1. 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

2. 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.

3. 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

4. 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

5. In other words it’s a ..
HEADACHE

6. 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

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

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

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

10. Using the right angulation
LAO unfolds the aorta

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

12. 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

13. 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.

14. Tortuous ICA loops - The agony

15. And the ecstasy

16. 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

17. Tortuous ICA

18. 7F sheath + Tracker 38
7F sheath
Tracker 38

19. 7 F sheath + Tracker 38 + SL 10
Post procedure
SL 10
Tracker 38

20. 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.

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

22. Direct carotid

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

24. Bilateral DACA

25. The right DACA aneurysm could be successfully coiled via femoral access

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

27. Therefore a Direct carotid puncture was performed and aneurysm coiled successfully

28. 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

29. Trans brachial approach

30. Post stenting

31. 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

32. PRE
POST

33. 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

34. 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

35. 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

36. Thank you !
At times its better to give up …