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|Year : 2013 | Volume
| Issue : 6 | Page : 650-652
Indocyanine green video angiography-assisted surgical management of coil migration resulting from the endovascular treatment of anterior communicating artery aneurysm: Technical case report and instrumentation assessment
Zion Zibly1, Gustavo G Rajz2, Mayur Sharma3, Sagi Harnof2
1 Department of Neurosurgery, Ohio State University, Wexner Medical Center, Columbus Ohio, USA; Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
2 Department of Neurosurgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
3 Department of Neurosurgery, Ohio State University, Wexner Medical Center, Columbus Ohio, USA
|Date of Submission||17-Sep-2013|
|Date of Decision||26-Oct-2013|
|Date of Acceptance||18-Dec-2013|
|Date of Web Publication||20-Jan-2014|
Department of Neurosurgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
Source of Support: None, Conflict of Interest: None
We describe surgical management of herniated coil using indocyanine green video angiography (ICGA) following failure of endovascular retrieval methods in a patient who had endovascular treatment for anterior communicating artery aneurysm. The interdisciplinary cooperation between the endovascular and neurosurgical teams proved to be crucial for obtainment of a desirable outcome in this case. ICGA technology applied in such difficult cases may improve the surgical outcome.
Keywords: Aneurysm, angiography, coil herniation, embolization, indocyanine green
|How to cite this article:|
Zibly Z, Rajz GG, Sharma M, Harnof S. Indocyanine green video angiography-assisted surgical management of coil migration resulting from the endovascular treatment of anterior communicating artery aneurysm: Technical case report and instrumentation assessment. Neurol India 2013;61:650-2
|How to cite this URL:|
Zibly Z, Rajz GG, Sharma M, Harnof S. Indocyanine green video angiography-assisted surgical management of coil migration resulting from the endovascular treatment of anterior communicating artery aneurysm: Technical case report and instrumentation assessment. Neurol India [serial online] 2013 [cited 2019 Mar 25];61:650-2. Available from: http://www.neurologyindia.com/text.asp?2013/61/6/650/125274
| » Introduction|| |
Coil migration and herniation is a rare complication of endovascular treatment for intracerebral aneurysms. There are no specific guidelines regarding the management of dislodged coils which are difficult to retrieve despite multiple attempts, due to the rarity of such an event. It is difficult to retrieve the dislodged coils and added attempts at pulling the coil may cause a perforation through the aneurysm wall, while invasive microsurgical procedures carry its risks. This report describes the surgical removal of a coil which migrated from its desirable location and got lodged in the lumen of the right A1-2 junction.
| » Case Report|| |
A 67-year-old male was admitted with a history of massive subarachnoid hemorrhage (SAH) due to A-com artery aneurysm for which he was treated by endovascular coiling (two coils) 6 months before this admission. Follow-up angiography revealed the coils to be compacted, leading to a third coiling attempt. During the procedure there was dislodgement of initial coil into the lumen of the right A1-2 junction. He was started on heparin and multiple attempts to retrieve the migrated coil using endovascular balloon and Amplatz "Goose-Neck" microsnare (Microvena, White Bear Lake, MN) catheter were unsuccessful. In view of multiple unsuccessful attempts and possible risk of parent vessel occlusion, a decision was made to surgically rescue the dislodged coil.
The patient was taken up for urgent surgery and heparin was maintained in order to ensure the patency of the parent vessel until the initiation of the surgical procedure. Right pterional craniotomy was performed under thiopental anesthesia-induced burst suppression and gradual cooling to core temperature of 34°C.  to have direct exposure of the A2 segment and removal of the coil with an optional trapping and distal A2-A2 anastomosis. During the surgical procedure the anterior complex was exposed and the aneurysm with dislodged coils could be seen through the translucent trunk wall. At this stage, an indocyanine green video angiography (ICGA) using the near-infrared fluorescent dye was performed. A Zeiss OPMI Neuro NC4 microscope-fitted with an infrared 800 illumination head for fluorescence-based angiography was used to visualize the ICG fluorescing cerebral blood flow.  The information thus obtained was used for the effective planning of the surgical rescue procedure [Figure 1]. Temporary clips were placed on the right and left A1 as well as on the left A2 segments. A small arteriotomy was subsequently performed in the patent part of the aneurysm neck, distal to the final location of the permanent clip. The lodged coil was carefully removed using microforceps. A permanent straight SUGITA clip was placed on the remnant aneurysm, after which a check ICGA was performed, followed by confirmatory intra-operative diagnostic angiography [Figure 2] and [Figure 3]. Both the diagnostic procedures demonstrated a full removal of the herniated coil, as well as a complete closure of the remnant aneurysm, with no evidence of flow obstruction in the parent vessel.-procedure-Post patient developed mild left-sided hemiparesis which resolved at 6-week follow-up.
|Figure 1: Optical (left) and ICG-based video angiography (right) of the aneurysm pre-arteriotomy. (a) right A1 segment of right ACA; (b) Right A2 segment of right ACA; arrowhead: left A1 segment of left ACA; arrow: Right recurrent artery of heubner; asterisk: Remnant of aneurysm; dashed line: Margins of aneurysm neck; arrowheads: Arteriotomy site; GR: Gyrus rectus; LON: Left optic nerve; RON: Right optic nerve; OC: Optic chiasm|
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|Figure 2: Optical (left) and ICG-based video angiography (right) of the aneurysm Post-arteriotomy. Aneurysm is completely secured and the incision site obliterated. a: right A1 segment of right ACA; b: right A2 segment of right ACA; AcomA: anterior communicating artery; arrowhead: left A1 segment of left ACA; arrow: right recurrent artery of heubner; arrowheads: region of secured aneurysm|
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|Figure 3: (a) Preoperative angiography showing herniation of coil through the aneurysm (b) Intraoperative angiography following surgical retrieval of herniated coils and clipping showing complete occlusion of the aneurysm|
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| » Discussion|| |
Technological advances in the field of endovascular neurosurgery have led to an increased number of intracranial aneurysms being treated by endovascular approach. The favorable outcome in the endovascular arm in the International Subarachnoid Aneurysm Trial  has contributed to this shift. The N-ISAT study found cognitive impairment more frequently in the patients randomized to the microsurgical arm compared to those in the endovascular arm.  With an increase in the endovascular procedures for the treatment of intracranial aneurysm, the rate of complications like flow-obstructing herniated coil as in this patient are likely to increase. Very few cases have been described using the surgical techniques for the management of coil herniation arising from the endovascular treatment of intracranial aneurysms. ,
Intraoperative blood flow visualization was an extremely important component in the management of our case. The rate of unexpected major branch occlusion resulting from the clipping of an aneurysm as demonstrated with postoperative angiography, varied between 4% and 12%.  In this patient, the herniated coil was obstructing the parent vessels and possibly compromising multiple perforating branches. In light of these findings as well as the complex anatomy of the aneurysm pre- and post-clipping blood flow visualization using either intraoperative digital subtraction angiography (DSA) or ICGA were important. ,,
Intraoperative DSA is considered a safe procedure. However, it is difficult to carry out due to the technical demands, time delays it results in the operating room, the requirement of additional manpower and additional costs. Furthermore, it may not evaluate small perforating arteries as well as the recurrent artery of Hubner. , ICGA has been found to be a simple, safe, timely and inexpensive method for visualizing vascular flow in major arteries and small perforating vessels. ,, Thus, we often use this method multiple times during the procedure which increases the confidence of the surgeon in locating the arteriotomy and placement of the permanent clip which may lead to a favorable outcome.
Kim et al.  emphasized the importance of understanding the guidelines for "complementary methodological crossovers" from a first-line attempt of endovascular coil embolisation to urgent microsurgical intervention. We also believe that it is crucial to develop and standardize such guidelines, since the prevalence of such crossover seems to vary among institutions.  However, the use of newer techniques such as pipeline embolization devices or silk flow diverter stents is safe and associated with high rate of angiographic success and might reduce the incidence of such complications in the future. ,
| » Conclusion|| |
Our report demonstrates one of the unique challenges in vascular neurosurgery, requiring specific skills and technologies imperative for the achievement of a desirable outcome. We demonstrate the importance of interdisciplinary cooperation between neuro-interventional and neurosurgical teams and the utility of intraoperative ICGA to deal with such a rare complication.
| » References|| |
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[Figure 1], [Figure 2], [Figure 3]