Direct Percutaneous Puncture Approach versus Surgical Cutdown Technique for Intracranial Neuroendovascular Procedures: Technical Aspects

• Published in: World neurosurgery Vol. 77; no. 1; pp. 192 - 200
• Main Authors: Dorfer, Christian, Standhardt, Harald, Gruber, Andreas, Ferraz-Leite, Heber, Knosp, Engelbert, Bavinzski, Gerhard
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 2012
• Subjects: Aged; Aged, 80 and over; Alternative sites of access; Aneurysm embolization; Balloon Occlusion - methods; Brachial Artery - surgery; Carotid Arteries - surgery; Carotid Artery, Internal - surgery; Carotid-Cavernous Sinus Fistula - surgery; Catheterization; Cerebral Arteries - surgery; Cerebral Hemorrhage - surgery; Cutdown; Direct puncture approach; Embolization, Therapeutic; Endovascular Procedures - methods; Endovascular treatment; Female; Humans; Intracranial Aneurysm - surgery; Intracranial Arteriovenous Malformations - surgery; Male; Middle Aged; Neurosurgery; Neurosurgical Procedures - methods; Stents; Venous Cutdown - methods; Vertebral Artery - surgery; CCA; PP; Endovascular treatment; ICA; CCF; Direct puncture approach; Aneurysm embolization; VA; Common carotid artery; mRS; Alternative sites of access; Percutaneous puncture; Modified Rankin scale; SCD; Surgical cutdown; Internal carotid artery; AVM; Vertebral artery; Cutdown; Arteriovenous malformation; Carotid cavernous fistula
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2010.11.007

Objective To present the authors' experience with a direct transcervical or transbrachial puncture approach in neuroendovascular procedures in which cranial access via the commonly used percutaneous transfemoral route was impossible because of tortuous upstream angioarchitecture. Methods During 1992-2007, 23 neuroendovascular procedures were performed in 21 patients via a direct puncture approach. In 12 patients, surgical cutdown (SCD) and cannulation of the targeted artery (carotid, n = 8; vertebral, n = 4) were done. A direct percutaneous puncture (PP) of either the carotid ( n = 5) or the brachial ( n = 4) artery was done in nine patients. Treated pathologies were as follows: 10 ruptured and 6 unruptured cerebral aneurysms including two stent-assisted coiling and one internal carotid artery (ICA) balloon occlusion, four brain arteriovenous malformations (AVMs) and one carotid cavernous fistula (CCF). Results Of 21 patients, 19 (90.5%) had a direct puncture introduction of the microcatheter and successful endovascular procedure. No complications related to the technique were encountered either in the PP or in the SCD group. Conclusions Transcervical or transbrachial direct puncture accomplished with PP or by SCD is an effective and safe access route in patients in whom neuroendovascular interventions cannot be done transfemorally. In cases where extensive perioperative anticoagulation is mandatory, bleeding at the puncture site may be a serious problem and can be controlled more effectively through an open surgical approach than by percutaneous maneuvers.