Case Sharing: Perfiller® Expansible Coil for Treatment of Posterior Communicating Artery Aneurysms of Internal Carotid Artery

Case 1

Patient Information

• Female, 72 years old, admitted to the hospital with IC-Pcom artery aneurysm.

Pre-operative imaging

• DSA multi-angle angiography showed that the patient had a relatively wide-necked saccular aneurysm in the posterior communicating segment of the right internal carotid artery. The size of the aneurysm was about 8.0mm×6.0mm. "Stent-assisted coil aneurysm embolization" was proposed.

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Procedure

• Under the guidance of the intraoperative road map, the embolization microcatheter and the stent microcatheter were placed successfully, and the stent microcatheter was in place in advance for use. After that, TJWY Perfiller® 7mm*20cm-3D expansible coil was used to form a basket. Since the Perfiller® expansible coil was perfectly attached to the wall for framing and was very stable, the stent was not implanted. Next, the expansible coil was filled.

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• Then the basket was filled with TJWY Perfiller® 6mm×12cm-3D, 5mm×15cm-2D, 3mm×6cm-2D, 2mm×3cm-2D expansible coils. At the end, the basket was closed with Perfiller®2mm×4cm-2D expansible coil.

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After Operation

• Immediate postoperative angiography showed that no contrast agent was residual in the aneurysm cavity, and the aneurysmal body and neck were tightly embolized, without the need for stent implantation.

Case 2

Patient Information

• Female, 58 years old.

Pre-operative imaging

• Preoperative DSA showed a saccular aneurysm in the posterior communicating artery. The three-dimensional image showed that the size of the aneurysm was about 4.1mm×2.3mm, and the neck of the aneurysm was about 3.1mm.

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Procedure

• Under the image of the intraoperative working position, the stent microcatheter and the embolic microcatheter were smoothly placed. Then TJWY Perfiller®2mm×4cm-3D expansible coil was used to form a basket.

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• After the basket is formed successfully, the stent was released partially, and the basket was filled with Perfiller®1.5mm×3.0cm-3D and 1.0mm×2.0cm-2D each, and finally closed with Perfiller®1.0mm×2.0cm-2D.

After Operation

• The stent was completed released, and the stent was rubbed by the guide wire. The postoperative angiography showed that the aneurysm was densely embolized, and no contrast agent was residual.

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Posterior communicating artery aneurysm (PCoAA) is one of the most common intracranial aneurysms. Due to its high rate of rupture, the rate of death and disability after rupture is extremely high. The posterior communicating artery is surrounded by the oculomotor nerve. Because of its special anatomical structure, the PCoAA is easy to rupture and hemorrhage, which will paralyze the oculomotor nerve and damage hypothalamic function, resulting in increased difficulty in treatment and prognosis^[1]. The literature has reported that the incidence of unilateral oculomotor nerve palsy (ONP) caused by PCoAA is 30% – 50%^[2-4].

Coil embolization of aneurysms in this site has been the first choice for routine treatment^[5-7], and the recurrence rate of aneurysms can be as high as 30%^[5]. Therefore, for the endovascular interventional treatment of PCoAA, many technical requirements are put forward for the coil. For example, the basket should be more stable; the filling should be dense to reduce the recurrence rate; the coil body should be soft to ensure safety; the closing coil has a small impact on the branch blood.

TJWY Perfiller® polymer filament expansible coils marketed recently include a complex type (3D) and a helical type (2D). The polymer filament swells when exposed to water, which can effectively increase the embolization density, and immediately achieve the effect of dense embolization. Moreover, the expansion of the polymer filament can effectively increase the stability of the coil body, avoid the overall compression of the coil caused by the impact of blood flow, thereby providing longer-lasting protection for the aneurysmal neck, avoiding "dog ear signs", and effectively reducing the long-term recurrence rate.

After the polymer filament expands with water, it is smaller than the first-level helical diameter of the coil. Its use process is not limited by time. It will not squeeze the adjacent coil and the wall of the aneurysm. It will only expand to the place with gaps. It will not over-expand that will cause the rupture of aneurysm.

The new push system makes the push rod transfer the force more accurately, and the push process is easier and smoother.

References:

[1] Liu Donghui, Duan Pengpeng, E Yajun, et al. Analysis of refractory spasm of the tumor-bearing artery during interventional embolization of anterior communicating aneurysm[J]. Journal of Practical Radiology, 2018, 34(7): 1094-1097.

[2] Leivo S, Hernesniemi J, Luukkonen M, et al. Early surgery improves the cureofaneurysm— inducedoculomotor palsy [J]. Surg Neurol, 1996, 45:430434.

[3] Dimopoulos VG, Fountas KN, Fehes CH, et al. Literature review regarding the Methodology of assessing third nerve paresis associated with non-ruptured posterior communicating arteryaneurysms[J]. Neumsurg Rev, 2005, 28:256-260.

[4] Yang MQ, Wang S, ZhaoYL, et al. Postoperative recoveryfrom posterior communicating aneurysm complicated by oculomotor palsy [J]. ChinMed J (En91), 2008, 121: 1065-1067.

[5] Kawabata Y, Nakazawa T, Fukuda S. Endovascular embolization of branch- incorporated cerebral aneurysms[J]. Neuroradiol J, 2017, 30(6):600-606.

[6] Yang Y, Su W, Meng Q. Endovascular treatment of ruptured true posterior communicating artery aneurysms[J]. Turk Neurosurg, 2015, 25(1):73-77.

[7] Kim BM, Park SI, Kim DJ, et al. Endovascular coil embolization of aneurysms with a branch incorporated into the sac [J]. AJNR Am J Neuroradiol, 2010,31(1):145-1 51.