EndovascularEndovascularNeurosurgery:Neurosurgery:

a history of electricity a history of electricity balloons, wires and glueballoons, wires and glue

L. Fernando Gonzalez, MDL. Fernando Gonzalez, MDSeptember 18, 2009September 18, 2009

William Harvey (1578 – 1657)

Thomas Willis, London 1663

EndovascularEndovascular::procedures and procedures and

techniques that use a techniques that use a vessel (artery or vein) vessel (artery or vein)

as the route to establish as the route to establish diagnosis or treat diagnosis or treat

diseasesdiseases

1864 1864 Moore, in England performed Moore, in England performed an autopsy on a sailor that died an autopsy on a sailor that died from a gunshot to the chest. from a gunshot to the chest. Autopsy revealed the bullet Autopsy revealed the bullet located at the thoracic aorta located at the thoracic aorta embedded in fibrinembedded in fibrin……

““The foreign body which according to our The foreign body which according to our current knowledge would produce least current knowledge would produce least irritation is wire. If a large quantity were irritation is wire. If a large quantity were

coiled in an aneurysm it would attract fibrin coiled in an aneurysm it would attract fibrin as the twigs do in whipping freshly drawn as the twigs do in whipping freshly drawn

blood, support the mass which it entangled blood, support the mass which it entangled and lead to the cavity of the aneurysm being and lead to the cavity of the aneurysm being

eventually filled.eventually filled.The wire might be passed in through a small The wire might be passed in through a small cannula with care not to leave the last end in cannula with care not to leave the last end in

the minute wound, and not to direct a coil the minute wound, and not to direct a coil into the orifice of the arteryinto the orifice of the artery””

Moore, 1864

18641864 Moore, Introduced 26 yd of Moore, Introduced 26 yd of wire in a thoracic aneurysm wire in a thoracic aneurysm obtaining immediate reduction obtaining immediate reduction of blood pressure and decrease of blood pressure and decrease in size. in size. Patient died from sepsisPatient died from sepsis……

““the interior of the tumor was filled, for the the interior of the tumor was filled, for the most part, with a fibrinous coagulum, most part, with a fibrinous coagulum,

enveloping and embedded in the coils of wire enveloping and embedded in the coils of wire and firmly adherent to the wallsand firmly adherent to the walls””

Moore recognized that subtotal packing of Moore recognized that subtotal packing of the aneurysm would not protect from the aneurysm would not protect from hemorrhage and distal embolization of hemorrhage and distal embolization of

the coil could cause thrombusthe coil could cause thrombus

1866 Duncan described the “electropuncture of aneurysms”

Multiple local complications, skin necrosis, abscess formation, etc50% cure rate

Vs. 33% mortality vessel ligation14% mortality

1871 Domville 14 In of iron wire into an thoracic aneurysm

1877 Montenovesi used watch-springs to pack aneurysms

1897 Stewart packed gold wires into syphilitic aneurysms

Multiples attempts with high incidence of Multiples attempts with high incidence of failuresfailures…… different current settings different current settings …… multiple multiple stagesstages……

1879 Corradi recognized the use of metalic coils + electrical current

10 ft of wire “75 parts of cooper and 1000 parts of 1000 of silver” applied 75mA for 1 hr

Direct approach using trocars to deliver the wire, Linton

200 ft of #30-gauge stainless wire

1895 1895 RRööentgen described entgen described xx--ray ray X for X for unknownunknown

19011901 Received the Nobel Received the Nobel Prize in PhysicsPrize in Physics

18961896 Haschek & Linderthal Haschek & Linderthal demonstrated the arteries of demonstrated the arteries of the hand on a corpse the hand on a corpse

Teichmann mixtureTeichmann mixtureLime, mercury, petroleumLime, mercury, petroleum

19111911 Matas described the importance Matas described the importance of assessing tolerance and of assessing tolerance and increasing collateralincreasing collateral vessels before vessels before ligations.ligations.

wire insertion is wire insertion is ““semisurgical or quasimedicalsemisurgical or quasimedical””

19161916 ““appeal to us more as placebos appeal to us more as placebos than as real remediesthan as real remedies””

19191919 Knauer, started intraarterial Knauer, started intraarterial (direct puncture) injections of (direct puncture) injections of neoneo--salvaran to cure paralysis salvaran to cure paralysis of the insaneof the insane

Antonio Caetano de Abreu FreireAntonio Caetano de Abreu Freire

MD, neurologist, writerPolitically active as a student, Run for presidentBecame a member of parliamentWas Portugal’s signatory of Treaty of Versaille, MinisterReturn to the academy at 51 yo

Egas Moniz de Ribadouro, fought Egas Moniz de Ribadouro, fought against the Moors in the 12against the Moors in the 12thth centurycentury

““Brain is mute to X raysBrain is mute to X rays”” MonizMoniz

Cerebral angiography on cadavers that Cerebral angiography on cadavers that were transported on his car.were transported on his car.

18961896 Teichmann mixtureTeichmann mixture

Lime, mercury, petroleumLime, mercury, petroleum

19261926 Sodium bromide, Sodium bromide, 70% strotnium bromide injected in dogs, 70% strotnium bromide injected in dogs, and in one patient that died afterwardsand in one patient that died afterwards25% sodium iodine25% sodium iodine6 patients died on the 96 patients died on the 9thth patient succeeded to patient succeeded to demonstrates a pituitary tumordemonstrates a pituitary tumor

19271927 Starts using thorium diaxide, radioactive compound not Starts using thorium diaxide, radioactive compound not popular in USpopular in US

Moniz cerebral angiogram of a dog strontium bromide

Moniz Showing an Angiogram in ParisBabinski, Sicard and Roussy

19271927 Moniz introduced Moniz introduced ““arterial radiographyarterial radiography”” with a with a ““cut downcut down”” techniquetechniqueAlmeida Lima obtained the Almeida Lima obtained the access to diagnose tumorsaccess to diagnose tumors

Almeida Lima

Moniz, coined the termsCarotid siphonSylvian arteries Carotid Occlusionarterial, capillar and venous phases“miracle of Moniz” Walter Freeman, 1936

C. Miller Fisher“Oclussion of the internal carotid artery”Arch Neurol Psychiat 63:346-377, 1951

19281928 Fuller Allbright convinced Dandy to ligate the ICA in a patient with a III palsy and a pcom aneurysm.

Patient died from Stroke

Walter Dandy reports aneurysm Walter Dandy reports aneurysm clipping with McKenzie clip. clipping with McKenzie clip. ““Aneurysms could only be cured Aneurysms could only be cured by clipping, trapping, stuffing with by clipping, trapping, stuffing with muscle, coagulation or excisionmuscle, coagulation or excision””

Ann Surg 1938;107:654Ann Surg 1938;107:654--99

Pcom, no angiogram, 1st silver clip

19291929 Fuller Allbright Fuller Allbright ““it is to be hoped that, as the it is to be hoped that, as the diagnosis become more exact, diagnosis become more exact, some surgical techniques can some surgical techniques can be developed to save these be developed to save these group of patientsgroup of patients””

1933 1933 Norman Dott, Edinburgh Norman Dott, Edinburgh operates the first aneurysm, pcom,operates the first aneurysm, pcom,demonstrated by demonstrated by ““arterial radiographyarterial radiography””

1933 Moniz reports the use of angiography to demonstrate a cerebral aneurysm

1931 Brooks first to occlude CCF internally with muscle embolus

1933 Hambly & Gardner describe the physiopatology of pulsatile exophthalmous

Treatment of pulsatile exophtalmousArch Surg 27:676-685, 1933

19361936 Myerson and Loman described Myerson and Loman described the percutaneous puncture the percutaneous puncture

19371937 Dandy presents the treatment of Dandy presents the treatment of CCF, including partial proximal CCF, including partial proximal occlusion and distal ligation of the occlusion and distal ligation of the ICA ICA …… trappingtrapping

Dandy’s treatment of CCF

19401940’’s s Thorostat was considered a Thorostat was considered a dangerous agent, radioactive, dangerous agent, radioactive, responsibly of liver cancer and responsibly of liver cancer and cirrhosiscirrhosis

19411941 Dyke Dyke ““the main indication is to the main indication is to determine whether an aneurysm determine whether an aneurysm exists or notexists or not””

19411941 Werner, reported the use of Werner, reported the use of wire, and electricity to wire, and electricity to thrombose an intracranial aneurysmthrombose an intracranial aneurysm

19411941 Werner, reported the use of Werner, reported the use of wire, wire, and electricity to and electricity to thrombose an thrombose an intracranial aneurysm. Used direct intracranial aneurysm. Used direct puncturepuncture……. .

19471947 Radner reports 221 Radner reports 221 angiograms angiograms including including selective selective catheterization of vertebral arteriescatheterization of vertebral arteries

19491949 Moniz received the Nobel Prize Moniz received the Nobel Prize for his work on frontal leukotomy.for his work on frontal leukotomy.Nominated in 1927, 1928 and 1933Nominated in 1927, 1928 and 1933

Hans Christian Jacobaeus, Chairman of Nobel Committee

Recommended Dandy for his work on Myelogram and pneumoventriculogram

19601960 Luessenhop and Velasquez, Luessenhop and Velasquez, successfully advanced a successfully advanced a balloon into a carotid balloon into a carotid supraclinoid aneurysm supraclinoid aneurysm ““endoarterial embolizationendoarterial embolization”” with with methylmethacrylate particles methylmethacrylate particles for avmfor avm’’ss2.5, 3.0, 4.0, 4.2 mm spheres2.5, 3.0, 4.0, 4.2 mm spheres

19511951 Seldinger developed the technique Seldinger developed the technique of of ““guide wireguide wire””

Krayenbuhl & Yasargil accumulated Krayenbuhl & Yasargil accumulated significant experience in angiography with significant experience in angiography with >10.000 studies (1953>10.000 studies (1953--1964)1964)

Yasargil, 1953

19641964 Gallagher, developed the Gallagher, developed the ““piloejector gunpiloejector gun””, pneumatic , pneumatic deliver of horse hair into the deliver of horse hair into the aneurysmaneurysm

1965 Parkinson, defines the direct exploration of the cavernous sinus“Parkinson’s triangle”

Dwight Parkinson, 1964Dwight Parkinson, 1964

“The exposure resembled a proctoscopic passage through massive

internal hemorrhoids.”

“The neurosurgeon is required to make a rapid excursion through the tightly

packed tangle of abnormally dilated, thickened, adherent veins to the

underlying arterial wall as he dissects his way to the fistula.”

1965 1965 Mullan, Chicago, using Mullan, Chicago, using stereotactic technique inserted a stereotactic technique inserted a needle puncturing the aneurysm needle puncturing the aneurysm and passed wires through it and passed wires through it then administered current 200 then administered current 200 ––2000 mAm during 12000 mAm during 1--2 hour periods. 2 hour periods.

Angiograms q30 min to follow Angiograms q30 min to follow the progress the progress ……

1 pt worst after1 pt worst after

3 required further clipping3 required further clipping

Antifibrinolytic therapy to prevent aneurysm re-rupture

Electrothrombosis

1965 1965 Yasargil was considered an expert Yasargil was considered an expert in angiography and stereotaxy in angiography and stereotaxy introduced a introduced a specialspecial technique to technique to Robert Rand and John Alksne Robert Rand and John Alksne (UCLA)(UCLA)

1965 1965 Alksne navigated 3micron diameter Alksne navigated 3micron diameter carbonyl sphere rubbing carbonyl sphere rubbing a magnet a magnet on experimental aneurysms created on experimental aneurysms created in dogsin dogs

1969 1969 Alksne and Rand published their Alksne and Rand published their result with 9 patients, 6 had result with 9 patients, 6 had complete occlusion and 3 had complete occlusion and 3 had partial occlusion with a strokepartial occlusion with a stroke

19691969 Dotter, describes for peripheral Dotter, describes for peripheral vascular stenosis vascular stenosis ““tubular prosthesis within the tubular prosthesis within the blood vesselblood vessel””

Improved the gum for dental Improved the gum for dental impressions, impressions,

internal prosthesisinternal prosthesis““Strech outStrech out””bile duct prosthesisbile duct prosthesis6666’’s Weldon introduced s Weldon introduced the word to cts the word to cts ““To To stent stent a mitral valvea mitral valve””

Charles T. Stent 1807- 1885

““After ligation of the CCA the After ligation of the CCA the CCF continues CCF continues

to carry out its draining function, to carry out its draining function, being supplied being supplied

from the ipsilateral ECA and the Circle of from the ipsilateral ECA and the Circle of Willis. Consequently, the therapeutic Willis. Consequently, the therapeutic effect achieved with this operation is effect achieved with this operation is

insignificantinsignificant..””

A.I. Arutiunov

1969 Tethered embolus originally described by Arutiunov, Serbinenko, and Shcheglov

Combined with distal ligation, embolization and proximal ligation of cervical ICA

Tethered Embolus

19741974 Serbinenko introduced Serbinenko introduced detachable balloons (1959), detachable balloons (1959), initially for cavernous aneurysmsinitially for cavernous aneurysmsAffected by the Affected by the Cold WarCold War

May 1

Temporary occlusion of the cavernous carotid revealed flaws in the Matas’ test

Detachable balloons

19781978 Debrun reported his results Debrun reported his results using balloons to treat 14 using balloons to treat 14 carotid siphon aneurysmscarotid siphon aneurysms8 success, 5 pts had parent vessel 8 success, 5 pts had parent vessel preservation, 4 pts died and 2 had strokepreservation, 4 pts died and 2 had stroke

Temporary ICA occlusion with balloon catheter while injecting through the vertebral artery

Delineates site of fistula through the filling from posterior communicating artery

8080’’s s Debrun, Shcheglov (725), Debrun, Shcheglov (725), Serbinenko (267), Higashida Serbinenko (267), Higashida (87), Berenstein balloon (87), Berenstein balloon occlusion of aneurysms, occlusion of aneurysms, cavernous sinus aneurysms, CCFcavernous sinus aneurysms, CCF’’ss

parent vessel occlusionparent vessel occlusiontransient ischemic eventtransient ischemic eventaneurysm ruptureaneurysm rupture

Failure to fill the geometry of the Failure to fill the geometry of the aneurysmaneurysm

unprotected fundusunprotected fundus

ball valve systemball valve system

parent vessel occlusionparent vessel occlusion

Guido Guglielmi (1947 Guido Guglielmi (1947 -- ))Inspired by Mullan, Serbinenko, Inspired by Mullan, Serbinenko, DebrunDebrunFather suffered SAH, pcomFather suffered SAH, pcomExpert in electricityExpert in electricityEncouraged by Guidetti, Charles Encouraged by Guidetti, Charles Drake & Fernando ViDrake & Fernando Viññuelauela

Target was initiated by an Target was initiated by an oncologist to embolize collagen and oncologist to embolize collagen and chemotherapy on liver masses chemotherapy on liver masses

Variable stiffness catheter Variable stiffness catheter Joint efforts with Target Joint efforts with Target

Therapeutics Ivan SepetkaTherapeutics Ivan SepetkaTarget was bought by 1 m in 1987Target was bought by 1 m in 1987

19901990 Guglielmi, invented in Italy Guglielmi, invented in Italy detachable coils (GDC)detachable coils (GDC)platinum coil that is attached to platinum coil that is attached to

a a stainless steel guide that allows stainless steel guide that allows to deploy the coil into the to deploy the coil into the aneurysm and electrolytically aneurysm and electrolytically dissolve the connection dissolve the connection

between the guide and the coil.between the guide and the coil.Positive current facilitates thrombosis of Positive current facilitates thrombosis of the aneurysm attracting negative charged the aneurysm attracting negative charged particles (rbc, plt, wbc, fibrin)particles (rbc, plt, wbc, fibrin)

Guglielmi. JNS 09

Guglielmi. JNS 09

19921992 Guglielmi reported 43 pts pGuglielmi reported 43 pts p--fossa aneurysms fossa aneurysms JNS; 77:515JNS; 77:515--524, 1992524, 1992

85% occlusion of small neck85% occlusion of small neck15% occlusion of wide neck15% occlusion of wide neck5% morbidity5% morbidity

2.5% mortality2.5% mortality

1995 GDC cleared for market by FDA, 9/95

USCUSC

BNIBNI

19961996 Byrne, 50 pts treated with Byrne, 50 pts treated with GDC, immediate results and at GDC, immediate results and at 6 months (42 pts)6 months (42 pts)

100% 100% 83 % small aneurysms83 % small aneurysms

95% 95% 81 % large aneurysms81 % large aneurysms

85% 85% 50 % giant aneurysms50 % giant aneurysms

J Neuro Neurosur Psych 1995;59:616-620

6m0

19961996 McDougall reports series McDougall reports series 33 coiled basilar aneurysms 33 coiled basilar aneurysms

84% 84% >> 90% occlusion 90% occlusion at 12mat 12m

JNS; 84, 84:393-9

1997 1997 ViViññuela, reports multicentric uela, reports multicentric 403 coiled aneurysms 1990403 coiled aneurysms 1990--1995 1995

71%71% Small aneurysmsSmall aneurysms35% 35% MediumMedium50% 50% LargeLarge

JNS 1997;86:475JNS 1997;86:475--8282

19971997 Moret reports Moret reports ““reconstruction reconstruction techniquetechnique”” in the treatment of in the treatment of wide neck aneurysms, using wide neck aneurysms, using nonnon--detachable balloons.detachable balloons.

19971997 Higashida reports the use of Higashida reports the use of stent assisted coiling stent assisted coiling JNS 1997;87:944JNS 1997;87:944--99

1997 Boston Scientific buys Target Therapeutics in stock trade worth $2.1 Billion

2002 2002 ISATISATProspective, randomized, controlledProspective, randomized, controlledSAH, Suitable for either ttx, NSG,NRSAH, Suitable for either ttx, NSG,NRCoil Vs Clip reduce dead MRS 3Coil Vs Clip reduce dead MRS 3--6, 6, rebleed, qol, cost & effect, epilepsyrebleed, qol, cost & effect, epilepsy

43 centers, 2143 pts (2pts in US)43 centers, 2143 pts (2pts in US)88% in both groups were in good 88% in both groups were in good clinical status WFNS 1clinical status WFNS 1--2290 % aneurysms < 10mm90 % aneurysms < 10mm97 % anterior circulation97 % anterior circulationfollow @ 1 year in 1594 ptsfollow @ 1 year in 1594 pts

Craniotomy, it was thought the aneurysm was more feasible for being clipped

78% excluded from the study

Coil Coil 22.6 %22.6 % 6.1%6.1% 2.4% *2.4% * 66%66% 5%5%

ClipClip 30.6 %30.6 % 6.8%6.8% 1.2%1.2% 82% **82% ** 9%9%

Dead or poor RMS Rebleed Occlusion

* Risk of rebleding 0.2/pt/y (1-8 mean 4y)** 450 / 1070 had angiogram

SeizuresDead from rebleeding

Lancet sep 2005

ISAT

CAVEATSCAVEATS

ISAT population is very special, does not match US practiceNeurosurgeons were general neurosurgeons

3.5 % wrapped, no clipped or partially clippedHighly specialized endovascular

No intra or even no postoperative angiogram, “visual estimation”

78% of eligible pts were not randomized ! Just for ruptured aneurysms !!!Pts that had surgery were treated 2 days later than pts that were coiled

97.3% Anterior Circulation90 % Good clinical status WFNS 1-290% <10mm

Applies to this population @ ISAT centers

Wide necksWide necksBalloon remodeling pioneered Balloon remodeling pioneered by Moret Provides temporary by Moret Provides temporary remodeling during the coil remodeling during the coil depositiondeposition

Stent assisted coiling

Stent reduces aneurysm inflow provides buttress for coils

Rescue for herniated coils

Stent thrombosis, myointimal proliferation

Fiorella ajnr, 2004

Synergism with coated coils

Coated coilsCoated coilsPlatinum coil coated with Platinum coil coated with polyglicolide (90%) and polylactid (10%)polyglicolide (90%) and polylactid (10%)ExpensiveExpensive

HydrogelHydrogelincreases the compaction of the increases the compaction of the coils coils within the aneurysm sackwithin the aneurysm sack

Matrix

Hydrogel

Conformal deploymentConformal deploymentACT MicroCoil, Anatomical ACT MicroCoil, Anatomical Conformable Three D follows Conformable Three D follows aneurysm geometry and aneurysm geometry and detaches detaches instantaneouslyinstantaneously

Liquid embolic agentsLiquid embolic agents

Balloon assisted and filling Balloon assisted and filling of the aneurysm Onyxof the aneurysm Onyx

Flow Diversion PEDFlow Diversion PED

70

POSTPOST--TREATMENT TREATMENT –– Lateral Lateral DSA/nativeDSA/native

71

6 months f/u6 months f/u

Djindjian

diChiro

Moret

MerlandLasjaunias

Debrun

AcknowledgementsAcknowledgementsFelipe C Albuquerque, MDFelipe C Albuquerque, MDCameron McDougall, MDCameron McDougall, MD

Gregory Lekovic, MD, PhD, JDGregory Lekovic, MD, PhD, JDMark Preul, MDMark Preul, MDMarie ClarksonMarie ClarksonC.J. MapsonC.J. Mapson