PMC5820865_01
(a) Three-dimensional angiogram shows a large aneurysm of right internal carotid artery with caudally extended sac (arrow). (b) Two microcatheters are positioned in the aneurysm. The one (Excelsior 1018) is advanced along inside the aneurysm wall and its tip reaches the caudal sac (small arrow). Its proximal marker is also inside the aneurysm (arrow). The other microcatheter (Excelsior SL10) is positioned in the mid of the aneurysm (small arrow head) and its proximal marker is in the parent internal carotid artery (arrow head). (c) Schematic image of the course and position of microcatheters and their markers in the Figure 1b. (d) Several coils delivered from the Excelsior SL10 are positioned in cranial two-thirds of the sac and are not distributed into the caudal sac. The proximal marker of the Excelsior 1018 is behind the coil mass and invisible any more. (e) Several ED coils (ED14) are added via the Excelsior 1018 positioned in the caudal sac and complete occlusion is achieved
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F1
The aneurysm had an irregular shape extending toward the caudal side [Figure 1a]. The tip of the second catheter was placed near the center of the aneurysm, and the second marker was placed in the ICA (outside the aneurysm) to prepare for the use of various coils other than ED coils [Figure 1b and c]. When the coils (ED14 and Orbit Galaxy; Cordis) were inserted through the catheter placed near the center, the coils could not be distributed to the caudal extended region [Figure 1d]. The caudally extruded region could be filled with ED coils (ED14) placed via the deeply inserted catheter, achieving complete occlusion [Figure 1e].
(a) Left carotid angiogram shows left occipital arteriovenous malformation supplied from feeders arising from left middle cerebral artery. The feeder bifurcates to superior (arrow head) and inferior (arrow) division at close to the nidus. (b) Plain skull X-ray film shows that two Marathon catheters were advanced close to the nidus in the inferior feeder. The tip of the one Marathon is positioned slightly proximal to the other (arrow heads). The arrow indicates previously injected Onyx in the superior feeder that did not successfully penetrated into the nidus. (c) Plain skull X-ray film: Via the proximal Marathon catheter, ED coil (ED10-extrasoft 2.5 mm x 3 cm) is delivered just proximal to the tip of the other distal Marathon catheter. (d) Plain skull X-ray film: The proximal Marathon catheter was advanced into the coil mass and 3 ED coils were added to make a compact and short plug. Tip of the proximal Marathon catheter is hidden in the coil mass. The feeder was packed at the proximal side of the distal Marathon's tip. (e) Onyx 18 is infused from the distal Marathon and infiltrated into the nidus from the beginning
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F2
For an incidentally diagnosed cerebral AVM in the left occipital lobe, embolization, and excision of the nidus were scheduled [Figure 2a]. The balloon catheter was removed, and 2 Marathon catheters were advanced into the feeder close to the nidus [Figure 2b]. An ED-Extrasoft coil (2.5 mm x 3 cm) was placed through the proximal Marathon to cover just proximal to the tip of the Marathon on the distal side [Figure 2c]. Tip of the proximal Marathon catheter is hidden in the coil mass, but coil positioning for detachment was easily and precisely done independently on the visibility of positional relation of the coil and the microcatheter [Figure 2d]. Onyx reflux. Onyx penetrated the nidus from the initiation of injection [Figure 2e], and the compartment perfused by this feeder was filled.