Case Studies

EmerAX / TracLine LDP (088-90) large bore intermediate catheter facilitates right ICA posterior communicating aneurysmectomy

Surgeon's profile

Zou Wenfan
Chongqing Liangping District People’s Hospital
Department of Neurosurgery, Chongqing Liangping District People’s Hospital. Chief physician. Graduated from Xinjiang Medical University in Clinical Medicine in 2012. Studied cerebrovascular intervention at the Xinqiao Hospital, affiliated with the Army Medical University, in 2016. Completed neurointerventional training at Xuanwu Hospital, Capital Medical University, in 2023.
Specializes in the diagnosis and treatment of cranial and cerebral trauma, cerebral hemorrhage, cerebrovascular diseases, intracranial tumors, epilepsy, and other diseases, especially skilled in the diagnosis and treatment of cerebral hemorrhage and cerebrovascular-related diseases. Pioneered neurointerventional therapy in the local district and county, currently proficient in cerebrovascular disease intervention therapy, hypertensive cerebral hemorrhage, cranial and cerebral trauma, and related surgeries.
Serves as a member of the Chongqing Physicians Association Neurointervention Branch, a member of the Chongqing Liangping District Physicians Association, and a member of the Chongqing Liangping District Physicians’ Association Neurosurgery Branch.

Case information

Chief Complaint: Sudden explosive headache for over 1 hour.
Present Illness: At 12:00 PM, the patient experienced a sudden explosive headache without apparent cause, which was intolerable. However, there was no loss of consciousness, nausea, vomiting, limb convulsions, or urinary or fecal incontinence. The patient was brought to the emergency department by ambulance and underwent a head CT scan, which showed subarachnoid hemorrhage. Therefore, the patient was admitted to our hospital. Further examination with head and neck CTA revealed a right posterior communicating artery aneurysm, a fetal-type posterior cerebral artery on the right side, and severe tortuosity in two continuous locations at the origin of the right internal carotid artery.
Past Medical History: The patient has a history of hypertension for over 10 years, with no detailed record of the highest blood pressure. The patient regularly takes antihypertensive medication but has not undergone regular blood pressure monitoring. There is no history of diabetes or heart disease.
Physical Examination on Admission: GCS score of 15 points (E4V5M6), FISHER grade 2, HUNT-HESS grade II. The patient was conscious, alert, and oriented with clear and fluent speech. Cooperative during examination, able to move limbs upon command. Pupils were equal in size and round, with a diameter of about 3 mm, and reacted sensitively to light. Positive neck stiffness, normal muscle strength and tone in all four limbs, and absence of Babinski sign.
Diagnosis:
Spontaneous subarachnoid hemorrhage.
Right internal carotid artery posterior communicating artery aneurysm.
Hypertension stage III (extremely high risk).

Preoperative imaging

Cranial CT plain scan: Indicates subarachnoid hemorrhage, mainly concentrated in the perimesencephalic cistern.

CT angiography (CTA) of the head and neck reveals the formation of arterial plaques and severe arterial sclerosis. There are two consecutive severe bends with luminal narrowing at the origin of the right internal carotid artery.

CT angiography (CTA) findings show a posterior communicating artery aneurysm on the right side, fetal-type posterior cerebral artery. The right posterior cerebral artery originates from the aneurysm.

DSA (digital subtraction angiography) of the aortic arch reveals a type III aortic arch configuration.

The three-dimensional reconstruction indicates that the aneurysm measures approximately 6 mm × 4.7 mm × 5.1 mm, with a neck width of 4.4 mm. The diameter of the posterior cerebral artery is approximately 2 mm.

Right ICA digital subtraction angiography reveals significant tortuosity and stenosis of the initial segment of the internal carotid artery, with two severe bends and associated luminal narrowing. Additionally, there is an aneurysm in the posterior communicating segment of the artery, with the posterior cerebral artery arising from the aneurysm, indicating a fetal-type posterior cerebral artery.

Preoperative analysis

  1. Surgical Objective: To embolize the aneurysm, protect the posterior cerebral artery.
  2. Key Points of Surgery: It is crucial for the surgery to establish a stable pathway to ensure safe and effective access to the aneurysm and posterior cerebral artery. The pathway must maintain an open lumen to facilitate the passage of compatible microcatheters and provide stable support.
  3. Surgical Challenges/Risks: Difficulty in navigating the guiding catheter through the two bends at the beginning of the internal carotid artery poses a challenge. Additionally, the guiding catheter may not reach the cavernous or petrous segments of the internal carotid artery. Poor stability of the guiding catheter after placement and inadequate support may lead to poor stability of the microcatheter, hindering complete embolization of the aneurysm and protection of the posterior cerebral artery. Risks include embolization of atherosclerotic plaques causing distal vessel occlusion and functional deficits, as well as rupture and hemorrhage of the aneurysm due to poor stability of the microcatheter during embolization.
  4. Others: Due to the patient’s advanced age and compromised cardiopulmonary function, they may not tolerate the trauma associated with open craniotomy. Therefore, interventional treatment is preferred for this case.

Surgical procedure

Hemo’s EmerAX / TracLine LDP (088-90) and the intermediate access catheter were successfully navigated coaxially through continuous vascular bends.

During the embolization of the aneurysm, the microcatheter stability was excellent, confirming the outstanding stability of Hemo’s TracLine LDP (088-90).

After the embolization was completed, it was observed that the position of Hemo’s TracLine LDP (088-90) remained unchanged, indicating excellent stability.

Throughout the step-by-step embolization process, both the tip of the microcatheter and the tip of Hemo’s TracLine LDP (088-90) remained “rock-solid” stable.

Post operative imaging

Postoperative DSA shows dense embolization of the aneurysm, good protection of the posterior communicating artery, and Hemo’s TracLine LDP(088-90) did not irritate the intima of the cervical artery, indicating excellent safety. After anesthesia, natural recovery was observed with no neurological deficits, and the patient was safely transferred back to the intensive care unit.

Postoperative Cranial CT

Postoperative follow-up head CT showed no intracranial hemorrhage. Postoperative follow-up CTA showed no injury to the cervical arteries, and no stenosis or plaque formation at the two curved segments of the cervical artery.

Case summary

  1. Patient Characteristics: The patient is elderly (81 years old) with a long history of hypertension, with blood pressure control status unknown. The patient has fair cardiac and pulmonary function but cannot tolerate the trauma associated with traditional craniotomy. Considering the patient’s age and the preferences of the family, interventional treatment is the preferred option.
  2. Preoperative Assessment Key Points: Evaluation of the patient’s age, intracranial hemorrhage status, and consciousness level. Assessment of cardiac and pulmonary function preoperatively. Evaluation of vascular conditions in the patient preoperatively. Selection of appropriate embolic materials based on vascular conditions (establishing a suitable vascular pathway is particularly important).
  3. Surgical Technique Key Points: Use of Hemo’s EmerAX / TracLine LDP (088-90) “large bore distal pathway platform” to enter the internal carotid artery and successfully navigate through two vascular bends, providing strong support for the stability of the intermediate catheter. Positioning the TracLine LDP as high as possible, closer to the aneurysm, simplifies the operation of the embolic microcatheter, improves the stability and supportiveness of the distal end, and makes the surgery more perfect and safe.
  4. Instrument Usage Techniques: The use of the longer and softer distal end of Hemo’s EmerAX / TracLine LDP is essential for navigating through vascular bends, insertion of EmerAX / TracLine LDP can be done without the use of violent force, entering at an even pace along the blood vessel. It is advisable to insert EmerAX / TracLine LDP (088-90) coaxially with the intermediate catheter to facilitate observation of any kinking of the catheter lumen at the vascular bends (EmerAX / TracLine LDP has a longer and softer distal end, enabling smooth passage through tortuous vessels and providing good luminal support at curved vessel segments, allowing it to reach higher positions in the internal carotid artery and providing excellent support for the entire pathway).

About Hemo

Hemo Biotechnology Co., Ltd. (referred to as “Hemo”) officially commenced operations in 2017. Hemo’s global headquarters is located in Singapore, with research and development centers in both Singapore and China. It collaborates with long-term partners in the United States to focus on new product design and keep abreast of cutting-edge global technologies. 
Hemo is dedicated to integrating high-quality global research and development, production, clinical, and academic resources to provide innovative vascular and neurointerventional products for patients and medical professionals. It aims to offer comprehensive intervention solutions for cerebrovascular diseases, including ischemic stroke, hemorrhagic stroke, and intracranial vascular stenosis.