Overcoming difficult access in intracranial interventions: A to Z M. P. Cherian, P. Mehta T. Kalyanpur, S. S. Hedgire, K. S. Narsinghpura, V. Kasi, R. R, K. Muthukrishnan, V. K,; Kovai Medical Center & Hospital, Coimbatore INDIA

Introduction Neuro intervention is a challenging field. It demands high level of expertise and knowledge about hardware. This can be further compounded by difficulties faced in accessing intracranial vessels We describe techniques to overcome these situations with the help of animations.

Conditions leading to difficult access Tortuous iliac Dilated tortuous aorta Acute take off of arch vessels Tortuous neck vessels with prominent loops Tortuous IC vessels Acute angle of ACA and ICA Total occlusion infra renal aorta Crossing a wide neck giant aneurysm

Problems with unfavourable vascular anatomy Lack of pushability of wires and catheters leading to failure of superselective placement of catheters Lack of torque / Wires have no response Sudden forward movement of micro-catheters over the wire leading to lack of control over superselective intubation of vessels / aneurysms Long procedure and anaesthesia time resulting in more complications

In other words it’s a .. HEADACHE

How to navigate across a tortuous Iliac segment An angled catheter in combination with an angled Nitinol wire (.35 Terumo) is placed at the first bend. The wire is navigated upto each bend and catheter advanced over it. At times a torquer may be necessary Once in the aorta, the angled wire is exchanged for an extra stiff wire Long sheath placed across the iliac vessel

Tortuous vessels can be crossed with a glide coated wire. Loss of torque can be corrected with...

A long sheath that enters the aorta will correct the Tortuous vessel. Long sheaths commonly used are Destination (Terumo ), Balkin’s (Cook), and Arrow.

Accessing a difficult neck vessel AP view is not the ideal view to access neck vessels

Using the right angulation LAO unfolds the aorta

A Simmons 1 catheter can be used for selective catheterization of arch vessels

Separating the Rt carotid from SC In AP view the right common carotid cannot be separated from right subclavian, for which RAO 30° view is helpful RAO 30 AP

Steps of placing a guiding catheter in tortuous arch and neck vessels Under road map an angled wire is first navigated into the external carotid. Cerebral diagnostic catheter is passed over it. The angled wire is then exchanged for a exchange length stiffer wire (eg. Roadrunner, Amplatz). The guiding catheter is advanced and placed in the CCA. An appropriate catheter is used to hook the ostium of the vessel. The wire is then withdrawn and passed into the Internal carotid. Guiding catheter advanced over it into the ICA.

Tortuous ICA loops - The agony

And the ecstasy

Multiple loops in the ICA 7 F long sheath is kept at origin of ICA 1 mg of Nimodipine in 50 cc of NS is infused over 10 mins to prevent vasospasm. Under road map guidance, the guiding catheter / Neuron delivery catheter is further advanced over angled terumo wire into the ICA through the sheath. Tri axial system – 3 infusions needed

Tortuous ICA

7F sheath + Tracker 38 7F sheath Tracker 38

7 F sheath + Tracker 38 + SL 10 Post procedure SL 10 Tracker 38

If access is still not possible a Direct puncture of the carotid can be performed Under fluoroscopic guidance with intermittent injection of contrast, the CCA is punctured at the lowest possible point. Roadmap is misleading here because the artery generally moves with the needle. Angled guidewire is introduced into the ECA. An appropriately sized sheath is then passed over the wire and placed in distal CCA. The sheath and guidewire are firmly taped over the neck to prevent any movement The wire is then navigated into the ICA. Guiding catheter advanced over it.

Difficult access – Tortuous ICA and acute take off of the left ACA

Direct carotid

Direct carotid puncture not only helps in greater control of hardware but also reduction in procedure time

Bilateral DACA

The right DACA aneurysm could be successfully coiled via femoral access

The femoral access however did not allow desired control over the wire while accessing the left DACA aneurysm

Therefore a Direct carotid puncture was performed and aneurysm coiled successfully

Rt carotid accessed with SIM1 catheter via Rt brachial puncture No femoral access Carotid stenting through brachial route Brachial or axillary puncture may be the only access route in a case of inrarenal aortic occlusion or if femoral arteries are occluded or severely diseased. Infrarenal aortic occlusion Rt carotid accessed with SIM1 catheter via Rt brachial puncture

Trans brachial approach

Post stenting

Negotiating an acute ICA–ACA angle A microcatheter is advanced just beyond the ICA bifurcation such that it points towards the MCA A .14 guide wire with a large J curve is passed into the MCA. At times a loop of wire naturally points into ACA allowing the microcatheter to be tracked over it The microcatheter is then advanced into the proximal portion of the loop within the ACA and aneurysm subsequently intubated

PRE POST

Crossing a wide neck giant aneurysm Wide neck large aneurysms require stents to be placed across the neck but the guide-wire usually falls into the aneurysm Take a 4mm hyper-glide balloon and x-pedion wire and loop the wire in the aneurysm Take hyper-glide balloon over the wire Inflate balloon Pull back the balloon catheter to straighten loop Replace the Xpedion wire for an exchange length Accelerator .10 wire Remove balloon & take appropriate microcathter for the stent

Giant MCA aneurysm – stent across neck Micro with stent across aneurysm Balloon with the wire looped in the aneurysm Stent deployed across neck of aneurysm Balloon inflated

What to keep 45 cm and 75 cm sheaths in 6F and 7 F ( Terumo/ Arrow / Cook) Amplatz extra stiff wires / road runner (Cook) 260 cms 5F / 6F sheaths 90 cms (shuttle-Cook) .18 micro puncture set Cook / Cordis .14 wires Transend / Terumo / Syncro Exchange length .10 and .14 wires Remodelling balloon (eV3) Sim-1 / Sim-2 / Head hunter catheters

Thank you ! At times its better to give up …