Balloon remodeling of complex anterior communicating artery aneurysms: technical considerations and complications

Reports of the limitations and feasibility of balloon remodeling for treatment of complex anterior communicating artery (ACoA) aneurysms are scarce.

Ninety-nine patients were treated with balloon-assisted coil embolization for ACoA aneurysms between August 2004 and October 2012. Records were reviewed for aneurysm characteristics, balloon trajectory (vessel and side), bilateral access, treatment-related complications, and aneurysm recurrence determined by magnetic resonance angiography (MRA). Morphological outcomes following treatment were categorized into Raymond class I, II, or III.

Fifty-three aneurysms (53.5%) were unruptured and 46 (46.4%) were ruptured. Aneurysmal occlusion (Raymond I or II) was achieved in 89 patients (89.9%); three (3.0%) were incompletely embolized and treatment was aborted in six (6.1%). Balloon trajectories were from the A1 to either the ipsilateral or contralateral A2. In 17 cases (17.2%), bilateral A1 access was used to achieve balloon protection of the contralateral A2. In four cases (4.0%), balloon remodeling was aborted due to technical difficulty. There were 15 (15.2%) treatment-related complications; five (5.1%) were intraoperative ruptures, one of which resulted in a neurological deficit and another in death. All other complications were clinically silent, producing a permanent complication rate of 2.0%. Mean radiographic follow-up was 2.5 years, and six patients (6.1%) were retreated for recurrence or known remnant.

Balloon remodeling should be considered for broad-based complex ACoA aneurysms. This technique provides a high rate of aneurysm occlusion with an acceptable complication profile, and avoids the need for dual antiplatelet therapy. The balloon trajectory will depend on aneurysm morphology and bilateral access may be useful in selected cases.