SACT
INCREASEDTO 73.4% IN SACTVS 54% IN SAC

21. MORBI-MORTALITY
WITH STAND ALONE
COILING OR BRT
MORBI-MORTALITY
WITH STENT ASSISTED
COILING
Nishido et al.(AJNR 2014)
unruptured and ruptured
aneurysms
5.6% 9.4%
Shapiro et al. (AJNR
2012) review, unruptured
and ruptured aneurysms
NA 12.2%
GeyIk at al (AJNR 2013) NA 6.4%
Stent assisted coiling .. Complication rate
M Piotin et al , Frontiers in Neurology, 2014

22. Balloon – specific situations
 Branchfromaneurysm–overinflationtech.
 Near the neck rupture – catheter reposition tech.
 Unstable catheter coils- Single inflation
 Circumferential involvement- end hole technique
 Verysmallaneurysm–partialinflationtech
 Displaced coil loop – balloon reposition
 Balloon assisted MC placement

23. A B
Branch from aneurysm- Overinflation technique

25.  Near the neck rupture

26. Multi-lobulated aneurysms-
Catheter reposition

28.  Single inflation technique

29.  Circumferential involvement-End hole

30. Follow-up

33. Very small aneurysm-
partial inflation technique

34.  Displaced coil loop(s)- Balloon repositioning

37. Balloon assisted coiling
 Extremely versatile technique
 Almost essential in treating difficult
ruptured aneurysms
 Modern balloons – easier, better
 Overall doesn't increase complication
rate
 Stent when needed
 Personal balance

38. Complications
 ? Higher thromboembolism, rupture - van
Rooij at al AJNR 2006
 Review of literature Shapiro M et al, AJNR
2008
 No significant difference in thrombo-
embolism and rupture rate
 Better occlusion rate
 Improvement in technology

39. Thank you ….

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