Neuroradiology 9, 145-- 156 (1975) © by Springer-Verlag 1975

Superselective Internal Carotid Arteriography and Embolization R. Djindjiau Department of Neuroradiology, Hopital Lariboisi~re, Paris, France Received: April 5, 1975 Summary. Superselective arteriography and superselective embolisation is the future of a part of neuroradiology. After the first realisation in the territory of the external carotid artery, it was logical to extend it to the territory of the internal carotid artery. The technic of the balloon-cathe~:er of Serbinenko is described and problems of embolisation in the internal carotid artery are discussed. L'embolisation super-sdlective de la carotide interne Rdsumd. L'art~riographie super-s61ective et son corollaire

l'embolisation super-s61ective repr6sente l'avenir d'une partie de la Neuro-Radiologie. Appliqu~e d'abord ~ la carotide externe, il &air logique de vouloir la r~aliser au niveau de la

Introduction The current trend in neuroradiological angiography is towards superselectivity. This has as its aim the low pressure injection of a small quantity of contrast medium into an arterial branch of the 6th or 7th order so as to visualize very fine arterio1Les (between 30 and 100 ~tm in diameter) with high definition.

Superselective AngiographyHistorical Superselective angiography was first practiced in the study of the spinal cord in 1966 [5] and as a result of the quality of the pictures and the importance of the information obtained it replaced aortography. In the cervical region selective transfemoral injection of the vertebral and deep and ascending cervical arteries superseded the techniques of axillary or brachial angiography [6, 9]. In cerebral studies, selective injection of the internal and external carotid arteries may be employed instead of injection into the common carotid artery. Even'this degree of selectivity, however, is inadequate for the more detailed demonstration of the branches of these arteries. Superselective external carotid arteriography [7] has allowed us to study the arteries of this territory in great detail and, by means of catheters of even smaller calibre, certain secondary branches (selective middle meningeal, transverse facial, ascend-

carotide interne. Les diff6rentes possibilit~s de cet examen sont d6crites, la sonde ~t ballonnet de Serbinenko e n e s t actuellement la seule possibilit6. SuperseIektive Arteriographie der A. carotis interna und Embolisierung Zusammen/assung. Nach einem geschichtlichen i)berblick

tiber die superselektive Arteriographie der Gef~iBe des Rifkkenmarks und der A. carotis externa wird die Technik der Katheterisierung der einzelnen Zweige der A. carotis interna beschrieben. Ferner wird auf die Technik und die n~iheren Einzelheiten der Embolisierung bei Erkrankungen im Versorgungsgebiet der A. carotis interna und der A. vertebralis eingegangen.

ing palatine arteriography, etc). Thus, using radiographic magnification with a 0.1 m m focal spot, arteries hitherto invisible, but not unfamiliar to earlier anatomists, have been shown. Moreover, superselectire angiography has enabled us to perform superselective embolization of these branches with Gelfoam fragments. The effectiveness and low morbidity of such embolization would appear definitely superior to non-selective techniques utilising plastic spheres or muscle. It seemed logical to wish to carry out superselective angiography of the branches of the internal carotid and vertebral arteries. In a small number of cases in which the carotid siphon was relatively straight we have been able to inject the middle cerebral or, more commonly, the ophthalmic arteries (Fig. la, b), witl~ the use of very fine catheters. However, the tortuosities of the siphon and the loops of the vertebral artery usually prevent the passage of catheters or of straight or curved guide-wires of the smallest available size. They fail to follow the curve of the vessel, stick against an intimal fold or catch on a tortuous wall (Fig. 2a, b). In some cases, a Fogarty catheter with its inflatable balloon will pass more easily than an ordinary catheter. It therefore appeared necessary to use even finer catheters, of very low rigidity, to be able to adapt to all the tortuosities of the vessels. The idea of using catheters with a magnetized metallic tip developed, then directing these very soft catheters by a magnetic

146

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization

Fig. 1 a and b. Selective ophthalmic artery injection (Brunswick catheter), with the middle meningeal artery arising from the ophthalmic

a

b

Fig. 2 a and b. Unsuccessful attepts at carotid siphon catheterization with small calibre, highly flexible guidewires

field outside the skull. This "intravascular navigation" was achieved by Yodh [28], Alksne [1] and Hilal [10], in animals and in several humans. The few published results do not seem as yet to have proven the effectiveness of this technique. We [8] have undertaken similar studies, with a magnetic catheter tip and a pulsed magnetic field, without the hoped-for results.

Rand [21] has used a helium "super-magnet", which would seem to be more effective than the electromagnets previously used. Until we have evidence to the contrary, it would seem that this work is experimental rather than clinical, and does not offer a practical method for superselective internal carotid arteriography.

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization The Technique of Catheterization of the Branches of the Internal Carotid Artery by Means of a Balloon Catheter

(developed by Serbinenko [2] who has been doing research on angiography with an inflatable ballon catheter since 1963).

Technique A latex balloon is half-inserted onto the end of a very fine catheter, to which it is attached by a thriceknotted silk thread (Fig. 3a). The balloon is filled with contrast medium (Fig. 3b), and the small opaque

a

b

Fig. 3. Balloon catheter before and after filling with contrast medium sphere representing the balloon may then be followed on the television screen; the progress of the balloon is due essentially to its perfectly spherical form. The needle used for carotid puncture has a side-hole, allowing injection into the lumen of the artery. Progression of the balloon is thus acheived partly by advancing it and partly be increasing the flow in the artery by forceful injection of saline, which has a "parachute" effect on the balloon (Fig. 4). Because of this fact, the curves and bends of the cervical internal carotid artery and of the siphon present no hindrance to catheterization of the cerebral vessels, as the ballon slides around the bends and does not snag like an ordinary catheter tip. It is seen to pass freely through the petrous portion of the carotid artery and the loop of the siphon, to enter the middle cerebral artery

147

directly (Fig. 5). It then tends to pass rapidly onwards into the branches. The catheter is prepared by smearing it with a heparin cream, allowing it to slide easily through, first the needle, and then the artery. Using balloons 0.5, 0.7, 1.2 and 1.5 mm in diameter, it is possible to catheterize the posterior, middle and anterior cerebral arteries. With a larger balloon, a branch may be occluded while a second catheter is advanced through the same needle. The first is inflated so as to abstruct the origin of the middle cerebral artery, forcing the second to enter the anterior cerebral; the same method is used to pass from the anterior cerebral into the anterior communicating artery. To facilitate superselective ophthalmic arteriography, a balloon may be inflated in the internal carotid artery above the origin of the ophthalmic artery and contrast medium injected via the side hole of the needle. It is possible to carry out simultaneous catheterization of the various cerebral vessels with three balloon catheters. For catheterization of the vertebrobasilar system the Seldinger transfemoral technique should be employed. In this case we use a 160 catheter of large internal diameter through which a balloon catheter 1.20 m in length will slide easily. The tip of the catheter is placed in the vertebral artery, the guide wire is withdrawn and the previously siliconized balloon catheter advanced in its place. Direct puncture of the horizontal segment of the vertebral artery may also be used, with the introduction of a normal length balloon catheter through the needle. With such an apparatus we may carry out superselective arteriography of the branches of the internal carotid artery. Injection of contrast medium through the balloon is rendered possible by the production of one or two distally- or proximally-facing holes by means of a tantalum microelectrode. If the hole is small the contrast medium may form a fine jet, and the balloon overinflate, with the risk of its bursting, while if the hole is too large the balloon will no longer inflate and intracerebral catheterization will be impossible. The contrast medium is injected by hand, using a lcc syringe with a metal connection. A set of connectors and spigots, to prevent reflux of blood, complete the apparatus. Our radiographic installation includes instantaneous television subtraction and a television monitor with zoom, allowing considerable magnification of the image. As the ascent of the balloon is followed on the television screen, its diameter is controlled so that it adapts to the varying calibre of the siphon or of the middle cerebral artery. With the balloon in place, lateral and posteroanterior series are obtained, inflating the balloon so as to eject contrast medium from it. A very small quantity will suffice;

148

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization

Fig. 4. Ascent of the ballon catheter in the cervical portion of the internal carotid artery. Progressive inflation as the balloon emerges from the needle

Fig. 5. The balloon catheter in the middle cerebral artery

the flow seems quite sluggish during such superselective injection of a branch of the middle cerebral artery. A tube with a 0.1 mm focal spot is used for the series. The serial changer (Minimax, C.G.R.) offers the advantage of being able to observe the injection on the television while the series is in progress. Serbinenko [25] carried out more than 300 examinations from 1969 to 1972 and he reported two deaths from unexplained middle cerebral artery thrombosis in patients aged 20 and 50. The other complication observed was difficulty in withdrawing the balloon catheter, especially when it lay at some distance from the puncture site, e. g. in the anterior, middle or posterior cerebral artery. Difficulty may also be encountered in withdrawing the balloon catheter through the puncture needle, particularly when it is not fully deflated; forceful suction on the syringe is required, together with gentle rotation of the catheter to engage the balloon in the needle. Serbinenko performs all his studies under local anaesthesia, so that any neurological deficit occurring during the examination may be observed. He has seen no arteriographic or clinical evidence of either local or generalized arterial spasm in a single case. We prefer general anaesthesia because of the carotid puncture, the possibility of spasm and the immobility of the patient during the serial runs, which is important for subtraction.

R. Djindjian: S]aperselectiveInternal Carotid Arteriography and Embolization

Clinical Application and Interest in Superselective Internal Carotid Angiography Two forms of balloon catheter are used, permitting different types of procedures. Using a fenestrated balloon catheter it is possible to inject contrast medium for superselective arteriograms of the ophthalmic, anterior or middle (Fig. 6) cerebral arteries, while, with smaller balloons, superselective injection of the branches of the middle (Fig. 7), anterior or posterior cerebral arteries is possible.

149

The exact distribution of these branches and their draining veins may thus be demonstrated in vivo, confirming the familiar anatomical data. The injection of a dye (2Yo bromophenol blue) into the feeding vessel of a tumour enables the neurosurgeon to find the tumour some hours later at operation, its exact extent demonstrated by the dye, thus facilitating controlled excision. With an intact balloon, temporary occlusions of the cerebral arteries may be produced. Such an obliteration of the arterial lumen allows assessment of

Fig. 6. Superselective middle cerebral arteriogram. The balloon is at the origin of the middle cerebral artery

Fig. 7 a

150

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization Embolization in the Territories of the Internal Carotid and Vertebral Arteries

Embolization was first carried out by Brooks in 1930 [4] in the treatment of a posttraumatic carotid cavernous fistula, by placing a long muscle fragment marked with a clip in the internal carotid artery, a method sometimes known as the Brooks technique.

Embolization with Plastic Spheres

Fig. 7 b

Fig. 7 c

the possibilities for collateral revascularization of the territory distal to the occlusion, or the therapeutic value of occlusion of the orifice of a shunt (e. g. carotid cavernous fistula) or of a vessel feeding an arteriovenous aneurysm, from the viewpoint of surgery or definitive vascular occlusion. Serbinenko performed 154 such temporary occlusions of various cerebral vessels in adults aged from 12 to 67 years between 1969 and 1971.

Luessenhop [16] was the first to perform embolization of cerebral malformations, and since then there have been many publications on this subject, concerning particularly embolization of carotid cavernous fistulae [3, 11, 13, 15]. All these workers used plastic spheres or muscle for embolization, introduced via a carotid arteriotomy; the fragments were generally carried along to the malformation by the increased flow. Luessenhop [17] described 94 procedures carried out during the last 14 yeas on 55 patients, which

Fig. 7 d required the use of more than 3000 emboli. The indications for embolization are as follows: surgically inoperable angioma; angioma with large feeding vessels running directly to it; angioma with severe neurological deficit. The aim of embolization is not the eradication of the entire malformation, but reduction of the flow, of the steal effect and of the pressure of the draining veins, which may cause hydrocephalus. The technique consists of injecting small emboli (6 mm

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization

151

Fig. 7 e

Fig. 7 f

or larger) so as to occlude the malformation as much as possible, finishing with two or three larger emboli. One can give no firm rule as to when embolization should be terminated; experience is necessary. Obstruction of the middle cerebral artery by large emboli may produce severe complications: Tzono, Bergleiter and Pampus [26] found two cases of neurological deterioration among 10 patients; WuUenweber [27] reported a patient who became decerebrate, with a dilated pupil on the embolized side, on hour after treatment; Seeger [24] believes that such complications cannot be predicted, since they depend not on technical factors, but on the degree of development of collateral vessels when the middle cerebral artery is occluded. Sano [23] and his colleagues described a series of 13 cases treated by embolization with spheres, including two deaths after emboli lodged in the main trunk of the middle cerebral artery, six cases with postembolization neurological deficit and five without complications. These authors could only rarely occlude a malformation in its entirety with pheres; thus the patients are still prone to seizures or to recurrent subarachnoid haemorrhage, as Luessenhop's latest statistics show.

152

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization

Fig. 7g--7h Fig. 7. a) Common carotid arteriogram, lateral projection; b) and c) Lateral view of superselective injection of an anterior branch of the middle cerebral artery, arterial phase; d) capillary phase; e) venous phase; f) common carotid arteriogram, AP projection; g) AP projection of superselective injection of an anterior branch of the middle cerebral artery showing the position of the balloon; h) after subtraction; i) venous phase

Embolization by Silicone Polymerization The aldvantage of this technique, according to Sano, is that the angiomatous mass itself may be embolized, whereas when spheres are used, the feeding vessels only are occluded, at a variable distance from the angioma. The plastic liquid permeates the angioma and solidifies within it, thus effecting an ideal embolization, and because of its viscosity, does not pass on into the draining veins. Sano uses dimethyl polysiloxane (phycon 6500), which has a viscosity of 10 000 centipoise at 25°; with the addition of one drop of catalyst to 5 ml of phycon, polymerization begins in one minute and is completed in three minutes. Eight "inoperable" angiomas have been treated in this way, without fatalities, five cases without complications and three with a neurological deficit after embolization. Contraindications to this plastic embolization technique are anatomical. When the middle cerebral artery is a direct continuation of the internal carotid, injection is feasible; conversely, when there is a marked curve at the origin of the middle cerebral, it is wiser to refrain from embolization since the silicone might also enter the anterior cerebral artery. The firmest indication for this technique is for embolization of branches of the terminal middle cerebral artery

(M 4); when M 1 or M 2 are involved, there is a significant risk of neurological deficit. These methods employing liquid or solid plastic materials are unsuitable for non-selective intracerebral injection.

Embolization with Ferromagnetic Silicone Mosso and Rand [18] injected a suspension of iron microspheres in a rapidly polymerizing silicone liquid into an arterial catheter; a magnetic field was used to direct this mixture and to hold it in place during solidification without the risk of dispersion of the embolic material. This technique represents an advance on previous methods in that it points the way to a selective embolization, but in practice it is still in an experimental stage. Only one case (embolization of the lingual artery for a carcinoma of the tongue) has been treated so far.

Embolization with a Balloon Catheter This procedure is the latest of a number of techniques, now largely abandoned, for embolization of carotid cavernous fistulae, with trapping or after failure of attempts at trapping. The balloon catheter technique for obliteration of a carotid cavernous fistula was described first by Prolo

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization

153

Fig. 8 a

Fig. 8 b

and Hambery [20], followed by Leblanc [14] -three cases -- and Rougerie, Guilmet and BambergerBozo [22]. A Fogarty catheter introduced by arteriotomy is advanced as far as the fistula; the balloon is inflated with opaque medium, and complete obliteration of the artery is checked by injection of contrast

medium at the arteriotomy site. The artery is then closed over the catheter, and the latter divided flush with the arterial wall after being sealed by two crisscrossed clips. Picard, Lepoire and their coworkers [19] introduce a No. 3 Fogarty catheter percutaneously through a 16 gauge Seldinger needle and advance it

154

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization

Fig. 8 c

Fig. 8 e Fig. 8. a) Temporal tumour (meningioma). Common carotid arteriogram, lateral projection; b) superselective injection of branch of the middle cerebral artery, arterial phase; c) venous phase; d) AP projection, global, and e) superselective injections

Fig. 8 d

Fig. 9. Balloon catheter containing a silicone preparation which hardens in 20 minutes; the centre of the balloon is filled with saline

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization up to the fistt]la; the balloon may enter the fistula itself when this is large, assuming then a characteristic hourglass shape. When the balloon is placed correctly, two clips are applied to the lower part of the catheter, which is then buried in the subcutaneous tissues. When the balloon catheter is inserted under local anaesthesia, one may keep a check on the visual acuity and look for any evidence of a contralateral hemiparesis, while the disappearance of the bruit noticed by the patient is evidence of closure of the arterivenous shunt. The major drawback of this otherwise very valuable therapeutic technique is that the catheter remains within the carotid artery. Progressive thrombosis of the artery is a possibility and, after several days when the catheter is withdrawn, there is a very real risk of upward migration of emboli. Serbinenko has carried out intraarterial occlusion of carotid cavernous fistulae by balloon catheter since 1971, preceded by a haemodynamic study of the potential revascularization of the l~emisphere following balloon-occlusion of the pathological carotid artery. Since 1972 he has used a catheter with a balloon filled with a liquid silicone which hardens in ten minutes. The balloon can be detached (by a still secret method) and the catheter withdrawn. It is thus possible to close carotid cavernous fistulae while preserving the flow in the carotid artery (Fig. 10, 11). This technique may also be used for definitive occlu-

155

sion of the feeding vessels of angiomas (after previously confirming that temporary inflation of the balloon does not result in any neurological disturbance), of posterior communication aneurysms, and even of aneurysms of the anterior communicating artery.

Fig. 10. Posttraumatic carotid cavernous fistula (cataclysmic epistatis)

Fig. 11. A balloon catheter has been placed in the fistula. The latter is no longer seen, while the internal carotid artery is fully patent. The catheter was withdrawn, leaving the bolloon, filled with solid silicone, in place (detachable balloon). (Radiographs by courtesy of Dr. F. A. Serbinenko, May 1974)

156

R. Djindjian: Superselective Internal Carotid Arteriography and Embolization

Thus, superselective angiography of the internal carotid artery branches, and embolization of vascular lesions (angiomas, aneurysms and carotid cavernous fistulae), by means of an elegant and practically bloodless procedure, are at last realities. A c k n o w l e d g e m e n t : We thank Dr. I. Moseley of the National Hospital, Queen Square for his translation.

References 1. Alksne, J. F.: Magnetically controlled intravascular catheter. Surgery 64, 339-- 345 (1968) 2. Arutiunov, A. I., Serbinenko, F. A , Shlykov, A. A.: Surgical treatment of carotid cavernous fistula. Progr. Brain Res. 30, 441--444 (1968) 3. Boulos, R., Kricheff, I. I., Chase, N. E.: Value of cerebral angiography in the embolization treatment of cerebral arteriovenous malformations. Radiology 97, 65-- 70 (1970) 4. Brooks, B.: The treatment of traumatic arterio-venous fistula. Sth. med. J. (Bgham, Ala.) 23, 100--106 (1930) 5. Djindjian, R., Houdart, R., Hurth, M.: Acquisitions r~cents en angiographie m6dullaire. Rev. neurol. 115, 1068--1069 (1966) 6. Djindjian, R.: Technique de l'art6riographie de la molle 6pini~re par aortographie s61ective. Progr. m6d. (Paris) 76, 159-- 162 (1968) 7. Djindjian, R., Hurth, R., Houdart, R.: L'art6riographie s61ective de la molle 6pin,re cervicale (Technique art6riographie normale et pathologique). Rev. neurol. 122, 321-335 (1970) 8. Djindjian, R., Houdart, R., Cophignon, J., Hurth, M., Corny, J.: Premiers essais d'embolisation par vole f6morale de fragments de muscle dans un cas d'angiome aliment~ par la carotide externe. Rev. neurol. 125, 119-- 130 (1971) 9. Djindjian, R., Cophignon, J., Th6ron, J., Merland, J. J., Houdart, R.: Embolization by hyperselective arteriography from the femoral route in neuroradiology. Review of 60 cases. Neuroradiology 6, 2 0 - 26, 132--154 (1973) 10. Hilal, S.: Catheter with a magnetic tip for cerebral angiography. Med. Trib. med. News 2 January 1969 11. Isamat, F., Salleras, V., Miranda, A. M.: Artificial embolization of carotid-cavernous fistula with post-operative patency of internal carotid artery. J. Neurol. Neurosurg. Psychiat. 33, 674--678 (1970) 12. Ishimori, I. S., Hattori, M., Shibata, Y., Shizawa, H., Fujinaga, R.: Treatment of carotid-cavernous fistulas by gelfoam embolization. J. Neurosurg. 27, 315--319 (1967) 13. Kricheff, I. I., Madayag, M., Braunstein, P.: Transfemoral catheter embolization of cerebral and posterior fossa arteriovenous malformations. Radiology 103, 107--111 (1972)

14. LeBlanc, J.: Communication to the Congress of the Royal College of Surgeons of Canada, October 1972 15. Lang, E. R., Bucy, P. C.: Treatment of carotid cavernous fistula by muscle embolization alone. The Brooks method. J. Neurosurg. 27, 387--393 (1965) 16. Luessenhop, A. J., Spence, W. T.: Artificial embolization of cerebral arteries. Report of use in a case of arteriovenous malformation. J. Amer. med. Ass. 172, 1153--1155 (1960) 17. Luessenhop, A. J.: Artificial embolization of inoperable arteriovenous malformations. In Cerebral Angiomas. Pia et al. (eds.), pp. 198--201. Berlin, Heidelberg, New York: Springer 1975 18. Mosso, J. A., Rand, R. W.: Ferromagnetic silicone vascular occlusion: a technic for selective infarction of tumors and organs. Ann. Surg. 178, 663--668 (1973) 19. Picard, L., Lepoire, P., Montaut, J., Heppner, H., Roland, J., Guyonnand, J. C., Jacob, F., Andre, F. M.: Endarterial occlusion of carotid-cavernous sinus fistulas using a balloon tipped catheter. Neuroradiology 8, 5-- 10 (1974) 20. Prolo, D. J., Hambery, J. W.: Intraluminal occlusion of a carotid-cavernous sinus fistula with a ballon catheter: technical note. J. Neurosurg. 35, 237--242 (1971) 21. Rand, R. W.: A therapeutic supermagnet. Med. Wld. Newsl. 10 November 1972 22. Rougerie, J., Guilmet, D., Bamberger-Bozo, C.: An6vrysme carotido-caverneux. A propos d'une orientation th6rapeutique nouvelle. Neuro-chirurgie 19, 649--654 (1973) 23. Sano, K., Jimbo, M., Saito, I., Basvgi, N.: Artificial embolization of inoperable angioma with polymerizing substance. In Cerebral Angiomas. Pia et al. (eds.) pp. 221-229. Berlin, Heidelberg, New York: Springer 1975 24. Seeger, W.: The artificial embolization of inoperable angiomas. In Cerebral Angiomas. Pia et al. (eds.) pp. 213-221. Berlin, Heidelberg, New York: Springer 1975 25. Serbinenko, F. A.: Balloon catheterization and occlusion of major cerebral vessels. J. Neurosurg. 41, 125--145 (1974) 26. Tzonos, T., Bergleiter, R., Pampus, F.: Experiences in the use of artificial embolization as a method of treating cerebral angiomas. In Cerebral Angiomas, Pia et al. (eds.) pp. 206--212. Berlin, Heidelberg, New York: Springer 1975 27. Wullenweber: In Cerebral Angiomas. Pia et al. (eds.) Berlin, Heidelberg, New York: Springer 1975 28. Yodh, S. B., Pierce, N. T., Weggel, R. J., Montgomery, D. B.: A new magnet system for 'intravascular navigation'. Med. biol. Engng 6, 143--147 (1968) Dr. R. Djindjian 16, rue de l'Universit6 F-- 75007 Paris France