WILLPOWER MELTDOWN SOMETIMES

A woman in her early forties undertook a coil embolization for a ruptured cerebral aneurysm of the right internal carotid artery. I was assigned a secondary operator. The aneurysm was heart-shaped. A primary operator so skillfully shaped a microcatheter tip that it naturally entered the aneurysm while he was retracting the microcatheter, it naturally entered the aneurysm. I thought things would proceed smoothly from there and I could go home early, but they did not. He chose too large size of a first coil to place it. He attempted to advance it using a balloon, but the microcatheter tip inevitably backed out from the aneurysm during the final few millimeters. He switched the first coil size smaller and shorter. As of a second coil, the same thing happened. Consequently, the neck area became sparse. Even with a balloon, oversized coils are difficult to place properly. A delta-shaped neck remained, so we added a smaller coil. However, when he was withdrawing the microcatheter, a loop of the coil was snagged and partially emerged. We discussed whether the coil might migrate peripherally. We concluded it should be fine since the coil was properly entangled within the coil mass, located in the neck rather than the parent vessel. Personally, I would have packed it in a piecemeal fashion. While this might result in insufficient coiling, given the acute phase of rupture, I believe a simple, quick, and safe approach is preferable.