JNET 9:219 225, 2015 テクニカルノート 脳 動 脈 瘤 塞 栓 術 に 際 し 血 管 陰 影 の 重 なりにより 適 切 な working projection image が 得 られない 場 合 の double microcatheter technique を 応 用 した 対 処 法 An optimal visualization of a cerebral aneurysm without interference of other arteries by using modified double microcatheter technique during endovascular embolization Masataka YOSHIMURA Shin HIROTA Thiparpa THAMAMONGOOD Natsumi ITO Shinji YAMAMOTO Department of Neurosurgery, Tsuchiura Kyodo General Hospital Abstract Objective: Obtaining a clear working projection image (WPI) is mandatory for secure and effective embolization of a cerebral aneurysm. However, there are some cases where contrast medium injection through a guiding catheter (GC) does not provide an optimal WPI due to overlapping of the arteries. Here, we report a case of an anterior communicating artery aneurysm which was successfully treated by modifying double microcatheter technique (DMT) in order to obtain an optimal WPI. Case presentation: A 79-year-old woman was admitted to our hospital due to subarachnoid hemorrhage from an anterior communicating artery aneurysm. CTA revealed that the right A1 was too thin to be detected and that the aneurysmal neck was wide enough to involve both A2. Thus, an optimal working projection (WP) was to clarify relationship between both the A2 and the aneurysmal neck. Nevertheless, contrast medium injection through the guiding catheter at the WP provided an overlapping image of the aneurysm and the left internal carotid artery. Therefore, we introduced DMT to place one microcatheter (MC) at A1 to obtain an optimal WPI. The MC was further used for frame coil and kept holding the frame coil until the last filling coil was detached. In addition, another MC was first used to affirm the frame conformation, and then to fill coils. Preservation of the frame coil outline was confirmed by blank roadmap method during the procedure. Conclusion: When a guiding catheter does not provide an optimal WPI, our modified DMT could be a choice. Key words intracranial aneurysm, endovascular treatment, working projection, double microcatheter technique 300-0053 11-7 E-mail: mstkktsm@yahoo.co.jp Received May 11, 2015 Accepted June 3, 2015 doi: 10.5797/jnet.tn.2015-0026 緒 言 1 5 working projection WP WP working projection image WPI WPI 1 WP guiding catheter GC WPI 219
double microcatheter technique DMT 症 例 呈 示 79 CT Fisher group 3 Glasgow coma scale GCS 13 E3V4M6 World Federation of Neurosurgical Societies WFNS grade III 3D-CTA 7 mm A1 wide-neck A2 neck 3D-CTA workstation A2 WP approach route GC WPI DMT microcatheter MC A1 A1 WPI CTA workstation 36 34 30 30 Fig. 1A B 7Fr Radifocus introducer IIH 3000 A Fig. 1 Fluoroscopic images of the head position during the procedure. The position provides better C-arm movements than the straight head position. A: The head is rotated about 30 degrees to the left. B: The head is anteflexed about 30 degrees. B 220
7Fr Roadmaster 3D-rotational angiography 3D-RAG CTA WP projection GC Fig. 2A Headway 17 straight MicroVention TERUMO, Tustin, CA, USA Chikai 14 200 cm A1 1 ml A1 A2 WPI Fig. 2B 5.7 mm 5.0 mm 7.0 mm neck 5.1 mm image overlay Headway 17 Excelsior SL 10 straight Stryker, Kalamazoo, MI, USA A1 Headway A B C D Fig. 2 Intra-procedural angiograms. Contrast medium was injected from the guiding catheter (A and C) or from the microcatheter (MC) in the left A1 (B, D). A and B: The same working projection provides different aneurysmal visualization. The optimal working projection image is obtained only by MC injection. C and D: Lateral view of the aneurysm. 221
17 Cosmos 18 7 mm 23 cm MicroVention TERUMO A2 frame Fig. 3A E SL 10 A2 frame Fig. 3B F Coil frame first coil detach SL 10 frame Orbit Galaxy Fill 5 mm 10 cm Codman Neuroendovascular, Johnson & Johnson, Miami, FL, USA second coil Fig. 3C G first coil neck blank road map Second coil detach Orbit Galaxy Fill 5 mm 10 cm Orbit Galaxy Xtrasoft 4 mm 6 cm 3 mm 4 cm 4 mm 8 cm Codman Neuroendovascular, Johnson & Johnson DelataPaq 3 mm 4 cm Codman Neuroendovascular, Johnson & Johnson 1 DeltaPlush 2 mm 4 cm Codman Neuroendovascular, Johnson & Johnson 2 DeltaPlush 2 mm 3 cm 1 Third coil second coil first coil detach blank road map Fig. 3D H SL 10 A B C D E F G H Fig. 3 Intra-procedural plain craniograms (A, C E, G, H) and angiograms (B, F). The projection angles of A D and E H are identical to those of Fig. 2B and D, respectively. A and E: The framing coil is inserted into the aneurysmal sac through the first microcatheter (MC; Headway 17) and the second MC (SL 10, arrow) is placed in the left A1. B and F: Contrast medium is injected through SL 10 in order to determine if the frame coil is placed properly. The figures show that both A2 and perforating arteries are preserved. C and G: The SL 10 MC is now placed in the aneurysm, and the second coil is inserted through it without detaching the frame coil. Dual monitor enables us to see both road map image (images not shown) and plain craniogram at the same time. The stability and outline of the frame coil is being watched during the second coil placement and afterwards. D and H: The final coil is placed. The outline of the frame coil stays the same (please compare Fig. A and E with D and H, respectively, the same magnification). 222
Headway 17 first coil detach Headway 17 A1 A2 Fig. 4A D 8Fr Angio- Seal St. Jude Medical, Minnetonka, MN natural reverse CT MRI 10 25-4 modified Rankin scale 3 8 12 MRI 考 察 coil WPI A B C D Fig. 4 Post-procedural plain craniograms (A, C) and super-selective angiograms (B, D). The projection angles of A, B and C, D are identical to those of Fig. 2B and D, respectively. A and C: The tip of the microcatheter is indicated by an arrow. B and D: Both A2 and perforating arteries are preserved, and contrast medium is not detected in the aneurysm. 223
1 WP bleb 1,2,6 image 1 5 WP try and error 3D-RAG workstation WP 3 WPI 7 workstation WP WPI C-arm WP C-arm 3,4 C-arm WP WP 4 CTA WP GC approach route WPI DMT DMT 2 MC MC coil wide neck frame 8 11 Durst 10 interleaving technique locking technique Interleaving technique 2 MC 2 coil frame locking technique 1 MC 1 coil frame coil detach 2 MC 2 coil frame locking technique 1 MC 2 MC frame coil coil detach first coil first coil 18 triaxial system 12,13 simple technique approach approach A1 approach route WPI DMT WPI 結 語 WP WPI WPI DMT 利 益 相 反 (Conflict of Interest)の 開 示 文 献 1 2010 126 137. 224
2 2015; 24: 159 164. 3 Abe T, Hirohata M, Tanaka N, et al. Clinical benefits of rotational 3D angiography in endovascular treatment of ruptured cerebral aneurysm. AJNR Am J Neuroradiol 2002; 23: 686 688. 4 Anxionnat R, Bracard S, Ducrocq X, et al. Intracranial aneurysms: clinical value of 3D digital subtraction angiography in the therapeutic decision and endovascular treatment. Radiology 2001; 218: 799 808. 5 Kitazawa K, Sorimachi T, Ito Y, et al. A carving method to determine an optimal working projection using threedimensional volume rendering digital subtraction angiography in coil embolization of cerebral aneurysms. J Neurointerv Surg 2013; 5: 253 257. 6 Ishida F, Kawaguchi K, Mizuno M, et al. The accuracy and usefulness of 3D-DSA and 3D-CT angiography for cerebral aneurysms. Interv Neuroradiol 2001; 7: 181 186. 7 Imamura H, Sakai N, Sakai C, et al. Endovascular treatment of aneurysmal subarachnoid hemorrhage in Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2. Neurol Med Chir 2014; 54: 81 90. 8 Starke RM, Durst CR, Evans A, et al. Endovascular treatment of unruptured wide-necked intracranial aneurysms: comparison of dual microcatheter technique and stent-assisted coil embolization. J Neurointerv Surg 2015; 7: 256 261. 9 Chung EJ, Shin YS, Lee CH, et al. Comparison of clinical and radiologic outcomes among stent-assisted, doublecatheter, and balloon-assisted coil embolization of wide neck aneurysms. Acta Neurochir 2014; 156: 1289 1295. 10 Durst CR, Starke RM, Gaughen JR, et al. Single-center experience with a dual microcatheter technique for the endovascular treatment of wide-necked aneurysms. J Neurosurg 2014; 121: 1093 1101. 11 Baxter BW, Rosso D, Lownie SP. Double microcatheter technique for detachable coil treatment of large, wide-necked intracranial aneurysms. AJNR Am J Neuroradiol 1998; 19: 1176 1178. 12 Colby GP, Lin LM, Huang J, et al. Utilization of the navien distal intracranial catheter in 78 cases of anterior circulation aneurysm treatment with the pipeline embolization device. J Neurointerv Surg 2013; 5: iii16 21. 13 Hauck EF, Tawk RG, Karter NS, et al. Use of the outreach distal access catheter as an intracranial platform facilitates coil embolization of select intracranial aneurysms: technical note. J Neurointerv Surg 2011; 3: 172 176. JNET 9:219 225, 2015 要 旨 working projection image WPI double microcatheter technique DMT A2 working projection DMT 2 microcatheter MC A1 frame MC WPI DMT 225