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Stent Assisted Coiling Of An Ophthalmic Aneurysm

2021-04-07 张晓龙

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由张晓龙医生带来的Stent Assisted Coiling Of An Ophthalmic Aneurysm,欢迎阅读、收藏~!

Our case


History

• Female, 31 years old.

• Sudden onset of blurred vision of the left eye for 1 month was diagnosed as Adie pupil syndrome. A right ophthalmic artery aneurysm was found incidentally. 

• Past medical history: No hypertension or diabetes.

• PE: dilated left pupil (R=2mm, L=4mm), slow light reflex of the left pupil. 

• 患者为31岁女性

• 患者突发左眼视物模糊1月,被诊断为艾迪综合征;偶然发现右侧颈眼动脉动脉瘤。

• 既往病史:无高血压、糖尿病。

• 体格检查:左侧瞳孔扩大(右=2mm, 左=4mm),左侧瞳孔对光反射迟钝。



Video 1. Rotational angiography shows an irregular wide neck ophthalmic artery aneurysm with a daughter sac. 视频 1. 旋转血管造影可见一不规则宽颈颈眼动脉动脉瘤伴子瘤。


1

Strategy

• The carotid-ophthalmic aneurysm with a daughter sac indicates a high rupture risk.

• The daughter sac is the risk point which must be revealed clearly during embolization of the related region. The daughter sac should be embolized to avoid peri-operative hemorrhage after antiplatelet therapy.

• Stent assisted coiling of the aneurysm with densely packing the aneurysm neck can reduce the recurrence rate.


• 颈眼动脉瘤伴子瘤破裂风险高。

• 子瘤作为破裂的危险点在栓塞相关区域时必须被清晰地显示。

• 应栓塞子瘤来避免抗血小板药物治疗后的围手术期出血。

• 支架辅助栓塞动脉瘤中瘤颈的致密栓塞可降低复发率。


2

Operation

Figure 1 GIF. Measurement: Aneurysm 3.6mm; Neck 3.67mm; Parent artery 3.49mm. 图 1. 测量:动脉瘤 3.6mm;瘤颈 3.67mm;载瘤动脉 3.49mm。

Figure 2. Working projection I was selected to show the aneurysm neck and proximal parent artery, not the daughter sac. 图 2. 工作角度 I 用于显示动脉瘤颈和近端载瘤动脉,而不是子瘤。

Figure 3 GIF. General heparinization. The guiding catheter (6F Envoy DA) was advanced as far as possible to provide stable support for coiling. 图 3. 全身肝素化。导引导管(6F Envoy DA)尽可能到走远,为弹簧圈栓塞提供稳定的支撑。

Figure 4 GIF. XT-27 microcatheter was navigated to the distal right MCA. 图 3. XT-27微导管到达右侧大脑中动脉远端。



Video 2. Echelon-10 45° with spiral curved tip. The microcatheter tip was advanced into the daughter sac. 视频 2. Echelon-10 45°微导管头端塑形为螺旋形。微导管头端进入子囊内。



Video 3. Neuroform 4.0*15 mm. The delivery system was entangled with the proximal part of the stent, requiring pushing the whole system to free the delivery wire. Neuroform 4.0* 15mm. 视频 3. 输送系统与支架近端缠绕,需要推动整个系统来使输送导丝游离。

Figure 5 GIF. Working projection II was selected to show the risk point-daughter sac. 图 5. 工作角度 2 用于显示子瘤这一危险点。

Figure 6 GIF. Target 360 ultra 4mm*6cm. Adjusting the framing to embolize the daughter sac with partial loops. 图 6. Target 360 ultra 4mm * 6cm弹簧圈。调整成篮,以部分圈栓塞子瘤。

Figure 7 GIF. Target 360 ultra 2mm*4cm. Partial loops embolized the daughter sac. 图 7. Target 360 ultra 2mm*4cm弹簧圈。部分圈栓塞子囊。

Figure 8 GIF. Target 360 ultra 2mm*4cm. 图 8. Target 360 ultra 2mm*4cm弹簧圈。

Figure 9 GIF. Target 360 nano 1.5mm*4cm. 图 9. Target 360 nano 1.5mm*4cm 弹簧圈。

Figure 10 GIF. Target 360 ultra 3mm*6cm. 图 10. Target 360 ultra 3mm*6cm 弹簧圈。

Figure 11 GIF. Target 360 ultra 3mm*6cm. 图 11. Target 360 ultra 3mm*6cm 弹簧圈。

Figure 12 GIF. tuAngiography shows parent artery patent and intracranial vessels are intact. 图 12. 血管造影显示载瘤动脉通畅,颅内血管完整。

Figure 13 GIF. Working projection III was chosen to show the inflow tract. Insert the final coil Target 360 ultra 2mm*3cm without much tension. 图 13. 工作角度III 用于显示流入道。填入最后一枚Target 360 ultra 2mm*3cm 弹簧圈,没有给予过多张力。

Figure 14 GIF. Post operative angiography on working projection. 图 14. 于工作角度行术后血管造影。

Figure 15 GIF. Post operative rotational angiography shows densely packing of the aneurysm with the parent artery patent. Tirofiban (Xinweining) 10ml was administrated. 图 15. 术后旋转血管造影显示动脉瘤致密栓塞,载瘤动脉通畅。应用替罗非班(欣维宁)10ml。

Figure 16 GIF. Dyna CT shows no hemorrhage. 图 16. Dyna CT未见出血。

Figure 17. The three working projections have different purposes:

I: show the aneurysm neck and adjacent parent artery.
II: reveal the daughter sac for embolization and in case of accidental puncturing the danger point.
III: show the inflow tract for densely packing and reduce the recurrence rate.

图 17. 三个工作角度有不同的目的:

角度I:显示动脉瘤颈和相邻的载瘤动脉。

角度II:显示子瘤以便于栓塞并显示意外穿破的危险点。

角度III:显示流入道以便于致密栓塞,降低复发率。


3

Summary

1.The carotid-ophthalmic aneurysm with a daughter sac indicates a high rupture risk.

2.The daughter sac is the danger point of rupture which must be revealed clearly while embolizing the related region. The daughter sac could be embolized to avoid peri-operative hemorrhage after antiplatelet therapy. Small coils after the first two framing coils can penetrate into the daughter sac.

3.Densely packing a relatively wide-necked aneurysm with stent assisted coiling can decrease the recurrence rate.

4.The guiding catheter was advanced as far as possible to provide stable support for coiling which also can improve maneuverability.

5.The three working projections have different purposes:

    I: to show the aneurysm neck and adjacent parent artery

    II: to reveal the daughter sac for embolization and in case of accidental puncturing.

    III: to show the inflow tract for densely packing and decrease the recurrence rate.


1.颈眼动脉瘤伴子瘤破裂风险高。

2.子瘤作为破裂的危险点在栓塞相关区域时必须被清晰地显示。应栓塞子瘤来避免抗血小板药物治疗后的围手术期出血。在最早的两枚弹簧圈成篮后,小弹簧圈可以顺利穿行到达子囊。

3.相对宽颈动脉瘤采用支架辅助栓塞术进行致密栓塞可以降低复发率。

4.导引导管尽可能走远,为弹簧圈栓塞提供稳定的支撑,同时也提高了可操作性。

5.三个工作角度有不同的目的:

角度1:显示动脉瘤颈和相邻的载瘤动脉

角度2:显示子瘤以便于栓塞并显示意外穿破的危险点。

角度3:显示流入道以便于致密栓塞,降低复发率。



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