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Ruptured vs unruptured aneurysm presentation
Age of patient
Anatomy of aneurysm including size, dome to neck ratio and anatomy of branch vessels
Concomitant medical problems
Anterior vs. anterior circulation aneurysms.
Pre Procedure Workup
Medical clearance including relevant labs. For ruptured aneurysms evaluation of cardiac function with Troponin enzymes, EKG, and/or trans-thoracic echo might be indicated.
Consider antiplatelet agent for enraptured aneurysms. Although this is not a standard practice in all centers, this is a common practice to reduce thrombi-embolic complications.
Need for aspirin and Plavix when stent is placed. This is a controversial practice in ruptured aneurysms. This is related to higher rate of hemorrhagic complications in patients with ruptured aneurysm and being treated with dual anti-plateletes therapy.
Sterile preparation of both femoral artery access sites
Placement of sheath, at least 6French femoral sheath access.
For unruptured acheive ACT of 250-300/ for ruptured aneurysm consider half heparin dose before first coil and more heparin to acheive ACT of 250-300 once first one to two coils deployed.
Place guide catheter in target vessel, 6 French guide catheter is usually preferred especially in cases of balloon remodeling coiling where micro-cathter and balloon are inserted through the same guide.
Find best working views and confirm measurements, the working projection should show the aneurysm neck, and the adjacent parent vessel.
The aneurysm is catheterize with micro-catheter aneurysm. Forward advancement of the micro-wire or the micro-catheter in the aneurysm can lead to aneurysm perforation.
The first coil is called the framing coil, this will provide the initial basket that will hold the rest of the coil in place, this is usually sized to match the diameter of the aneurysm in un-ruptured aneurysms. Most operators tend to under size the framing coils in ruptured aneurysms. Place coils sequentially: avoid placing tiny coils at neck. Use negative roadmaps to assess where coils are being deployed in aneurysm and look for "painting". Avoid "excessive force".
Perform final working view angiogram (consider 3D).
Standard cranial final AP/Lateral cranial angiogram to rule out distal thrombo-embolic complications.
Perform final cervical angiogram to rule out iatrogenic guide catheter related vascular dissections.
Perform common femoral artery angiogram of access site and consider closure device. Many operators will keep the femoral sheath in place until the effect of heparinization is revised, a target of ACT <160 is often sought before removing femoral sheath.
Stroke, related to thromboembolic complications related to the indwelling catheters and /or flushing solutions.
Aneurysm rupture, this is related to mirowire, miro-catheter or coil perforation during the coiling procedure. Higher risk have been reported with aneurysms smaller than 3mm in diameter.
Herniation of coils into parent vessel. This is more common problem in aneurysms with wide neck, where the coil mass might herniate into the parent vessel. Balloon remodeling technique have proven to be decrease the risk of coil herniation into the parent vessel.
Partial aneurysm coiling, with a potential risk of aneurysm re-rupture if the aneurysm is not secured. The risk of aneurysm re-bleeding increases with larger aneurysm remnant.
Retroperitoneal hematoma related to common femoral artery access. The risk increase in patients who received thrombolytic therapy, prolonged anticoagulation of dual anti-plateletes therapy.
Cervical vessel dissection, the risk increase with patient with looped vessels, and in patients with fibromuscular dysplagia.
Medical complications, including compromise of cardiac function, or respiratory failure
Risks related to prolonged radiation exposure in complex long cases.