ASSISTANT:
ANESTHESIOLOGIST:
ARASH PADIDAR, M.D.
PROCEDURE:
1. Cerebral angiography.
2. Surgical induction of needle and catheter into the right common femoral artery
at approximately 1830 hours.
3. Selective catheter placement, arterial system right common carotid artery,
second branch arterial system at 1835 hours.
4. Angiography of arterial system, right common carotid injection in __________
lateral projection at 1936 hours.
5. Selective catheter placement, arterial system right internal carotid artery third
OM branch arterial system at 1937 hours.
6. Angiography of arterial system right internal carotid injection and selective AP
and lateral projections at 1940 and 1941 hours.
7. Selective catheter placement, arterial system marker catheter into posterior
communicating artery region aneurysm, and in the third OM branch arterial
system at 1900 hours.
8. Angiography during first coil embolization of posterior communicating artery
aneurysm in AP projection at 1910 hours.
9. Angiography arterial system during first coil embolization of aneurysm in AP
projection at 1911 hours.
10. Angiography arterial system, right internal carotid injection after coiling of
posterior communicating artery aneurysm in AP projection at 1913 hours.
11. Angiography of arterial system right, internal carotid injection and selective
with 6 degrees LAO with 14 degrees cranial angulation branch occlusion shot at
1914 hours.
12. Angiography of arterial system, right internal carotid artery injection and
selective in lateral projection branch occlusion shot at 1915 hours.
13. Angiography arterial system, right internal carotid artery injection in selective
lateral projection at 1916 hours.
INTRAVENOUS PROCEDURES: None.
VASCULATURE:
1.
Transcatheter therapy/endovascular surgery coil embolization of right
posterior communicating artery aneurysm.
ENDOVASCULAR SURGERY:
1.
Transcatheter therapy/endovascular surgery coil embolization of right
posterior communicating artery aneurysm, with supervision and interpretation
with requirement of an assistant surgeon.
2.
Transcatheter therapy surgery/endovascular surgery, closure of arterial
site right common femoral artery with the use of an 8 French Angio-Seal device.
4.
Transcatheter surgery/endovascular surgery, closure of arterial site right
common femoral artery with the use of an 8 French Angio-Seal device, with
supervision and interpretation with requirement of an assistant surgeon.
PREOPERATIVE DIAGNOSIS:
1.
Ruptured right posterior communicating artery aneurysm.
POSTOPERATIVE DIAGNOSIS:
1.
Ruptured right posterior communicating artery aneurysm.
OPERATOR: Reza Malek, M.D. and Arash Padidar, M.D.
ANESTHESIA:
General anesthesia.
DURATION OF PROCEDURE:
2 hours.
INDICATION FOR PROCEDURE: A 41-year-old female presenting
with lethargy, nausea, vomiting and headache, which was
shown to have diffuse subarachnoid hemorrhage, more so in
the right sylvian fissure.
CONSENT: Verbal and written consent were obtained after a
discussion of the risks and benefits of the procedure with
the patient's family. Risk of intracranial hemorrhage,
stroke, death, nephrotoxicity to contrast allergy and other
adverse events were discussed in detail. The patient
understood and consented to the procedure.
TECHNIQUE: The patient was prepped and draped in the usual
sterile fashion over both groin areas. General anesthesia
care was provided by Good Samaritan Hospital who provided
anesthesia throughout the procedure. Area over the right
common femoral artery was anesthetized with 1% lidocaine
solution with epinephrine in the subcutaneous and
subcuticular tissues. A small skin incision was done with
#11 blade. Tissue was separated with a Hemostat. Access
was gained into the common femoral artery with addition of
single one-puncture needle, and over a Bentson wire a 7
French arterial sheath was placed. The sheath was secured
to the skin with 2-0 silk suture. Then it was connected to
__________ heparinized saline drip. A 6 French MPD Cordis
catheter was negotiated over a wire and over a 5 French
diagnostic 125 cm Berenstein catheter into the right common
carotid artery and after obtaining a lateral angiogram of
the common carotid artery bifurcation into the internal
carotid artery, a small puff of contrast excluded
__________ for vasospasm. A second angiography of the
intracranial vessels was done by right internal carotid
artery injection. Angiogram done a few hours prior to the
study by Dr. Padidar was also reviewed along the CT
examination. Access was gained to the aneurysm initially
with the 90 degree Echelon 14 microcatheter catheter over
0.014 Synchro wire by Boston Scientific. Initially a 6 mm
diameter by 20 cm long Morpheus ultrasoft coil by EV3 was
attempted to be deposited into the aneurysm. The catheter
angle proved to be unfavorable. The catheter was exchanged
for a 45 degree Echelon 14 catheter and the same coil was
introduced into the aneurysm after it was properly cleaned
and flushed without difficulty. Followup angiogram
demonstrated complete exclusion of the aneurysm with no
significant coil material protruding into the vessel. The
catheter was removed and the coil was detached. AP and
lateral angiograms of the brain excluded any evidence of
distal embolization. The patient tolerated the procedure
well. The common femoral arterial puncture was closed with
the use of an 8 French Angio-Seal device.
SPECIMENS TO PATHOLOGY:
None.
FINDINGS:
1.
The right common carotid artery bifurcation is
unremarkable.
2.
The right internal carotid artery injection
demonstrates, again noted a blue-chip aneurysm arising from
the PCOM region directed laterally. The origin is apart
from the posterior communicating artery, which is a
prominent branch on the left side.
This aneurysm was
completely excluded with a 6 mm x 20 cm long Morpheus EV3
detachable coil. Both anterior cerebral arteries filled
via the right-sided A1 segment.
IMPRESSION: Successful coil embolization of right
posterior communicating artery aneurysm. The patient
tolerated the procedure well. Followup CT examination will
be obtained. The patient received 4000 units of heparin
during this procedure.