Transcirculation endovascular treatment of complex cerebral aneurysms: Technical considerations and preliminary results

Background: Unfavorable anatomy can preclude embolization of intracranial aneurysms. Transcirculation techniques, in which a catheter is navigated from one side of the brain to the other or from the anterior to the posterior circulation, are alternative pathways for primary or balloon- or stent-assisted coiling. Objective: We report the largest experience in coil embolization of aneurysms using transcirculation techniques. Methods: We reviewed our endovascular database from 2006 to 2009 and identified 18 patients who had aneurysms treated with transcirculation techniques. Results: Eight patients had anterior and 10 had posterior circulation aneurysms. Overall, 8 patients were treated with stent-assisted coiling and 9 with balloon-assisted coiling, including 1 patient treated with a "kissing balloon" technique. Of the 9 patients treated with balloon-assistance, 1 also was stented at the conclusion of aneurysm coiling. One patient with a left fourth vertebral artery (V4) aneurysm was treated with coiling alone via a bilateral vertebral artery (VA) approach. In 14 patients, the anterior communicating and posterior communicating arteries were used as conduits. In 4 patients, both VAs were traversed to treat 2 V4 aneurysms and 2 posterior inferior cerebellar artery aneurysms. One patient died as a result of treatment and was the only permanent complication (5.6%). Complete or near-complete (>95%) embolization was achieved in all patients. Conclusion: Transcirculation techniques are effective pathways for embolization of complex aneurysms. Although technically challenging, these techniques are associated with an acceptably low rate of complications when compared to the natural history of the treated lesion.