TECHNICAL NOTE Balloon-Assisted Coiling through a Single 6F Guiding Catheter G.D. Luzardo I.B. Ross G. Gal SUMMARY: The new version of the 6F Envoy guiding catheter, with its enlarged inner diameter of 0.070 inch, is capable of simultaneously accommodating both a 0.014-inch microcatheter and a balloon microcatheter for balloon-assisted coiling (BAC). We report our experience using this guiding catheter for access in BAC in 48 patients. The guiding catheter allowed for easy manipulations of 2 microcath- eters, while providing sufficient quality of control angiograms during the procedure. In cases in which BAC is indicated, a larger guiding catheter (7F) or the commonly used bifemoral approach is no longer necessary, making the procedure technically simpler for the operator and less traumatic to the vessel wall. B alloon-assisted coiling (BAC) has become widely accepted an adjunctive technique for endovascular treatment of ce- rebral aneurysms. 1-3 Until recently, the simultaneous use of a balloon microcatheter and a regular microcatheter required a 7F guiding catheter or 2 separate arterial punctures and 2 smaller guiding catheters to achieve access to cerebral circula- tion. Although manipulation of 2 guiding catheters with a size of 5F or 6F is not necessarily difficult or risky, they at least theoretically increase the risk of injury to the upstream vascu- lature and thromboembolism. In small, stenotic, or tortuous angioarchitecture, the use of BAC is limited. Furthermore, bi- lateral puncture of the femoral arteries may also increase the risk for postprocedural groin hematoma. We have found cur- rently available 6F guiding catheters with a larger inner diam- eter (ID) of 0.070 inch large enough to accept simultaneously both the balloon and the standard microcatheter necessary to perform BAC. The purpose of this short communication is to describe our experience in a series of 48 patients treated with BAC by using a single 0.070-inch ID, 6F Envoy guiding cath- eter (Cordis Neurovascular, Miami Lakes, Fla). Technique The new generation of 6F Envoy guiding catheters have an ID of 0.070 inch (compared with the previous 0.067 inch ID) and can be introduced by using standard 6F vascular access sheaths. We employed this new Envoy 6F guiding catheter in an unselected series of neuroendovascular patients requiring BAC. Forty-four procedures involved saccular cerebral aneu- rysms; one patient had 2 aneurysms, both treated in the same session. The series also included one patient with a fusiform dilation of the internal carotid artery (ICA) as a source of bleeding and 3 patients who had high-flow fistulas, requiring balloon-assisted flow arrest during vessel or fistula occlusion. Aneurysm location is tabulated in Table 1. Thirty-one patients had aneurysmal subarachnoid hemorrhage, of which 29 were treated in the acute phase. Bare platinum coils were used ex- clusively, in all aneurysm patients, with the exception of 4 patients who underwent embolization with liquid embolic agent (Onyx; Microtherapeutics, Inc, Irvine, Calif), one of whom also received a stent. Our standard procedure included single femoral puncture access with a 6F sheath, diagnostic angiogram when indicated (by using a 5F diagnostic catheter), and then navigation of the 6F Envoy guiding catheter into the cervical segment of the ICA or the vertebral artery for the intervention. During the proce- dure, intermittent angiographic runs were performed to doc- ument vessel patency and aneurysm packing and to identify complicating events such as clot formation. Heparinization, with an activated clotting time of at least twice the baseline, was employed in all cases. The balloon catheter was usually positioned first, followed by the microcatheter. In cases of par- ent vessel occlusion (n = 3), a preliminary balloon test occlu- sion was performed. All cases included the use of the 6F Envoy guiding catheter, a 10 or 14 microcatheter, and a balloon microcatheter, either the Hyperform, Hyperglide (Micro Therapeutics, Inc), or Sen- try (Target Therapeutics, Inc, Fremont, Calif). The microcath- eter/balloon microcatheter combinations are listed in Table 2. All treatments were considered successful in that the planned treatments were completed. There were no groin puncture site problems. It was our impression that the quality of the follow-up an- giograms performed by using the 6F Envoy guiding catheter, Received May 13, 2005; accepted after revision August 21. From the Department of Neurosurgery (G.D.L., I.B.R.), University of Mississippi Medical Center, Jackson, Miss; and the Department of Neuroradiology (G.G.), Akademiska sjukhu- set, Uppsala, Sweden. Address correspondence to: Gyula Gal, MD, Department of Neuroradiology, Akademiska sjukhuset, 751 85 Uppsala, Sweden. Table 1: Distribution by location Parent Vessel No. Aneurysms Internal carotid artery Ophthalmic artery 5 Posterior communicating artery 19 Carotid terminus 3 Anterior cerebral artery 1 Anterior communicating artery 7 MCA 1 Posterior circulation Vertebral artery 1 Superior cerebellar artery 1 Posterior inferior cerebellar artery 2 Basilar tip 4 Vessel occlusions/fistulae Dysplastic P-2 segment 1 ICA sacrifice for fusiform dilation 1 Parenchymal AV fistula MCA territory 1 Cavernous-Carotid fistula 2 Note:—P-2, posterior cerebral artery segment 2; AV, arteriovenous; MCA, middle cerebral artery. 190 Yen | AJNR 27 | Jan 2006 | www.ajnr.org