395
Treatment of Vascular Lesions with Balloon Catheters
G. Scialfa,1 F. Valsecchi , and G . Scotti
During a 4 year period, 48 patients were treated with balloon
catheters. There were 39 fistulas and nine aneurysms. Detachable balloons with a modified Debrun technique were used in 37
patients. Different kinds of technical problems were encountered. The arterial axis remained patent in 29 of the 37 fistulas ;
in the two mixed internal and external carotid-cavernous sinus
fistulas, combined embolization with dura , isobutyl cyanoacrylate, and detachable balloon was used. In six of the nine aneu rysms the arterial axis was occluded with a det achable balloon .
In three of 48 patients, severe neurologic complications resulted
in death .
Th e use of ball oo n cath eters is unquesti onabl y a significa nt
improve ment for th e treatment of vasc ular malform ati ons; for simple
fistul as thi s is th e onl y possible low-ri sk th erapeutic approac h.
Although different authors have used different types of materi al th e
results are very simil ar [1-1 2]. Th e aim of our wo rk was to analyze
the c linica l and angi og raphi c results during a 4 year peri od in th e
treatm ent of 4 8 pati ents w ith fi stul as and aneurys ms , usin g a sli ghtl y
mod ified Debrun techniqu e.
subc lavian arteriovenous fistul a, eig ht int racavern ous in tern al caroti d aneurysms, and one intracrani al verteb ral aneurysm. In most
cases (44 of 48 ) th e treatm ent W 3S ca rri ed out with th e pat ient
under general anesth esia; in the last 18 cases co nti nuous elec troence ph alog raphic (EEG) moni to rin g was obt ained . A 3 Frenc h
Fog arty cath eter was used on ly for th e first two ca rotid-cave rn ous
fi stul as, before the introducti on of detachab le ball oo ns. All th e o ther
cases we re treated w ith a mod ifi ed Deb ru n tec hni que. In one case
in whic h the carot id artery had been li g ated in the nec k some years
before , th e ba ll oon was in trod uced through th e supraclin oid part o f
th e intern al ca roti d artery , w hic h had been ex posed surgica ll y . O nl y
in seve n of 48 patient s was the ball oo n system introduced by th e
femora l route (verte bral artery aneurys m and arteri ove nous fi stulas,
c aroti d-cavern ous fis tul as in pati ents yo un ger th an 10 yea rs). In the
oth er cases th e syste m was in trod uced by d irec t ca ro tid puncture.
Th e detail s of thi s tec hn iq ue have been desc ri bed [ 12]. In co mbined
fi stul as between both th e intern al and extern al ca rotid arteri es and
th e cave rn ous sinus , embolization w ith dura and isobutyl cya noacrylate was used in associati on with de tac hable ball oon s.
Results
Materials and Methods
Forty-eight patients 4-70 years old we re treated . Of th ese , 3 1
had intern al caroti d - cavernou s sinu s fi stul as , three extern al carotid-jugular vein fi stul as, two co mbin ed intern al/ extern al carotidcavernou s sinu s fistulas , two ve rtebral arteriovenou s fi stul as, one
Angiog raphy was perfo rmed im mediately after the detac hment of
th e ball oon , and subseq uent foll ow-up studi es were ca rri ed out in
so me patient s up to 1 year after treatment. Table 1 summari zes the
c lini ca l and angiog raphic result s. In sim ple fistu las of th e extern al
carotid , ve rtebral, and subc lavian arteries (six of 3 7 cases) th e
fi stul a was always occ lu ded w hile maintainin g patency o f the art eri al
TA BLE 1: Angiographic and Clinical Results after Treat ment of Vascular Malformations with Balloon Cat het er s
No. Ca ses
To tats
Fistu las:
Intern al ca rotid-cavernous sinu s
Extern al carotid -j ug ular vein
Vertebral arteri ovenous
Subc lavian arteri ove nous
Combin ed extern al and intern al ca rotid-cavern ous sinu s
Aneurys ms:
Intracavernou s carotid artery
Vertebral artery
31
3
2
1
Occ lusion
of Lesion
Art eri al
Axis
Patency
Pse udoaneurysm .
Sac
Co mple te
Recovery
30
23
22
3
2
3
2
1
29
3
2
8
5
o
3
o
o
2
1
1
o
o
o
o
o
7
Nole. - Three p atients died from severe neurolog ic complications, one with a caro tid-cavern ous fistu la, one with an inl racavern ous ca ro tid ar tery aneurysm, and one with a ver tebral
artery aneurysm.
' All authors: Department of Neuroradiology, Osped ale Niguarda, Piazza Ospedale Magg iore. 3, Milano . Italy . Add ress reprint req uests to G. Scia lfa.
AJNR 4:395-398 , May / June 1983 0195 - 6 10 8 / 8 3 / 0403 - 0395 $00 .0 0 © Am erican Roentgen Ray Soc iety
3 96
A
INTERVENTIONAL PROCEDURES
B
AJNR:4 . M ay/ June 1983
c
Fi g. 1 . -Caroti d-cave rn ous fi stula. A. Two balloons were insufficient to exclude fi st ul a (arrows ). B. Second procedure. Two more ball oons in differen '
locations were suffic ient to obliterate fi stula (arrows ). C. Late angiog rap hic follow-up. Pseudoaneurysm of caro tid artery (arrow ).
Fig . 2. -A. Intracavernou s aneurysm. B. An
giog raphic follow-up. Aneurysm is partl y occ ludeo
and inlern al carotid is patent after detachment 0 ,
one balloo n infl ated with iodinated contrast an,.
silicone.
B
ax is. In th e oth er simple fi stul as between th e intern al carotid artery
and th e cave rn ous sinus (3 1 of 3 7 cases) th e fistula was occluded
in 30 of 31 . with intern al ca rotid patency maintained in 23 (76%) of
30 . Form ati on of an intracavern o us pseudoaneurys m usuall y occurs
in the treatm ent of caroti d-cavern o us fi stul as in whi c h th e arterial
axis has remain ed patent (fi g. 1). A pseudoaneurysm was also
observed at th e level of th e treated fi stula in one case of a subclavi an
fi stul a and in a second case with a fi stul a between th e extern al
caroti d and jugular ve in. In mi xed fi stul as between th e extern al and
th e in tern al carotid arteri es and th e cavern o us sinu s. onl y in one
case was th e fistul a co mpl etely occ luded. with occ lu sio n of th e
caroti d siphon and middle meningeal artery by a balloon and of th e
intern al maxillary art ery by dura and isobutyl cyanoacryl ate. In
intracavern ous sinus aneurysms th e carotid artery was occluded II
the level of th e aneurysm in five of eight cases. whil e in th e ol h r
three cases th e aneurysm was almost completely exc luded wi ll' a
balloon keeping th e ca rotid artery patent (fig . 2) . In one case of n
aneurysm of th e intracranial vertebral artery . th e ve rtebral art! y
was occluded at th e level of C1 sin ce th e balloon was not able 0
exclu de th e aneurysm. On angiog raphy of th e contralateral vel ,bral artery th e aneurysm appeared largely occluded (fig . 3).
Clini cal results co rrelated with th e angiographi c findin gs in sim, Ie
fi stul as of th e intern al and / or extern al ca rotid artery ; of th e verteb al
and subc lavi an arteries, a co mplete cure was obtained in 35 of \7
cases. In mi xed fi stu las only a parti al recovery was obtained in l'le
two treated cases. In th e aneurysm group a complete c ure v 15
A
397
INTERVENTIONAL PROCEDURES
AJNR :4, May / June 1983
B
c
Fig. 3. -Right vertebral aneurysm. A and B, Right vertebral angiog rams. Different positi ons of ball oon withi n aneu rysm bu t aneu rysm is still visible (arrows ).
C, Left vert ebral angiogram. Parti al visualizati on of aneurysm after occlusion of ri ght vertebral artery w ith ba lloon (arrow).
obtain ed in seven of nine cases, th ough in three th e aneurysms
remain ed parti all y pat ent. In one case of ca rotid-cave rn ous fi stul a
the treatm ent was un successful because th e balloon never entered
the fistul a and th e pati ent could not tolerate occlu sion of th e intern al
carotid artery. In three pati ents, on e with a ca rotid-cavernou s fi stul a
and one each with an intracavern ous and ve rtebral aneurys m,
severe neurologic compli cation s after treatm ent led to th e pati ent' s
death .
Discussion
Different kind s of probl ems we re enco untered in th e treatm ent of
our patients; tec hnical probl ems have been d escribed in a previou s
paper [1 2]. A revi ew of our materi al reveals th e following . In ca rotidcavernous fi stul as it is preferabl e to introduce th e system by direc t
puncture of th e ca rotid artery through a cath eter needle. Th e dead
space in th e Tefl on cath eter is less th an by th e femoral route, whic h
facilitates th e injec ti on of larg er amounts of silico ne when necessary. The femoral rout e is more convenient in fi stul as in vo lving th e
vertebral axis and in pati ents younger than 10 years. Th e most
delicate part of th e technique is th e detachment of th e ball oo n by
the coax ial catheter. If th e li gature of th e balloon on th e Tefl on
cath eter is too tight , th e diffic ulties of detac hment inc rease and
repeated traction can ca use spasm of th e carotid . A too-loose
ligature may cause a rapid d efl ation of a ball oo n inflated only with
iodine. In six of our cases th e d etachment had to be done without
the coaxial cath eter , which co uld not be ad va nced because of
marked tortu os ity of th e ca rotid at th e neck . Thi s maneuve r was
always difficult, di spl acement of th e balloo n occurrin g in two cases
with occ lu sion of th e ca rotid artery. In th ese cases th e balloo n mu st
be inflated with iodine and sili co ne and d etached w hen th e silico ne
beco mes solid . Exc hanging iod in e with silico ne in a we ll pos iti oned
balloo n is a probl em, because th e iodin e-fill ed ball oon ca n c hange
position within th e cavern ous sinu s du rin g th e exc hange of iodine
with silicone. Mo reover, in one of our cases th e silico ne-fill ed
balloon ruptured within th e cavern ous sinu s w hen solidificati on had
not yet occ urred ; th ere we re, however, no c linical co mpli cati ons.
We always fill th e balloo n w ith silico ne w hen th e ca roti d or th e
vertebral artery mu st be occluded , since in four o f our cases the
iodine-fill ed ball oon rapi dly defl ated and mi grated withi n the cavern ous sinu s at detachment. Th e form ati on of an intracavern ou s
pse ud oa neurys m is anoth er probl em. In our pati en ts th e sac was
always asymptomati c , but in two it enl arged with time, necessi tating
pl acin g a ball oo n inflated w ith iod in e and silico ne w ithin it. In our
experi ence a smaller pse udoaneurys mati c sac results when the
ba ll oo n is fill ed with iod ine and silico ne. Direct p lacement of th e
ball oo n with in th e supraclin oid al part of th e surgica ll y exposed
intern al carotid artery ca n be used to treat th ose cases already
un successfu lly treated in th e past with li gati on of th e caroti d art ery
in th e neck . Thi s was done in one of our pati ents. Acco rd in g to
Debrun et al. [5] occlusi on of th e ca rotid or ve rtebral artery represents th e procedure of c hoice to avoid co mpli cati ons w hen treatin g
aneurysms with ball oo n cat heters. In fact in one pa ti en t the attemp ts
to occ lu de th e aneurysm ca used rupture of th e aneurys m w ith
form ati on of a carotid-cave rn ous fi stul a cured onl y with occlu sion
of th e ca rotid artery at th e level of th e aneurys m. Recen tl y we have
preferred a parti al occlu sion of th e aneurys m with th e ba ll oo n since
thi s is accompanied by reg ression of sy mptoms. If th e symp toms
persist we occ lu de th e caro ti d artery at a second stage and aft er an
extern al-intern al ca rotid bypass is carri ed out. Ac ute occlu sion of
a caroti d artery , howeve r , is not always tolerated, even if preceded
by an ex tern al-i ntern al ca roti d bypass [5]. Th e onl y severe co mpli cati ons th at led to th e pati ent 's death occurred after acute occlu sion
of th e arte ri al axis w ithout an effi cie nt co ll ateral c irculati on . In a
pati ent with a giant aneurys m, spasm of the c irc le of Willi s secondary to subarac hn oid hemorrh age was responsible for an ineffi c ient
co ll ateral c irculati on aft er occlu sion o f the ca roti d artery . In a
second case with a ca roti d-cave rn ous fi stula even a perfec tly functi onin g preventive external-internal ca roti d bypass was ineffective
when th e ca roti d was occlu ded at th e level of the fi stul a since the
ball oo n did no t enter th e cave rn ous sinu s. In a th ird case of a g ian t
aneurysm of the intracra ni al part of th e ve rt ebral artery, occ lusion
of th e artery w ith a ba ll oon was carri ed out aft er the pat ien t had
tolerated a test c los ure of th e vertebral art ery at the level of C1
under heparin for 1 hr and w ith con ti nou s EEG mon itoring, desp ite
th e fact that the con tralateral ve rt ebral artery was small. The angio-
398
INTERVENTIONAL PROCEDURES
graphic co ntrol showed th at th e aneurys m was poorly opacified and
th e ve rtebrobasil ar c irc ulation was morphologically norm al (fig. 3).
Howeve r, 20 hr later an ac ute respiratory arrest led to th e patient ' s
death . Thi s co mplica tion cou ld have been due in part to an in effic ient co ll ateral c irc ulation. From our experience we can say that
neurorad iolog ic treatm ent w ith detac hable balloon s results in a
co mpl ete cure in most pa ti ents with fi stul as or aneurysms (42 of 48
cases); th e cure is in co mpl ete in mi xed fi stulas (two of 48 cases).
Severe co mpli cation s (three of 48 cases) ca n be avoided onl y if th e
problem of th e acute occlu sion of an arterial axis with ou t an effic ien t
co ll ateral c irc ulation is so lved. When th e balloon does not enter th e
fistula and no effi c ient co ll ateral circu lation ex ists, as happened in
one of our ca roti d-cave rn ous fi stulas, endoarteri al treatment with
detachable ba ll oo ns is not possible.
5.
6.
7.
8.
9.
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