Perdenser® and Frepass® in the Treatment of Posterior Communicating Artery Ruptured Aneurysms

Posterior communicating artery aneurysm (PCoAA), usually referred to as the aneurysm at the junction of internal carotid artery and posterior communicating artery, is a common type of intracranial aneurysms. PCoAA accounts for 29.3% of the ruptured aneurysms and 24.4%^[1] of the unruptured aneurysms. Since the posterior communicating artery aneurysm is adjacent to the oculomotor nerve, it will easily compress the oculomotor nerve, leading to oculomotor paralysis. Therefore, many patients with posterior communicating artery aneurysm are often complicated oculomotor paralysis^[2-4]. It was reported in the literature that the incidence of lateral oculomotor paralysis caused by PCoAA is about 30%~40%^[5].

Incarceration is a classical treatment of aneurysms. With the development of interventional therapy of cerebrovascular diseases, the coil system for embolism of aneurysms has been widely applied in the treatment of intracranial aneurysms due to small incision, short operation time, less intraoperative complications and fast postoperative recovery[4]. In recent years, foreign literature has reported the recovery of oculomotor paralysis after the embolization for posterior communicating artery aneurysm. After the treatment, the reason for its recovery may be related to the reduction in aneurysm volume, the pulsation of aneurysms and the remission of mass effect[6,7]. Thanks to these advantages, coil system for embolism has become the preferred treatment for posterior communicating artery aneurysm[8-10].

Patient Information

• Female, 59Y, hospitalized due to “headache for 1 week, blepharoptosis on the right side for 1 day”.

Pre-operative imaging

• Before operation, multi-angle DSA showed that the patient had a wide-necked aneurysm with daughter sac in the posterior communicating segment of the right internal carotid artery. “Stent-assisted coil aneurysm embolization" was planned to embolize the mother sac and daughter sac separately.

Procedure

• Guided by the intraoperative approach chart, first feed the guiding wire, and place the stent microcatheter at the distal end of the aneurysm neck, then enter Frepass®14 one-time use interventional microcatheter into the aneurysm cavity, followed by forming a basket for the mother sac with Perdenser® 3mm×4cm coil system for embolism-3D. The basket is well attached to the wall to form the aneurysm shape.

• Withdraw Frepass® 14 one-time use interventional microcatheter and liberate the stent. Pass the Frepass®14 one-time use interventional microcatheter through the stent mesh hole and fill Taijie Weiye’s Perdenser® 2×2mm×2cm coil system for embolism-3D and 3×1.5mm×2cm coil system for embolism-2D for packing.

• The daughter sac is packed with Perdenser® 3mm×4cm coil system for embolism-3D, then filled with one Perdenser®2mm×2cmcoil system for embolism-3D, 3mm×4cm coil system for embolism-2D and 2mm×2cm coil system for embolism-2D successively, and closed up with Perdenser® 1.5mm×2cm coil system for embolism-2D.

After Operation

• Immediately after the operation, DSA showed that the daughter sac of aneurysm was not completely developed and the mother sac was completely embolized. The operation was perfect!

In this case, the aneurysm hooked back. During operation, it was required the microcatheter should have good shape retention, so that it could be smoothly located without damaging the aneurysm and vessel. Frepass® one-time use interventional microcatheter features good shape retention and stability. In case the aneurysm opens downwardly, the microcatheter can enter the aneurysm cavity smoothly to lower the risk of aneurysm rupture and help embolize the aneurysm and protect the vessel.

After the one-time use interventional microcatheter is put in place, Perdenser® Coil System for Embolism is used to pack the mother sac and daughter sac. Perdenser® Coil System for Embolism is preset type coil, featuring stable basket and excellent space detection ability. While embolizing, it can pack the lesion inwards layer by layer, to as to lower pressure to the aneurysm wall and daughter sac and reduce the risk of bleeding due to aneurysm rupture during the process. In particular, the daughter sac is a risk factor that causes intracranial aneurysms to rupture. Not only can embolization of these daughter sacs reduce the risk of bleeding due to aneurysm rupture, but also it can lower the incidence of aneurysm. Perdenser® Coil System for Embolism is 360° Ω-shaped open-ring design with better shape retention. In embolization, it does not change the shape of aneurysm, but it can reduce the risk of bleeding due to the rupture of daughter sac. 

Product Introduction

Taijie Weiye’s independently developed Perdenser® Coil System for Embolism is divided into complex type and spiral type. The complex type can be used to make basket with its 360° Ω-shaped design with freely turning point to effectively protect the aneurysm wall and avoid its rupture. An excellent basket performance is not only helpful for aneurysm wall protection, but also provides a good foundation for subsequent packing. The head end of the coil system is designed with a polymer ball cap, which can ensure no damage to the aneurysm wall and avoid rupturing the aneurysm during the operation.

Excellent gap detection and packing ability effectively ensures that dense embolism can be achieved during surgery. Hundreds of models are available for basket formation to packing and close-up.

According to the different diameters of the coils, the system can meet the packing requirements of aneurysms of different sizes and support the whole process operation from basket forming to packing and close-up. Taijie Weiye’s ultrasoft coil system for embolism has good flexibility, which can be used for basket forming and packing in the microaneurysm treatment, but also can be used as close-up coil in the treatment of large-and medium-sized aneurysms, providing safe and reliable performance.

Taijie Weiye’s Frepass® one-time use interventional microcatheter is the first product used in the intracranial vascular surgery in China. It is designed with 3 layers of complex structure. The outer layer is made of thermoplastic resin, providing excellent shaping ability and shape retention ability. The middle layer is a metal support layer, which makes the microcatheter have thinner lumen thickness, providing smaller outer diameter and larger inner lumen diameter. The inner layer is PTFE (polytetrafluoroethylene) liner to effectively reduce friction and ensure other devices can be more smoothly pushed in the microcatheter.

For the Frepass® one-time use interventional microcatheter, the proximal end of metal support layer is stainless steel woven structure, providing good support force and force transmission. The distal end is platinum-tungsten alloy woven structure, improving the flexibility and anti-ovalization property of the distal end, conducive to passing through the tortuous vessel. At the same time, platinum-tungsten alloy has good developing properties and ensures clear development under fluoroscopy during operation.

References:

[1] Xing Guoxiang, Liu Jianmin, Xu Yi, et al. Relationship between the size and location of intracranial aneurysms and the risk of rupture. Chinese Journal of Cerebrovascular Diseases, 2010,7 (8):395401.

[2] Mao Junfeng, Wei Shihui, Xu Xueliang, et al. Clinical analysis of oculomotor paralysis caused by posterior communicating artery aneurysm. China Journal of Chinese Ophthalmology, 2010,20 (2): 84-86.

[3] Yin Du, Du Changsheng, Wang Shejun. Microanatomy and clinical significance of the oculomotor nerve. Chinese Journal of Neurosurgical Disease Research, 2012,11 (3): 249-252.

[4] Wang Shouan, Li Chengyan, Zhang Guibin, et al. Recovery of posterior communicating artery aneurysm-induced oculomotor nerve paresis after endovascular treatment and its related factors analysis. Chinese Journal of Neuromedicine, 2015,14(2): 151-155.

[5] Perneezky A, Czech T, Prognosis of oculomotor palsy following subarachnoid hemorrhage due to aneurysms of the posterior communicating artery. Zentralbl Neurochir, 1984.45(3): 189-195.

[6] Brchall D, Khangure MS, McAuliffe W. Resolution of third nerve paresis after endovascular management of aneurysms of the posterior communicating artery [J]. AJNR, 1999, 20(3): 411-413.

[7] Mavilio N, Pisani R, Rivano C, et al. Recovery of third nerve palsy after endovascular packing of internal carotid posterior communicating artery aneurysms[J]. Interventional Neuroradiology, 2000, 6:203-209.

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

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

[10] 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):145-151.