Aneurysm Coil Embolization Using a 1.5-Fr Distal Outer Diameter Microcatheter
A bilobed anterior communicating artery (ACoA) aneurysm in an 80-year-old man with a transient ischemic attack five years prior to presentation was noted to have aneurysm growth up to 7 mm in maximal diameter on serial imaging. During an elective endovascular embolization procedure, severe tortuosity was noted at the femoral iliac junction during guide catheter access, as well as at the origin of the left common carotid artery, which shared an origin with the innominate off the aorta. The f inal guide catheter access consisted of a 90 cm length multipurpose tip shape Neuron Max 088 (Penumbra Inc, Alameda, CA, USA) guide catheter to the left distal common carotid artery over a 115 cm length Navien 058 (Covidien Neurovascular, Irvine, CA, USA) intermediate guide catheter to the left distal cervical internal carotid artery (ICA). Both guide catheters were "hubbed-out" or inserted entirely into the patient. Attempts to advance a 150 cm length SL-10 (Stryker Neurovascular, Fremont, CA) microcatheter over a wire only allowed access to the A1 segment of the left anterior cerebral artery, whereby the hub of the microcatheter was in contact with the hub of the intermediate catheter.\nA 165 cm Marathon microcatheter with a distal inner diameter (ID) of 0.013" instead was advanced over a Synchro 10 guidewire (Stryker Neurovascular, Fremont, CA, USA) and access to the dome of the aneurysm was obtained (). A 5 mm × 13 cm Barricade coil (Blockade Medical, Irvine, CA, USA) was then advanced easily and smoothly through the Marathon microcatheter. The pusher wire length was insufficient to completely deploy the coil, necessitating removal of the rotating hemostatic valve (RHV), and therefore the continuous flush to the microcatheter. This shorter length was sufficient to completely deploy the coil with enough pusher wire length to attach a circuit clip to electrolytically detach the coil. Detachment was also complicated by the lack of a proximal radio-opaque marker on the distal aspect of the Marathon microcatheter which by convention is located 3 cm from the most distal tip of other catheters used to deploy coils. This required additional time to slowly and carefully advance the pusher wire until detachment zone was out of the microcatheter and detachment actually occurred. Five coils in total were deployed, including a 5 mm × 13 cm, 4 mm × 7 cm, 3 mm × 6 cm, 2.5 mm × 6 cm and a 2.5 mm × 4 cm. The f inal coil was able to achieve a satisfactory occlusion grade and the microcatheter was removed without issue (). The patient tolerated the procedure well and was discharged home the next day with a normal neurologic examination.