Images — and a big video at the end — give that one time to load
Volume Rendered DYNAs
There are two aneurysms. The distal one is most likely the rupture site. However dissection starts at the bifurcation — the branch without aneurysm is Rolandic.
Micro injections through the Phenom 27. Intermediate is a Sofia 5 115 cm
Use of a .014 wire (Synchro 2 soft in this case) for distal catheterization remains useful even though we have heavier .018 and .024 wires available. Why? Because an .008 wire (Hybrid is our choice) will fit alongside the .014 in .027 ID catheter (Phenom Plus) to allow for “buddy wire” or “parallel wire” technique catheterization. It is tricky to control both wires — especially to not let the .014 advance too much forward while inserting the .008 — be careful and very useful to have an assistant.
Top left image shows Phenom not advancing past the pseudoaneurysm due to step-off. The worst thing to do is to keep pushing and hoping it will work. Top right image — pull phenom back. Bottom left — both wires in position. Bottom right — successful crossing
Do NOT get into a situation where you cannot take a good image from a proximal position because the catheters are too tight. Distal catheterization can be difficult — lets say you want to make sure there is no perforation proximally, or need to check for antegrade flow. We use a good size intermediate catheter (5F Sofia here) to make sure we have decent space for imaging. Clear those bubbles beforehand!
Post PEDs — see video below for deployment snapshots
Multidevice coverage of pseudoaneurysms is important. Here, we have strategic double coverage of the aneurysm, while avoiding double-coverage of the Rolandic branch
Devices used — PED Shield 2.5×20 and 2.5×10 — the tallest and the smallest… first goest the long one, then the short one for double-cover. There will never be a case of this again — since both are no longer made.
Classic color scheme here
Video only below — no narration