Operative Planning

• Review imaging (prior angiogram, computed tomography, and magnetic resonance scans)
  
• Evaluate collateral flow through opposite vertebral and posterior communicating arteries
  
• Evaluate origins and supply to PICA and anterior spinal arteries

Special Equipment

• Biplanar fluoroscopy
  
• Selection of coils
  
  
  
  • Varied size and lengths
    
  • Varied stiffness
    
  • Varied manufacturers
  
  
• Coil detachment devices
  
• Steamer

Operating Room Set-up

• Back table
  
  
  
  • Additional bowls
    
  • One-, 5-, and 10-mL syringes flush and contrast
    
  • Microcatheter, balloon/stent flushed and set-up
    
  • Guide catheter flushed and set-up
  
  
• Front table
  
  
  
  • Heparinized saline flushes
    
  • Manifold for waste
    
  • Contrast and heparinized saline flush syringes, varied sizes

Anesthetic Issues

Miscellaneous

• Laboratory work
  
  
  
  • Platelet aggregation studies
    
  • Serum chemistry
  
  
• Premedication
  
  
  
  • Steroid and antihistamine for contrast allergy
    
  • Antiplatelet medication for 5 to 7 days, if stenting electively
  
  
• Ventriculostomy for hydrocephalus

• Diagnostic angiography to define aneurysm size, anatomy, and optimal working angles. Assess patency of collaterals and potential collaterals
  
  
  
  • Highlight aneurysm neck and parent vessel lumen
  
  
• All catheters on continuous flush through rotating hemostatic valve connectors
  
• Regular Accumetric (Accumetric LLC, Elizabethtown, KY) monitoring of systemic anticoagulation or antiplatelet therapy
  
• Guide catheter navigated into stable position within ascending V2 segment if possible
  
• Negative imaging (“roadmap”) of the vasculature
  
• Microcatheter over a microwire navigated into aneurysm
  
  
  
  • Each selected for stiffness, ability to navigate, inner and outer diameter
  
  
• Wire removed and coils deployed into aneurysm and detached
  
  
  
  • Coil selection by size, length, stiffness, and characteristics
    
  • First coil: largest diameter with a three-dimensional configuration
    
  • Subsequent coils: progressively smaller diameter with two-dimensional and three-dimensional configuration until filled
  
  
• Final angiograms
  
  
  
  • Complete vascular bed imaging to confirm no branch occlusion (distal emboli)

Balloon-Assisted Embolization

• Balloon over a microwire navigated across neck of aneurysm
  
• Inflate balloon during coil deployment
  
  
  
  • Inflation kept under 5 minutes, unless sufficient collateral flow from opposite vertebral artery
  
  
• Deflate balloon
  
  
  
  • Watch for herniation of coil mass into parent vessel. This can best accomplished by using a blank roadmap.

Stent-Assisted Embolization

• Can deploy self expanding stents before or after embolization
  
  
  
  • Before: Trap microcatheter against vessel wall while tip within aneurysm, or can navigate microcatheter into aneurysm through struts of stent
    
  • After: Complete the coiling and deploy across aneurysm neck

• For fusiform aneurysms and sufficient collateral flow from opposite vertebral artery
  
• Following systemic heparinization, proximal artery temporary occlusion with balloon or balloon-tip guiding catheter
  
• Under flow arrest, distal coil deployment within parent vessel
  
• Continued coil deployment while moving proximally, until beyond aneurysm

• Reversal or continued anticoagulant therapy, as is appropriate for result and individualized by treatment
  
• Antiplatelet therapy, as is appropriate for result and individualized by treatment
  
• Sheath removal from common femoral artery
  
  
  
  • Manual compression
    
  • Percutaneous arteriotomy repair (Perclose, Angio-Seal)