A Combined Microsurgical and Endovascular Approach to Giant Paraclinoid Aneurysm: 2-Dimensional Operative Video

Abstract Giant paraclinoid aneurysm remains a treatment challenge because of their complex anatomy and surgical difficulties stems frequently from a calcified or atherosclerotic aneurysmal neck and compression of the optic pathways.1-9 To improve exposure, facilitate the dissection of the aneurysm, assure vascular control, reduce brain retraction and temporary occlusion time, and enable simultaneous treatment of possible associated aneurysms, we combined the cranio-orbital zygomatic (COZ) approach9 with endovascular balloon occlusion of the internal carotid artery (ICA) and suction decompression of the aneurysm.4 The patient is a 50-yr-old female who presented with headache and hemianopsia. MRI, CT, and 4-vessel angiography revealed a giant right ophthalmic paraclinoid partially thrombosed aneurysm. Surgery was performed via right COZ approach with removal of the anterior clinoid. Unroofing the optic canal and opening the falciform ligament and the optic sheath, allowing the dissection and mobilization of the optic nerve from the aneurysm and the origin of ophthalmic artery. The endovascular team placed a deflated, double lumen balloon catheter in the ICA 2 cm above the common carotid bifurcation. Proximal control is achieved by inflating the balloon. Distal control is then gained by temporary clipping just proximal of the origin of PcomA.4 Retrograde suction decompression through the catheter partially collapses and softens the aneurysm.1,4,6-8 Carotid occlusion was applied twice, 2:47 and 2:57 min. Intraoperative angiogram revealed the obliteration of the aneurysm and the patency of the carotid and ophthalmic artery. The patient recovered well, and visual deficit resolved and was neurologically intact. Patient consented for surgery. Illustrations in video reprinted with minimal modification from Surgical Neurology, vol 50, issue 6, Arnautović KI, Al-Mefty O, Angtuaco E, A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneuroysms, 504–518,4 Copyright 1998, with permission from Elsevier Science Inc.

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Practical tips for performing resuscitative endovascular balloon occlusion of the aorta

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907921994422 ◽

2021 ◽

pp. 102490792199442

Author(s):

Sung Wook Chang ◽

Dae Sung Ma ◽

Ye Rim Chang ◽

Dong Hun Kim

Keyword(s):

Damage Control ◽

Balloon Catheter ◽

Common Femoral Artery ◽

Balloon Occlusion ◽

Trauma Patients ◽

Arterial Access ◽

Occlusion Time ◽

Sheath Insertion ◽

Multiple Trauma Patients ◽

Endovascular Balloon Occlusion

Background: Hemorrhage is the leading cause of death in trauma settings. Non-compressible torso hemorrhage, which is caused by abdominopelvic and thoracic injuries, is an important cause of subsequent organ dysfunction and poor outcomes in multiple trauma patients. The management of hemodynamically unstable patients with non-compressible torso hemorrhage has changed, and the concept of damage control resuscitation has been developed in the last decades. Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) as a method of temporary stabilization is the modern evolution of bleeding control, and it is in the middle of a paradigm shift as a treatment for non-compressible torso hemorrhage. Despite its effectiveness in patients with hemorrhagic shock, the application of REBOA remains limited because of lack of experience and troubleshooting guidelines. Objectives: The aim of study was to provide useful tips for the implementing a step-by-step procedure for REBOA in various hospital settings and capabilities. Methods: We introduced REBOA procedures using a REBOA-customized 7 Fr balloon catheter through the animation models or radiography from preparation to access, catheter management, and device removal after procedure completed. Results: We have described REBOA procedures as follows: identification of the common femoral artery, arterial access for placement of a guidewire, precautions during a sheath insertion, guidewire and balloon positioning in the aorta, occlusion zones and adjustment of balloon location, REBOA strategy for extending the occlusion time, balloon deflation and removal, sheath removal, and medical records. Conclusion: We believe that the practical tips mentioned in this article will help in performing the REBOA procedure systematically and developing an effective REBOA framework.

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Retrograde suction decompression of an ophthalmic artery aneurysm using balloon occlusion

Journal of Neurosurgery ◽

10.3171/jns.1991.75.1.0146 ◽

1991 ◽

Vol 75 (1) ◽

pp. 146-147 ◽

Cited By ~ 49

Author(s):

John A. Scott ◽

Terry G. Horner ◽

Thomas J. Leipzig

Keyword(s):

Ophthalmic Artery ◽

Internal Carotid ◽

Balloon Catheter ◽

Artery Aneurysm ◽

Balloon Occlusion ◽

Double Lumen ◽

Content Type ◽

Proximal Occlusion ◽

Distal Occlusion ◽

Temporary Clip

✓ A large ophthalmic artery aneurysm was ligated using a modification of the retrograde suction technique described by Batjer and Samson. Temporary proximal occlusion of the internal carotid artery was accomplished with a double-lumen balloon catheter, and distal occlusion was performed with a temporary clip. The aneurysm was collapsed by gentle aspiration through the distal lumen of the balloon catheter. This greatly facilitated dissection and clip ligation of the aneurysm.

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Direct clipping of basilar trunk aneurysms using temporary balloon occlusion

Journal of Neurosurgery ◽

10.3171/jns.1994.80.2.0230 ◽

1994 ◽

Vol 80 (2) ◽

pp. 230-236 ◽

Cited By ~ 40

Author(s):

Kazuo Mizoi ◽

Takashi Yoshimoto ◽

Akira Takahashi ◽

Akira Ogawa

Keyword(s):

Digital Subtraction Angiography ◽

Basilar Artery ◽

Balloon Catheter ◽

Balloon Occlusion ◽

Seldinger Technique ◽

Digital Subtraction ◽

Vascular Control ◽

Occlusion Balloon ◽

Temporary Balloon Occlusion ◽

Angiography Catheter

✓ In the surgical treatment of basilar trunk aneurysms, there is still considerable technical difficulty in gaining both proximal artery control and a sufficient operative field. The authors describe their experience in five patients with basilar trunk aneurysms treated using temporary balloon occlusion and intraoperative digital subtraction angiography. With the patient under general anesthesia, a heparinized angiography catheter was guided into the dominant vertebral artery by means of the Seldinger technique. A silicone balloon catheter was introduced coaxially through the angiography catheter to the basilar artery just proximal to the aneurysm. The balloon was inflated tentatively to evaluate the appropriate inflation volume, then the balloon catheter was withdrawn back into the angiography catheter to prevent thrombus formation. After exposure of the aneurysm, the occlusion balloon was advanced again and inflated temporarily within the basilar artery to prevent premature rupture and to facilitate dissection of the aneurysm. The mean duration of temporary balloon occlusion was 22 minutes. There were no patients with postoperative deficits attributable to the temporary occlusion. The results of aneurysm clip placement were confirmed by intraoperative digital subtraction angiography immediately after clipping. No patient suffered from distal embolism or other complications related to vessel catheterization. From this experience, it is concluded that this intraoperative endovascular technique can contribute to the success of surgery for complex cerebral aneurysms, particularly for basilar trunk aneurysms in which proximal vascular control is difficult.

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Use of balloon occlusion and substances to protect ischemic brain during resection of posterior fossa AVM

Journal of Neurosurgery ◽

10.3171/jns.1985.63.4.0626 ◽

1985 ◽

Vol 63 (4) ◽

pp. 626-629 ◽

Cited By ~ 9

Author(s):

Jiro Suzuki ◽

Akira Takahashi ◽

Takashi Yoshimoto ◽

Hirobumi Seki

Keyword(s):

Arteriovenous Malformation ◽

Posterior Fossa ◽

Basilar Artery ◽

Balloon Catheter ◽

Balloon Occlusion ◽

Ischemic Brain ◽

Content Type ◽

Occlusion Time ◽

Feeding Vessels ◽

Fine Print

✓ The successful resection of a large posterior fossa arteriovenous malformation (AVM) is reported. A balloon catheter was used for temporary intraoperative occlusion of the basilar artery and feeding vessels of the AVM. Prior to occlusion of these arteries, newly tested substances to protect the ischemic brain were administered to prolong occlusion time. Resection of the AVM was completed without complication, and the patient returned to normal life. This is a useful intraoperative procedure for the resection of AVM's considered inoperable by conventional approaches.

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Determination of optimal deployment strategy for REBOA in patients with non-compressible hemorrhage below the diaphragm

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000660 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000660

Author(s):

Nicholas L Johnson ◽

Charles E Wade ◽

Erin E Fox ◽

David E Meyer ◽

Charles J Fox ◽

...

Keyword(s):

Primary Source ◽

Multiple Organ ◽

Balloon Occlusion ◽

Hemorrhage Control ◽

Level Of Evidence ◽

Occlusion Time ◽

Deployment Strategy ◽

Multicenter Prospective Observational Study ◽

Selection Algorithms ◽

Post Hoc

BackgroundNon-compressible truncal hemorrhage (NCTH) is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control, supporting cardiac and cerebral perfusion prior to definitive hemostasis. Aortic zone selection algorithms vary among institutions. We evaluated the efficacy of an algorithm for REBOA use.MethodsA multicenter prospective, observational study conducted at six level 1 trauma centers over 12 months. Inclusion criteria were age >15 years with evidence of infradiaphragmatic NCTH needing emergent hemorrhage control within 60 min of ED arrival. An algorithm characterized by the results of focused assessment with sonography in trauma and pelvic X-ray was assessed post hoc for efficacy in a cohort of patients receiving REBOA.ResultsOf the 8166 patients screened, 78 patients had a REBOA placed. 21 patients were excluded, leaving 57 patients for analysis. The algorithm ensures REBOA deployment proximal to hemorrhage source to control bleeding in 98.2% of cases and accurately predicts the optimal REBOA zone in 78.9% of cases. If the algorithm was violated, bleeding was optimally controlled in only 43.8% (p=0.01). Three (75.0%) of the patients that received an inappropriate zone 1 REBOA died, two from multiple organ failure (MOF). All three patients that died with an inappropriate zone 3 REBOA died from exsanguination.DiscussionThis algorithm ensures proximal hemorrhage control and accurately predicts the primary source of hemorrhage. We propose a new algorithm that will be more inclusive. A zone 3 REBOA should not be performed when a zone 1 is indicated by the algorithm as 100% of these patients exsanguinated. MOF, perhaps from visceral ischemia in patients with an inappropriate zone 1 REBOA, may have been prevented with zone 3 placement or limited zone 1 occlusion time.Level of evidenceLevel III.

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Balloon Occlusion of a Recurrent Carotid-Cavernous Fistula Previously Treated by Carotid Ligations

Neurosurgery ◽

10.1227/00006123-198610000-00026 ◽

1986 ◽

Vol 19 (4) ◽

pp. 643-648 ◽

Cited By ~ 11

Author(s):

O'Reilly Gerald V. ◽

John Shillito ◽

Hani A. Haykal ◽

Jonathan Kleefield ◽

Wang Ay-Ming ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Carotid Artery ◽

Balloon Catheter ◽

Balloon Occlusion ◽

Intracranial Bleeding ◽

Carotid Cavernous Fistula ◽

Cavernous Fistula ◽

Previously Treated

Abstract A carotid-cavernous fistula recurred 16 years after a Hamby procedure. The recurrence was manifested by subarachnoid hemorrhage originating from dilated draining pial veins. The fistula was closed with a balloon catheter introduced through a patent remnant of the cervical carotid artery. Patients who have previously undergone Hamby trapping and embolization should be reassessed for an occult fistula that could predispose them to intracranial bleeding.

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Robot‐assisted laparoscopic partial nephrectomy with renal artery clamping using an endovascular balloon catheter for an allograft kidney tumor: A new perspective to manage renal vascular control?

American Journal of Transplantation ◽

10.1111/ajt.15151 ◽

2018 ◽

Vol 19 (4) ◽

pp. 1239-1240 ◽

Cited By ~ 1

Author(s):

Florian Laclergerie ◽

Marie‐Charlotte Delchier ◽

Bertrand Covin ◽

Fédérico Sallusto ◽

Michel Soulie ◽

...

Keyword(s):

Renal Artery ◽

Partial Nephrectomy ◽

Balloon Catheter ◽

Laparoscopic Partial Nephrectomy ◽

Kidney Tumor ◽

Vascular Control ◽

Robot Assisted ◽

Allograft Kidney ◽

New Perspective ◽

Renal Vascular

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Balloon Occlusion Test using a Double Balloon Catheter in Patients with Internal Carotid Artery Stenosis

Japanese Journal of Neurosurgery ◽

10.7887/jcns.6.530 ◽

1997 ◽

Vol 6 (8) ◽

pp. 530-535 ◽

Cited By ~ 1

Author(s):

Yoshinori Akiyama ◽

Tatemi Todaka ◽

Motoshi Sawada ◽

Masafumi Morimoto ◽

Shogo Nishi ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Carotid Artery Stenosis ◽

Internal Carotid ◽

Balloon Catheter ◽

Balloon Occlusion ◽

Internal Carotid Artery Stenosis ◽

Artery Stenosis ◽

Occlusion Test ◽

Balloon Occlusion Test

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Abstract 16745: It Would be Possible to Rescue Traumatic Hemorrhagic Shock Patients Who Failed to Fluid Resuscitation (Fluid Non-responder) but Succeed in REBOA Resuscitation (REBOA/IABO Responder)

Circulation ◽

10.1161/circ.132.suppl_3.16745 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Tomohiko Orita ◽

Tomohiro Funabiki ◽

Motoyasu Yamazaki ◽

Masayuki Shimizu ◽

Tomohiro Sato ◽

...

Keyword(s):

Survival Rate ◽

Hemorrhagic Shock ◽

Fluid Resuscitation ◽

Recovery Rate ◽

Balloon Occlusion ◽

Shock State ◽

Occlusion Time ◽

Aortic Balloon Occlusion ◽

Significant Difference ◽

Traumatic Hemorrhagic Shock

Introduction: Fluid resuscitation (FR) and massive transfusion protocol (MTP) are important initial strategies for traumatic hemorrhagic shock cases. But poor responded patients to them are difficult to rescue. In such cases, open aortic cross clamping or intra-aortic balloon occlusion (IABO) would be performed as a temporary hemostasis treatment. Recently, IABO for severe trauma has been named resuscitative endovascular balloon occlusion of the aorta (REBOA). But it is still unclear which case can be rescued with REBOA. So we studied the relationship between the responsiveness to FR and REBOA. Methods: Consecutive 46 traumatic hemorrhagic shock patients underwent REBOA at our ER for last 86 months were included. All of their FAST were positive and done FR and MTP as a first-line resuscitation. 10Fr or 7Fr IABO devices were inserted at supraphrenic level (zone I) and underwent fundamental hemostasis by operative management (OM) and/or transcatheter arterial embolization (TAE). They were sorted into responded group or non-responded group for REBOA. The primary end point was a recovery rate from the shock state within 48 hours. Secondary end points were a survival rate in 30th days and a rate of complications. Results: 26 transient or non-responded patients (Fluid Non-responder) responded for REBOA (REBOA Responder group). 20 Fluid Non-responders did not respond for REBOA (REBOA Non-responder group). There were no significant differences in ISS (REBOA Responder vs. Non-responder: 45.8+/-15.2 vs. 54.8+/-22.3), amount of total fluid (7187+/-5782ml vs. 6772+/-4851) and total blood transfusion (4816+/-3006ml vs. 5080+/-3330), required time to occlude after arriving ER (25.3+/-12.6min vs. 19.4+/-9.8) and total occlusion time (76.4+/-66.5min vs. 92.7+/-34.4). There was significant difference in the changes of systolic blood pressure before and after of REBOA (59.3+/-25.7mmHg vs. 38.3+/-39.4, p=0.04). A recovery rate from shock state was 65%(12/26) vs. 0%(0/20) (p<0.01) and a survival rate was 14/26(54%) vs. 0/20(0%) (p<0.01). One complication occurred in REBOA Responder group but was not lethal. Conclusions: It would be necessary to recognize that Fluid Non-responder but REBOA Responder with traumatic hemorrhagic shock could be possible to rescue.

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