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Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 70  |  Issue : 2  |  Page : 643-651

Balloon-Assisted Coiling of Intracranial Aneurysms: Technical Details and Evaluation of Local Complications


1 Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna, Bihar, 801507, India
3 Department of Radiodiagnosis and Interventional Radiology, Apollomedics Superspeciality Hospitals; Former Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4 Department of Interventional Radiology, Royal Care Super Speciality Hospital, Coimbatore, India, Former Neuroradiology Fellow; Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
5 Department of Interventional Radiology, CHL Hospital, Indore, India, Former Neuroradiology Fellow; Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
6 Interventional Radiologist, Fortis Hospital and Cancer Institute, Bengaluru, Karnataka, India, Former Neuroradiology Fellow; Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
7 Department of Radiodiagnosis (Former Neuroradiology Fellow), Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission27-Jun-2021
Date of Decision25-Oct-2021
Date of Acceptance09-Mar-2022
Date of Web Publication3-May-2022

Correspondence Address:
Dr. Vivek Singh
Department of Radiodiagnosis (Neuroradiology Section), Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.344626

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 » Abstract 


Background: Wide-neck intracranial aneurysms need additional devices like balloons or stent for management. Balloon-assisted coiling has evolved both with interventionalist experience and device modifications.
Objective: We discussed our experience, evolution, and complications with this novel technique.
Materials and Methods: Data of 2014–2019 was retrospectively reviewed for type of balloon used along with complications in intracranial aneurysm coiling. Two hundred five aneurysms were detected in 188 patients, of which balloon-assisted coiling was planned for 198 aneurysms. Both single and double-lumen balloons were used. Aneurysms were divided into bifurcation and sidewall aneurysms. The complications were compared between bifurcation and sidewall aneurysms, and between single and double lumen balloons.
Results: Balloon-assisted coiling was planned for 198 aneurysms but successfully done for 195 (98.5%) cases. Single-lumen balloons were used in 56 aneurysms (28.3%), and double-lumen balloons were used in 142 cases (71.7%). Procedural thromboembolism within parent vessel was seen in 28 cases (14.1%); however symptomatic were encountered in 5 cases (2.5%). Intraprocedural rupture of the aneurysmal sac was seen in 9 cases (4.5%). The procedure-related mortality in our series was 1.6% (3/188 patients), and morbidity was 4.3% (8/188 patients). The complications among bifurcation and sidewall aneurysms compared between single- and double-lumen balloons showed a greater number of symptomatic thromboembolic complications in sidewall aneurysms with the use of single lumen balloons.
Conclusions: There are significant symptomatic thromboembolic complications in sidewall aneurysms with the use of single-lumen balloons which decreased as interventionalist experience evolved and better hardware developed.


Keywords: Balloon assisted coiling, intracranial aneurysm, sub arachnoid hemorrhage
Key Message: Balloon-assisted coiling of wide-neck aneurysm is a novel technique which is safe once in an experienced hand. Balloons protect from any mishappening but also increase the risk of thromboembolism, so should be cautiously used.


How to cite this article:
Vignesh S, Prasad SN, Singh V, Phadke RV, Balaguruswamy MM, Udiya A, Shetty GS, Dhull V. Balloon-Assisted Coiling of Intracranial Aneurysms: Technical Details and Evaluation of Local Complications. Neurol India 2022;70:643-51

How to cite this URL:
Vignesh S, Prasad SN, Singh V, Phadke RV, Balaguruswamy MM, Udiya A, Shetty GS, Dhull V. Balloon-Assisted Coiling of Intracranial Aneurysms: Technical Details and Evaluation of Local Complications. Neurol India [serial online] 2022 [cited 2022 Jun 27];70:643-51. Available from: https://www.neurologyindia.com/text.asp?2022/70/2/643/344626




Since the international subarachnoid aneurysm trial (ISAT), there has been an increase in the endovascular treatment of intracranial aneurysms using detachable coils.[1] Conventional coil embolization (CCE) of these aneurysms was done without the use of adjunct devices.[1],[2] However, such a technique was not favorable for wide-neck aneurysms. Dense packing could not be achieved due to the fear of coil prolapse or migration.[3–6] This hurdle was partially overcome with the introduction of the balloon remodeling technique by Moret et al.[7] Wide-neck aneurysms are those whose neck measures more than 4 mm or the dome/neck ratio less than 1.5–2.[8–10] This technique required the placement of non-detachable balloons across the aneurysm's neck within the parent vessel and temporarily inflating it to occlude the neck.[7],[8]

Intracranial aneurysms can be classified into sidewall and bifurcation aneurysms. The sidewall aneurysms arise at locations with no branch vessel or where the branch vessel is smaller than the parent vessel. The bifurcation aneurysms occur at the major bifurcation points like the internal carotid terminus (ICA), anterior communicating artery (Acom), middle cerebral artery (MCA), and basilar top.[11] The sidewall wide-neck aneurysms are amenable to balloon-assisted coiling (BAC) relatively more comfortably than the bifurcation aneurysms, which are technically challenging.[8],[11]

The initial balloons were single-lumen catheter with a guidewire to block the catheter's distal opening during balloon inflation. Due to some of the shortcomings of the single lumen balloons, the co-axial double-lumen balloon catheter was developed, which consisted of a central lumen for the passage of the guidewire and an outer lumen for balloon inflation.[12–14]

Foreign objects such as the balloon within the parent vessel lead to an increased occurrence of local thromboembolic complications as shown by some studies,[15],[16] but others have not demonstrated this.[5],[17],[18],[19]

This study reports our experience with balloon-assisted coil embolization (BACE) of intracranial aneurysms. The occurrence of various complications with this technique and comparison of those complications among the bifurcation and sidewall aneurysms; and between the single lumen and dual lumen balloons are also evaluated.


 » Materials and Methods Top


Patients

We reviewed our database for the last five years (2014–2019), and 196 patients who underwent balloon-assisted coiling of the intracranial aneurysms were initially included in our study. Eight patients in whom the balloon was kept for assistance but not inflated during the procedure were excluded later. The final patient population was 188 patients, with 84 males (44.7%) and 104 females (55.3%). The mean age of the patients was 48.36 ± 0.89 years (range: 14–81 yrs). One hundred seventy-five patients (93.1%) presented with symptoms of subarachnoid hemorrhage (SAH). Among the remaining patients, five patients presented with ptosis and two patients with sixth cranial nerve palsy.

Aneurysm characteristics

Two hundred five aneurysms were detected in 188 patients, of which balloon-assisted coiling was planned for 198 aneurysms. The aneurysm's location was as shown in [Table 1]. The mean size of the aneurysms was 4.97 ± 0.17 mm (range: 1–16 mm).
Table 1: Location of aneurysm

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Balloon-assisted coil embolization procedure

All coiling procedures were performed under general anesthesia. Cerebral digital subtraction angiography (DSA) was carried out on a Philips Allura FD20 single plane or Siemens Artis Zee Biplane system. All patients were adequately anticoagulated with a 2500–3000 IU loading dose of heparin, followed by 1000 IU/hour as a maintenance dose. ACT was monitored to maintain it at double the baseline value. Protamine was administered at the end of the procedure if the ACT was more than 2–2.5 times the baseline value.

6–7 F guiding catheter via transfemoral approach was used, and the non-detachable balloon-microcatheters used in our patients were either of single-lumen type (Eclipse, Balt, Montmorency, France; Copernic, Balt, Montmorency, France; HyperForm, Covidien/eV3, Irvine, CA, USA; HyperGlide, Covidien/eV3, Irvine, CA, USA; TransForm, Stryker Neurovascular, Fremont, CA, USA) or coaxial/dual-lumen type (Scepter C, MicroVention Terumo, Tustin, CA, USA; Scepter XC, MicroVention Terumo, Tustin, CA, USA). The usage of single- or double-lumen balloons was determined on case basis. The balloon-microcatheter was negotiated through the parent vessel and placed across the neck of the aneurysm. The microcatheters to coil the aneurysm were Headway 17 (MicroVention Terumo, Tustin, CA, USA), Echelon 10 (eV3, Irvine, CA, USA), and Excelsior SL-10 (Stryker Neurovascular, Fremont, CA, USA). The balloon was placed across the aneurysm's neck, and coiling was done with balloon inflation as and when required to keep the coil within the aneurysm. The coiling was performed till the aneurysm was densely packed or till no further packing could be achieved without compromising the parent/branch vessel.

We evaluated for any intra- and post-procedural complications including thromboembolic episodes, aneurysmal rupture, coil migration and dissection of the vessel. The rate of complications between the bifurcation and sidewall aneurysms, and between single and double lumen balloons were evaluated using appropriate non-parametric tests of significance. P < 0.05 was considered to be statistically significant. Statistical Package for Social Sciences version 21 (SPSS-21, IBM, Chicago, USA) was used for statistical analysis.


 » Results Top


Out of 202 aneurysms detected in 188 patients, BACE was planned for 198 aneurysms. Out of this, successful treatment was done for 195 cases (98.5%). Treatment was abandoned in one patient, a case of ruptured Acom aneurysm, due to failure of optimum positioning of the balloon. In two other patients, the coiling procedure had to be converted to stent-assisted coiling. [Figure 1] and [Table 2] highlight the type of balloons used along with aneurysm classification.
Figure 1: Bar chart showing numbers where single- or double-lumen balloon are used in sidewall and bifurcation aneurysms

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Table 2: Use of different balloons in side wall and bifurcation aneurysms

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Thromboembolic events

Thrombus formation within the parent vessel was seen in 28 cases (14.1%); however symptomatic thromboembolism was encountered in five cases (2.5%) that resulted in neurological deficit. On imaging among these, three patients developed patchy infarcts in MCA territory, one patient in left ACA territory, and one patient had multiple small infarcts in right high frontoparietal region [Figure 2] and [Figure 3]. Twenty-three cases received intraprocedural tirofiban administration following which there was resolution of the local thrombus. Mortality due to symptomatic thromboembolism was seen in two patients.
Figure 2: (a) DSA image showing Acom (white arrow) and left ICA-PCom aneurysms (black arrow); during coiling of Acom aneurysm no complication occurred (b and c) but while coiling ICA-PCom aneurysm, there was a coil loop prolapsed (d and e) inside the ICA causing local thrombus formation (f) for which inj. tirofiban was given and stent was paced inside to secure aneurysm neck and stabilize prolapsed coil (g). Final angiogram normal filling of intracranial vessels noted (h)

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Figure 3: DSA image showing ICA-PCom aneurysm (a and b) for which balloon-assisted coiling was done. During microcatheter and balloon placement (c), there developed local thrombus at the site of balloon in terminal ICA and MCA (d and e). First, coiling of the aneurysm was done to secure the aneurysm. Thereafter tirofiban was injected both intravenously and through a microcatheter (f) at the thrombus site. (g) Final angiogram showed slow filling of distal cortical branches. (h) Post coiling DWI MRI shows multiple tiny diffusion restricting foci in right parietal lobe and bilateral watershed zones

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Among 28 cases of local thrombus formation, 5 developed it due to coil prolapse, of which 4 were Acom bifurcation aneurysms. Among these 5 cases of coil prolapse, 2 resulted in symptomatic thromboembolic episodes.

Dissection

Arterial dissection was seen in one patient, a case of ruptured left ICA-anterior choroidal aneurysm, resulting in complete occlusion of the anterior choroidal artery. The patient developed right hemiplegia [Figure 4].
Figure 4: CT head showing sub arachnoid bleed (a) with CTA showing supraclinoid ICA aneurysm (b) which on DSA was at the anterior choroidal artery ostia (c), for which balloon-assisted coiling was done (d and e) and during balloon inflation, there was local vessel dissection (f) and thrombus (g) which occluded the anterior choroidal artery and later was not opacified in final angiograms (h). DWI MRI post coiling showing diffusion restriction (i) in the left posterior limb of internal capsule (black arrow)

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Rupture of aneurysm

Intraprocedural rupture of the aneurysm was seen in nine cases (4.5%), of which eight were initially ruptured aneurysms and one was unruptured. Among these nine cases, six were Acom aneurysms, one was ICA-Pcom, one basilar top, and one SCA aneurysm. In the eight cases, the rupture was detected during the angiographic runs and was controlled by inflating the balloon in the parent vessel for ~ 5 minutes [Figure 5]. In one patient, rupture was not noticed during the procedure; post-procedure CT showed a new bleed in the anterior interhemispheric fissure. Retrospective angiographic image analysis showed subtle leak during the procedure, which was missed due to overlapping by the adjacent vessels. One patient expired due to aneurysmal rupture.
Figure 5: (a) DSA showing Acom aneurysm for which balloon assisted coiling was done (b, c and d). During deployment of last coil, aneurysm ruptured with active extravasation (e and f) of contrast which was managed by balloon inflation across the neck of the aneurysm (g) and angiogram taken after 5 minutes showed no active extravasation (h); final post coiling angiogram (i) showed complete obliteration of aneurysm and normal filling of intracranial vessels

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Coil prolapse

Coil prolapse was seen in 11 cases (5.5%), of which 7 cases were bifurcation aneurysms and 4 were sidewall. Two cases of coil prolapse required stent placement in the parent vessel. Two patients required removal of the prolapsed coil using a snare, and one patient required a stent retrieval device. In another patient with a paraophthalmic ICA aneurysm, the coils were well-packed post embolization, but after an hour, there was prolapse of the coil into the parent vessel [Figure 6]. The coil was removed with a snare, and later a stent was placed into the parent vessel. There was no mortality due to coil prolapse.
Figure 6: A small paraophthalmic ICA aneurysm (a and b) was taken up for balloon-assisted coiling which was done successfully (c and d). Post coiling when patient was extubated, her conscious level was not good so a fluoroscopic evaluation was done for the coil mass which showed coil loop had migrated into the ICA and was going into the MCA (e and f). This coil loop was snared out (g) and finally a stent-assisted coiling was done (h and i)

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Clinical outcome

The procedure-related mortality in our series was 1.6% (3/188 patients), and morbidity was 4.3% (8/188 patients). Two patients expired due to symptomatic thromboembolic complications. One patient died as a consequence of overinflation of the balloon and intraprocedural rupture of the aneurysm. One patient developed hemorrhage 6 hours post procedure due to tirofiban administration.

The patient demographics and complications were compared between the bifurcation and sidewall aneurysms, and between single- and double-lumen balloons in [Table 3] and [Table 4].
Table 3: Patient demographics and complications in bifurcation and sidewall aneurysms

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Table 4: Patient demographics and complications in relation to type of balloon used for coiling

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The complications among bifurcation and sidewall aneurysms compared between single- and double-lumen balloons show that there is significantly more number of symptomatic thromboembolic complications in sidewall aneurysms with use of single-lumen balloons [Table 5].
Table 5: Complications among bifurcation and side wall aneurysms compared between single and double lumen balloons

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 » Discussion Top


BACE has gained widespread use since the introduction of the balloon remodeling technique by Moret et al.[7] Without balloon assistance, initially complete aneurysmal occlusion could be achieved in 85% of aneurysms less than 4 mm, and only about 15% of the wide-neck aneurysms (greater than 4 mm).[20],[21] BACE is mainly used for wide-neck aneurysms and the presence of balloon gives an added advantage of occluding the parent vessel in case of an intraprocedural aneurysmal rupture.[4],[9],[13]

Initial balloons were stiff which were replaced by more compliant balloons later on. Hence earlier trials like ATENA and CLARITY involved distal aneurysms less frequently.[18–22] Advancement in the balloon technology from 010-inch microwire compatible single-lumen balloon to 014-inch microwire compatible single- and dual-lumen balloons led to better negotiation through difficult anatomy. Dual lumen balloon catheters have the added advantage of placing a stent through them if required and moreover, proximal tip of these can be steam-shaped for better trackability.[14],[23],[24]

Several variations in balloon remodeling techniques such as double-balloon remodeling, balloon trapping, and multiple microcatheters are described in literature.[25–29] In one of our cases, we used a modified remodeling technique called shelving technique [Figure 7], which was similar to the technique using stent demonstrated by Elizabeth Hai Yen Du et al.[30]
Figure 7: Ruptured Acom aneurysm with both A2 arising from the neck of the aneurysm (a), balloon-assisted coiling (b) was done and Scepter XC balloon was kept across the neck of the aneurysm with slight inward force over it, which while inflation, every time pushed the balloon slightly inside the aneurysm covering contralateral A2 ostia (c, d and e). Neck of the aneurysm was protected with this technique (f) with complete obliteration of the aneurysm and normal opacification of bilateral A2 (g and h)

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Earlier there were concerns that the use of a balloon may increase the risk of thromboembolic complications and intimal injury due to repeated inflations, and aneurysmal rupture by fixation of microcatheter, and blockage of distal outflow portion of neck leading to increased intra-aneurysmal pressure.[3],[16],[17],[31],[32],[33] In our study, there were nine cases of intraprocedural aneurysmal rupture, and in all but one case, the balloon's presence helped to control the extravasation of blood, which proved crucial. Overinflation of the balloon has to be avoided during coil deployment as it increases the intra-aneurysmal pressure leading to rupture: one such case is described in [Figure 8]. Balloon inflation during coiling is a double-edged sword; it helps to keep the coil mass away from the neck, but at the same time, due to temporary fixation of the coiling catheter, movement of the catheter tip is hampered, and can lead to rupture. The interventionalist's experience helps in such cases, as the pressure while deploying the coils can be gauged and adjusted accordingly.
Figure 8: A dysplastic bilateral posterior cerebral artery (small P1 segment aneurysm) along with basilar top aneurysm presented with SAH, angiogram revealed chronic occlusion of bilateral ICA with anterior circulation filling via PComs (a, b and c). Simple coiling of one P1 segment aneurysm done and balloon-assisted coiling for basilar top aneurysm and during coiling overinflation of balloon led to rupture of the aneurysm (d and e). Balloon was kept inflated to prevent extravasation (f). Coiling and securing the basilar top aneurysm was done (g and h) but outcome was not good and patient died after a few days

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Earlier studies reported an increased incidence of complications, including thromboembolic events and intraprocedural aneurysmal rupture. Sluzewski et al.[15] reported a 14.1% complication rate (9.8% thromboembolic, 4% rupture) with BACE as compared to 3% with CCE. Similarly, Henkes et al.[16] reported a 38.5% complication rate with the remodeling technique. However, in both of these series, BACE was performed only in 8.6% and 1.4% of the total cases respectively, and the balloons used were not compliant as the currently available ones. The results of various other large series did not demonstrate increased complications with BACE compared to CCE.[5],[17],[18],[19],[33],[34],[35],[36] In the largest meta-analysis to date on safety and efficacy of balloon remodeling technique by Shapiro et al.[5] in 2008, which included 83 studies and 4,973 patients, the authors concluded that BACE was not associated with a higher incidence of thromboembolic events or iatrogenic rupture (incidence of 1.7% and 1.8%, respectively). Similar results were obtained in two large multicenter studies on the endovascular treatment of unruptured aneurysms (ATENA) and rupture aneurysms (CLARITY). The overall complication rates were 10.8% with CCE and 11.7% with BACE for unruptured aneurysms and 17.4% and 16.9% respectively for ruptured aneurysms.[18],[19] The rates of thromboembolic events and rupture encountered were 5.4% and 3.2%, respectively. Cekirge et al.[37] did a study on balloon remodeling technique in 864 Acom, distal ACA, and MCA aneurysms and reported a complication rate of 3.6%, which included 1.9% thromboembolic and 1.7% hemorrhagic events.

In our study, the rate of symptomatic thromboembolic episodes was 2.5%, which is comparable to Layton et al.[17] series. There was no statistically significant difference in the rates of complications (thromboembolic, rupture or coil migration) between the bifurcation and sidewall aneurysms. We found more symptomatic thromboembolic complications in sidewall aneurysms with single-lumen balloons, which when we reviewed, were in our earlier cases when we started BACE. Later when more emphasis on repeated ACT monitoring and heparinization during procedure was done, these complications reduced. With the introduction of 0.014 inch compatible double- or single-lumen balloons which were more trackable, cannulation time was decreased and lesser thrombotic events were encountered.

Coil migration or prolapse is another complication encountered during coiling with an incidence between 2.5% and 6%, more common with wide-neck aneurysms.[16],[38] In non-flow limiting coil loop prolapse, if asymptomatic, nothing is to be done; but if causing local thrombus formation, then injectable anti-platelets are to be given like tirofiban or abciximab. Delayed coil migration has also been reported in various case reports and studies.[39–42] In our study, coil migration occurred in 11 cases, of which 5 had local thrombus formation which resulted in symptomatic complications in 2 cases. In one case, there was delayed migration of the coil detected an hour after the procedure during check fluoroscopy [Figure 6]. There are various techniques for managing the migrated coil which are flow-limiting, such as snare, retriever devices or placement of stents.[39],[43],[44],[45],[46] In two of our cases, snares were used to remove coils; in one case, Solitaire stent retrieval system was used.

In our study, procedure-related morbidity was 4.3% and there was no significant difference between single- or double-lumen balloons. The mortality due to balloon remodeling technique varied in different studies from no mortality encountered in some small series[3],[47] to 1.3%–1.4% in ATENA and CLARITY trials.[18],[19] In Sluzewski et al.[15] series, death was encountered in 14.1% of remodeling cases. In our study, the procedural mortality was 1.6%, comparable to that of the global studies.

One added advantage of BACE is in vasospasm cases where, during coiling, balloon angioplasty gives long-lasting relief from vasospasm, thereby improving the outcome. Balloon angioplasty at the site of aneurysm along with distal vasospasm site can be done to relieve the spasm [[Figure 9] showing how balloon inflation at the aneurysm parent vessel relieved the spasm].
Figure 9: (a) DSA showing ICA-PCom aneurysm (white arrow), also seen vasospasm of the supraclinoid ICA (black arrow); (b) AP projection of left ICA and (c) right ICA angiograms showing severe vasospasm of left A1, left M1 and right A1 segments along with left supraclinoid ICA; (d) balloon-assisted coiling of the aneurysm was performed; (e) Hyperglide balloon was inflated in the supraclinoid ICA (dashed white arrow), post coiling to relieve vasospasm; (f) final post coiling angio in lateral projection showing complete obliteration of aneurysm with normal caliber of supraclinoid ICA

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This study's limitation is its retrospective design and non-randomized comparison between the single-lumen and double-lumen balloons.


 » Conclusion Top


BACE has many advantages compared to CCE, especially in wide-neck aneurysms. It also helps to control the extravasation of blood during inadvertent aneurysmal rupture during the procedure. The double-lumen balloons have distinctive precedence over the single-lumen balloons due to their novel design. Overall morbidity of 4.3% and mortality of 1.6% in our study is in accordance with other studies. There is a significantly higher number of symptomatic thromboembolic complications in sidewall aneurysms with use of single-lumen balloons, but with newer and better navigable 0.014 inch single-lumen balloons, there should not be any difference between single- and double-lumen balloon complications.

Ethical approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional research committee. Retrospective analysis so ethical approval not taken.

Declaration of patient consent

Informed consent was obtained from all individual participants included in the study. Informed consent from all patients were taken for use of information in teaching and publication purposes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 9], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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