Well, good morning, everybody. As Adam said, I would like this to be very, very interactive. And so at any point during this talk and during anyone else's talks, you should raise your hand, key your mic, whatever, because obviously I can't see. If you have a question, bring it up. Let's talk, because this needs to be interactive. The only way it benefits you is if you do interact, because as far as we're concerned, it's not a big deal, because like Errol mentioned to you last night, we could sit back in the corner and jibber-jab all day, because we don't get a chance to catch up that often. So I've been tasked with talking about calling aneurysms and how I do it, but let me just briefly tell you where I'm from first. I grew up in Augusta, Georgia. Anybody who knows anything about golf knows this is number 12 at the Augusta National. I was the ne'er-do-well growing up, and I grew up watching Hershel Walker play at the University of Georgia, wanted to go to the University of Georgia. My parents said, no, if you go to the University of Georgia, you'll end up working for this man and not as a franchise owner, but probably as the guy with the little headpiece going, do you want me to biggie-size it? So fortunately, I got into Vanderbilt University and went there, and I get another ultimatum when I finish there that I could go anywhere I wanted to for medical school as long as I paid for it or I could come back home and my dad would pay for it. Easy, early decision, done. So I finished there, decided I wanted to do neurosurgery, matched at LSU in New Orleans, but decided I could do my internship anywhere I wanted because I could at that point, so why not go to New York City for a year? I did that at Lenox Hill, then got back down to LSU in New Orleans. There's Charity Hospital there on the left, which got closed by Katrina. Part of my time was at the Oxnard Clinic as well as the Children's Hospital. Finished there and did a stint in Buffalo with Dr. Hopkins, and when I was winding down, Dr. Hopkins said, why don't you stay up here with us, and so I weighed my options. I said, well, you know, Buffalo's nice. It's nice here in the springtime, but so is Savannah, and, you know, Buffalo's really good because in the back here, this was Miller Gates Hospital here. This is where I did the fellowship training, and that's the funeral home just up the street, Amigon Funeral Home. I'm sure it's not pronounced that way, but I chose to say it that way. Amigon, yes, indeed, I was, and so I'm now down at Savannah in the Neurological Institute of Savannah where I do all the vascular work for a 10-man group, and we're the only group in town, and we've enjoyed that position for many years. So the topic this morning, we're going to talk about what is coilable, what isn't. We're going to talk about techniques for catheterizing aneurysms. We're going to talk about placing coils. So before we jump in and talk about aneurysms, let me briefly give you my experience in the past 10 or so years. You can see the numbers here broken down into how I treat them, and then success of treatment is looked at in both aneurysmal obliteration and outcome. So here's your aneurysm obliteration rates because obviously they're better with surgery. Now, of those 20 patients, we'll get to those in a minute that were remnants, all my patients, my protocol, and this may differ from the other faculty and the centers where you are may differ. They get a 6-month angio, and then they get one at 18 months if they've been coiled, and then yearly MRAs unless there's a change. If there's a change in the aneurysm, obviously that whole follow-up is done differently. Those 20 aneurysms with residual filling, 16 were retreated, 16 being completely occluded. The rest have remained stable, and then all completely occluded or remnant aneurysms have stayed stable. Outcome, this to me is the most important thing about my role as a vascular and endovascular neurosurgeon is that the numbers here you can see are basically equal between the two treatment arms, and that's the way they ought to be. And then one thing you need to realize as we go through and we talk about aneurysm treatment that you must look at those patients that you do not actually do a treatment on. I heard a physician one time say, oh, you know, I've got great results and nobody ever dies in my hands and blah, blah, blah. He wasn't even counting the patients that he didn't treat. Those patients are your patients. You know, these 80 patients that I did not perform surgery or coil on, they're part of my patients. Those are outcomes that we have to consider. So the question is, again, what is coilable? Somebody give me some answers here. Answer that question for me. What is a coilable aneurysm? What comes to mind? Narrow neck. What else? Saccular, yeah. That's all you got? Everything what? That's a very good point. Any aneurysm is coilable. But the question is, should it be coiled? Should you put a coil on that aneurysm? And that's kind of what we want to talk about this morning. It's not, is it coilable? Of course it's coilable. I mean, I can put coils anywhere. If you can get there, you can put coils in it. But do you need to? So we'll talk about aspect ratio. We're going to talk about geometry of an aneurysm, location of an aneurysm, branches associated with the aneurysm, collateral flow, and access. All of these things contribute to answering that question, is it coilable? And then I'm going to throw this in the neurosurgeon in me. You've got to think about CSF diversion. Lumbar drains, ventriculostomies, if you're going to treat a subarachnoid hemorrhage. If you think you need to do it, if you're asking yourself, should I put it in, put it in. Because as my brother always says, when there's ever any doubt, there is no doubt. So this is my little plug there for CSF diversion. Now a word on technology. Dr. Mock will give us a wonderful litany of great things coming down the pipeline and things we'll be able to use. And technology is great. But it's not the end-all, be-all. Because when you look at things, what we do, the three rules of surgery are this, anatomy, anatomy, anatomy. I don't care how good a catheter you have, how good a wire you have, how hydrophilic, hydrophobic, whatever. All that's great, but the anatomy concept begins here at the groin stick all the way up to the aneurysm. Because at the end of the day, it's what you do. It's a poor surgeon that blames his tools. So when you look and say, oh, I used the wrong wire, I used the wrong catheter, it was the wrong coil. No, that's not the reason you had a complication. The reason you had something go wrong was because you made an error. And so numbers and experience. When I first started doing angiograms as a resident, I took issue with the fact that I had to do 100 of them before I could be qualified. And so I remember saying to my professor at that point, why do I got to do 100? And as I was struggling with some kind of crazy arch to get access to a right subclavian or something like that, and struggling, struggling, struggling, he comes in and does it like that. He goes, that's why. Because you got to do it. So every time you get a chance to put your hands on a catheter in a patient, do it. Now, again, every patient's different, and I can guarantee you none of them read the Netter Atlas. And this is true, you'll see it time and time again. So the more experience you get, the more patients you do, the more variables you'll see, the more techniques you'll gain. And it goes back to fundamentals and foundation that we talked about last night and will be preached again and again and again today. So here's this aneurysm. Maybe not, maybe. Yeah. Okay, so who thinks this aneurysm's coilable? I mean, it doesn't get much better than that. Small neck, straight shot to it, it's great, right? That's a coilable aneurysm. But what if this is the proximal anatomy? That's a whole host of issues you've got to bring to bear there. Do I coil this aneurysm or not? Because I argue that that aneurysm, while it's very coilable, it's definitely clippable. So you've got to look at proximal anatomy. What happens when you get a guide catheter in a vessel like this? How is that going to affect your ability to coil and navigate distally? Those are things you have to have in your mind as we go forward. So geometry, you've got multilobulated aneurysms. That determines how you place your catheter. Where are you going to place your catheter? Are you going to go in far? Are you going to go in far enough? I mean, these are questions you have to wrestle with. Long and skinny aneurysms. If you've got an aneurysm that's 8 by 2 millimeters, I don't even know if that's possible, let's just say it was, that changes your coil selection dramatically. Because if you've got a nice round 8 millimeter ball, yeah, that's easy. But the geometry of an aneurysm does change what you choose and how you choose it, so therefore it changes its coilability. Snowman-shaped aneurysms, another thing. Sometimes they function as two separate aneurysms. And so all of that has to do with how you think about whether or not this patient, this aneurysm, is a coilable lesion. Daughter lesions, again. Do I need to get a coil loop or loops into that little daughter sack or tit or not? Can I just pack the aneurysm and will that thrombose? Those are questions you have to ask. And then location. Why is this important? Well, basilarity is kind of the number one thing you think about. In this day and age, there's usually very little reason to take a basilar aneurysm to surgery, especially with all the techniques and the technology we have that we can bring to bear. Now, MCA aneurysms, that's a general rule. People say, oh, we don't coil aneurysms in the MCA bifurcation because of all the branches. That's not necessarily true. Same with the ACOM. They all have their peculiar do's and don'ts, but these are textbook answers, so don't get bogged down in textbook answers. They're a good place to start, but every aneurysm is different. It's a living, breathing animal itself. So branch vessels, as I just mentioned, they go hand-in-hand with location. Obviously, a middle cerebral artery aneurysm, bifurcation aneurysm is going to have those branches coming off, and you have to be wary of. And remember that surgery is a perfectly acceptable option. It's not great when you think about do I get a groin stick or do I get put to sleep with my head carved open. It's not fair to couch it like that because it's six months down the road when the hair has grown back and they're doing fine, and the aneurysm is fixed, and they've gone through very little risk compared to the endovascular route. It doesn't really matter. And so beware of thinking things like this. Oh, I think I can protect that vessel. Think? That's not something you want to do with a branch in the brain. Think you can protect it. You've got to be very, very sure that when you do something in the brain that you're going to get the result you want because when bad stuff happens, it happens fast, and it is horrific, and it will happen to you. You will see it. You're going to kill people. It's the nature of this business. And sometimes it's just best to put the hammer down, and I don't mean hammer down as in floor to the metal, or floor to the whatever, pedal to the metal, whatever you're talking about, but put the hammer down in the sense that it's not a nail. Put the hammer down. You don't have to hit it. You know, swallow your pride and maybe hand it off to someone who can maybe be better suited to take care of that lesion. Collateral flow. This is especially true for PCOMs and ACOMs, basilar arteries as well, and how you treat these patients. Are you going to put a stent? Are you going to use the collateral flow to get a stent there? Can you sacrifice that vessel because of collateral flow? These are things you need to keep in mind when you're asking yourself, is this aneurysm coilable? Here's an aneurysm here. This is this basilar tip aneurysm. You can see it incorporates both P1 segments. Is this a coilable aneurysm? Well, yes, it's coilable, but what are you going to run the risk of doing? Sacrificing both P1s, but if you've got good collateral circulation, if both posterior cerebral arteries feel readily from the front, then, yeah, you can do this. You end up sacrificing the P1 segments as you see on the far right, but you've got good collateral flow here. Patient did just fine, but that's understanding collateral flow as you decide whether or not you're going to treat this aneurysm because doing surgery on the aneurysm would have been a bear. Putting a stent up there would not be the end of the world, but why do something harder than it needs to be? Hey, Jay? Yeah. Do you worry about taking out perforate? Because that's a pretty strong move. I don't know that I would have done that. I'd have been worried about catching perforators at the top of the basilar there. Is that... What else are you going to do? Yeah, I don't even believe in the model, but then there's a higher likelihood of it coming back or something. I don't know, but I'm just wondering. Yeah, you run the risk of that. Everything went smooth? Everything went smooth, yeah. I might try that next time. I mean, the guy had three aneurysms. You can see here he had a PCOM here, and I cooled that, and he had a... What it bled was a right MCA. That's cool. So I clipped the right MCA after I cooled those two. Cool. Okay, as I said, going back here, you could put a stent up there. You could do balloon remodeling. You could go, say, from this PCOM, go across the top of the basilar, put a stent in and then put coils in. Yeah, you could. You protect the P1s, but don't make it harder than it needs to be. I mean, it's already hard enough. You've got a simple solution. If the simple solution works, use it. Now, I've got one of the vascular surgery or INR guys where I work is known for making things harder than they need to be. Like, I'll do a carotid stent. In and out, less than 30 minutes. He comes in, 2 1⁄2 hours later, there's blood on the floor. He's gone through eight different catheters, 14 different wires. What are you doing? I mean, this is not hard. Don't make it harder than it needs to be. Again, as I said, it's a poor surgeon that plays with his tools. You can't say, well, you know, the stent didn't go there or, you know, I used the wrong coil. That's just, that's a bunch of bull. And don't forget, craniotomy is a good option. I mean, the decision to coil should never be a decision that happens to be convenient. That happens to me a lot. I'll sit there on a Friday afternoon and get a silveractone hemorrhage in and I'm not on call that weekend. And I think, it'd be a lot easier to just go ahead and coil this right now. But it's not the best option when I weigh all options. And don't be afraid to turn it over. It's not a turf war. I mean, it's about taking care of a patient. And so you know you're into vascular limitations as well as those with craniotomy and weigh them fairly. Just an example of this, here's a woman that had this A1 segment aneurysm which presented with confusion and nothing to do with the aneurysm. It's because her calcium was all out of whack. And her primary care physician, the ear, nose and throat doctor wanted the aneurysm taken care of prior to the parathyroid surgery, which I told them it didn't need to be done that way. But they're all freaking out. So here's the picture upside down just to give you reference here. This is what it looked like intraoperatively. You can see there's the vascular tip down in the hole there. There's some atheroma at the ICA bifurcation right there. Then there's your ACA and there's the aneurysm kind of going back there. And I won't belabor this too long, but just to kind of give you an idea, you can see this branch vessel that the clip is about to kind of just tuck under right there. I mean, you've got to protect that. You put a stent across that and you could coil it. Yeah, you could, but you may end up losing that vessel. And so a craniotomy is a perfectly acceptable choice here. So again, what is coilable? It's a question that encompasses much more than just a simple aspect ratio, dome-to-neck ratio calculation, or whether it's saccular, fusiform, branch vessels. You've got to look at the patient as a whole and the aneurysm as a part of a much bigger picture going from the groin all the way up. Sure, you can coil it, but should you? Any questions about that kind of general philosophy before we move on? Anybody? Yes, sir. Anything? I have a question. So you say about having to decide between, you know, make the decision about what's best, but do you have some basic rules of guidance of this is when I do this versus that? Oh, yeah, that's a great question. Some general rules. Did everybody hear the question? General rules, obviously, sicker patients, I'm going to lean towards endovascular. Grade four, grade five patients, grade five, usually I don't even treat anymore, but those in the higher grade patients, I usually do those endovascular if I can, but general rules of Basler-Tipp aneurysms are going to go endovascular. PCOM aneurysms in younger patients, I'm going to do surgery on them. As a general rule, these are very general, broad-based guidelines, and I don't hold fast to them. I think about whether or not I'm going to have to put a ventriculostomy in if there's a lot of subarachnoid blood, and I'm thinking they're going to need a shunt ultimately. Then I may not want to put coals in knowing they have to be on aspirin or put a stent in knowing they have to be on aspirin and Plavix. As a hard-and-fast rule, I don't shy away from putting a stent and putting patients on Plavix that are ruptured, but I do bring that into consideration just because it can hit the fan real quick when you're on Plavix, especially when they're not on Plavix before, you unload them on IntegraLand, and you load them on Plavix, and then all of a sudden, you get an intraprocedural rupture, and it just doesn't stop. And so if you can get away from that, it obviously would be great. I would throw out on that, I mean, I try to avoid, at pretty much all costs, putting a stent in a ruptured aneurysm. And once or twice a year, it ends up happening because it needs to be done. And I recently had a perfect example of why you don't do this. So I had a woman who comes in, I balloon remodeled. It was a very complex, wide-necked aneurysm, but I did the conglomerate mass technique, balloon remodeled it, was very happy, put the balloon down, and the coil started shifting down. So I put the balloon back up, and I waited for a little while, put the balloon down, coil started coming back down again, put the balloon up, said, I got to put a stent. And I thought about it. She had presented like five days after her hemorrhage. She didn't have hydro, she didn't have a lot of blood. She was good grade. I said, if you're going to put a stent in, this is the one to do it, I'm going to do it. So I put the stent in. She did great, looked like a million bucks. We're watching her in the hospital about six, seven days later. She had some neurologic changes, suspicion of vasospasm on the CTA. So I was out of time. My partner brought her down, did the angio. The groin stick, by the way, looked totally perfect. They did the angio, didn't see any spasm, didn't treat, closed. No problem, goes upstairs. The next day, while going to the bathroom, she pops the groin closure device, but it bleeds internally. Nobody knows until she crashes where their pressure drops. She gets hypoperfused, goes into multi-organ failure and dies. And you wonder, would that patient have had that dramatic retroperitoneal hematoma if they weren't on aspirin and Plavix? And just a simple fact of the matter is these are complicated patients where seemingly benign things can go bad really quick. So I try very hard to avoid stents in those patients. You're lucky with this one because it's clearly your partner's fault. No, it wasn't. No, it was the fellow's fault. Yeah, I think it's to bring back up. The groin looked perfect. It was not high. I mean, there was nothing unusual about it. It was a completely smooth thing. And yet, because she was on aspirin and Plavix, she ended up dying. You know, it happens. Yeah, it definitely happens. I think one of the points you made last night that when a new technology comes down, it's like, I want to get my hands on that. I want to use it. And you have to temper that enthusiasm. Because a lot of these things that we do require putting patients at extreme levels of risk. They're already at risk enough doing what we do. And it goes back to that point I made. Don't make it harder than it really is. I mean, it's hard enough. And you'll see that as you go forward in your training. It's hard enough. And if you can avoid making it harder, I would avoid it. Angioseal. But I don't think it was the device's fault. I think the problem started a week before when I made the decision to put the stent in. And it happened. And that's a great point that it's going to kind of lead into kind of an overall philosophy as we move forward in this talk today. I don't know if Adam had joked about the other night. I'm a big water skier. That's kind of my hobby is slalom skiing. And the course is you go through six buoys you have to go around when you water ski. And if you fall at one buoy, you want to focus on, what did I do wrong there? And nine times out of 10, the problem began at the buoy before. And so it's a point that Jay just made. It wasn't the device's fault. It was a decision that was made before. And so you'll see as you get catheterization, if you're running into a snag, it's not that you're running into a snag because of something you're doing right there. It's because something you did before isn't doing what it's supposed to do. Does that make sense? Everybody follow that? OK. Let's talk about catheterization techniques. Big time proximal anatomy fan. You've got to understand what's there. The one-to-one response, what does that mean? Intracranial tortuosity, how to respect it, how to get around it. Using a 360 degree turn within an aneurysm to access it. The angle of attack and, of course, the circle of Willis. How all these things come to bear when you think about catheterizing. So proximal anatomy. Here's a bovine arch. The big questions are getting there. If you've got a left internal carotid artery aneurysm or a left anterior circulation aneurysm, getting there is going to be an issue here. And then what happens when you do get there? What's going to happen to this artery once you get a big stiff catheter in there with a wire? It's going to move. It's going to shift. It's going to potentially spasm. Those are things you need to have in your mind to understand what's going on inside the patient. And then staying there. Once you get there, can you stay there? As an example, here's some spasm you can see here. This is a young girl that I'm going to bring up this case later when we talk about complications. But you can see the spasm in that artery there. Being wary of that because if you go ahead and let's say the spasm is a little bit worse than this and you're doing this case, and the patient's under general anesthesia and you don't realize this is happening because you don't go down and look in the neck while you're up focused on the brain, they could be having a whole hemispheric stroke because they're under perfusing. So one-to-one response. Everybody understand what I mean by this? Okay, so when you're at the table, your right hand, when you're moving the catheter or the wire and you move it a centimeter, you should see a centimeter movement on the screen every time. If you don't, then you need to stop. Right then and there. Stop what you're doing, demagnify, pan down, puff some contrast, do something to figure out why you are not getting one-to-one movement. A lot of times that lack of one-to-one movement may be unavoidable because of tortuosity. But it's something you should be very, very cognizant of as you're getting your microcatheter up into the brain. So once you finally figure out what's going on, as you move forward, we like to have it all magged up because we love to see. We like to have that visualization. But it's important to know where your guide tip is, especially when we get to, say, AVMs, when you're trying to navigate way out. You want to make sure you're not pushing your guide catheter down. Because a lot of times you think, I'm ready to do this, I'm going to open up this can, whoop ass on the aneurysm. No, you open up a can of this because you didn't appreciate what's going on down below. And so you've got to stay cognizant of that. Intracranial tortuosity, the proximal anatomy, and one-to-one are key here. You've got to have those two things set and ready so that you can then move forward. With distal lesions, the proximal anatomy has to be handled and it has to be secured, meaning that your guide catheter replacement needs to be as high up as you can get it safely and as secure as you can make it. And sometimes this may require more than just an envoy guide catheter. Sometimes you want to use the distal soft tip access catheters where you get the distal guide catheter way up into the, say, petrous portion or even beyond it. Or, barring that, you may want to put like a six-fringe sheath that goes distal up into the common or internal carotid artery with the guide catheter through that. We used to call that the tower of power because it gives you that good proximal stiff support. So remembering that having that proximal anatomy secured is important. Then as you begin to navigate the intracranial, the one-to-one becomes crucial, and it becomes harder. Because of all the tortuosity you see, the inherent, just think about the carotid from the skull base to the ophthalmic artery. I mean, there's some big time turns there. So don't ever overestimate the kickback force of the microwire. The microwire wants to be straight. That's what it does. That's how it's made. It's stiff. Well, your microcatheter is a little limp noodle. I mean, if you've ever done an AVM where you've got a patient awake on the table, and you've got the microwire all the way out the distal metal cerebral territory, they're in agony because that wire is wanting to go straight where your vessels are not straight. As soon as you take the wire out with the microcatheter in, the pain goes away. But that also means there's a lot of force that's being kicked back on your microcatheter. And so what I mean by push-pull here is that you get to those difficult situations where you're pushing the microcatheter and it won't go. You'll watch sometimes you pull back on the microwire. The catheter will start to move forward. So it's a balance between pushing and pulling. Then once you get your catheter in place, let's say you get into an ACA aneurysm, an ACOM aneurysm, and you think you're in a good position. What I always do is I pull the microwire out of the intracranial circulation altogether, and then I go back up slowly. Because inevitably, that microcatheter will move just a little bit. And you don't want it to be moving when you go to put up your coil. You want to know what it's going to do. And so that's just kind of one more thing about being just really careful with your catheterization. Now 360 degrees within an aneurysm. What do I mean by this? Well, it's very difficult to show this angiographically with a nice movie. I wish I could. But imagine this is your aneurysm on the top right here. And you've got to get a stent across the neck of that aneurysm. Well, what's going to happen every time you go up with a microwiring catheter? It's going to go straight into the aneurysm every time. It's going to be very difficult to make this turn. But what you can do is go up in the aneurysm, loop around, and then go back out. So now you've got a loop of microwiring catheter within the aneurysm. And your distal catheter is much beyond all of that. What will then happen, you can pull your microwire back some and then begin to pull your catheter back. And that catheter will plop down along the bend of the artery. And so now you'll span the neck of the aneurysm without having to make that turn and struggle and struggle and struggle. Just one of those little things you can think about as you go forward. The angle of attack in the circle of Willis. This is a great picture back when the neuroform stent came out. And I would argue that doing this is next to impossible. Making your microcatheter do this through a stent, through the struts of a stent, and make a 180-degree bend into a small aneurysm is near impossible. Not impossible, but near impossible. This is one of those cases where you may want to jail that microcatheter. Get the microcatheter in the aneurysm first and then jail it to hold it there. And so being aware of that angle of attack, going back to deciding whether or not this is coilable or not. Any comments on that from faculty? I think another thing in these is it's not so much getting there, but getting your microcatheter to want to stay in position as you deploy the coil. It's very much will want to come out and sort of pop up. And so using a very, going to a very soft coil very quickly, I think, in these aneurysms. I mean, the angle of flow is such that you're not really worried about a high-pressure head and causing recanalization and the rest. You really just need to fill it. So getting, that's what I would do in the circumstances. I'd move quickly to a soft coil to fill it up. Because you can imagine, I went back and we talked about the kickback force of a wire. The same is going to happen with a coil. As you start to deploy right here, it's going to push that catheter right back out of the aneurysm. Every time. And that acute angle only makes that pushback that much worse. There's another video that doesn't really work. Yes. That's a good question. It's not as much as you think. It's also spread along the entire amount of the wall of the vessel, of the wire. So to see a whole wire pop through an aneurysm, maybe in a ruptured aneurysm, that's extremely friable. But in an unruptured aneurysm, the likelihood of that big wire in that turn popping through is nearly zero. You've got to remember, also, the distal 15 centimeters or so of any micro wire is almost the same amount of flimsy flexibility. Except for the platinum tips or the floppy tips. But by and large, you take a transcend, or a synchro, or anything like that, the tip is going to be uniform. And so as you go up through that aneurysm, it's going to be uniform across. It's not going to be where you put the first couple of centimeters through, and then you get this stiff pusher back end coming up there. Yeah, that's going to go right through the aneurysm. But by and large, that whole 15 centimeters is going to take that same path and do it evenly. OK, we'll kind of go into placing coils. Now, I hope there are no sensitive ears here. I'm going to move into the more colorful aspect of this talk. That placing coils truly is a lot like having sex. Or even just making love. Not only having sex, but making out. It's important to go slow. And it's also important that you should adapt to any changing circumstances. You should change the circumstances. Change positions, if you will. Move things in and out. This is very, very important when it comes to cooling an aneurysm and making love. It should be satisfactory for both parties. It's got to be good for the patient. It's got to be good for you. And sometimes, you do need some toys. So having said that, the coil, as we were just kind of hinting at when we talked about that one picture with the stent a minute ago, it is a wire. The coil is a wire. Granted, it's not as stiff as a transcend, or a synchro, or you name the wire. But it's a wire. Don't be afraid to use it as such. When you start to back out of an aneurysm and you've got half of a coil in, use that coil as a wire and get back in the aneurysm. Pull back on the coil, push on the catheter, and climb back up it. It's not as easy to do as it is with a micro wire, but it's definitely doable. And then as a general rule, I try to get it as far into the aneurysm as I can. Yesterday, I had a 16 millimeter PCOM aneurysm. And I went into the aneurysm with the catheter all the way pointing back towards the neck of the aneurysm, almost back at the mouth of the aneurysm, and then began to put my coils in. Because what that does there is gives you a more stable position of your micro catheter, long term. And it allows you to cover the neck, which is what you're trying to do anyway. You're trying to separate the aneurysm from the parent circulation. And that occurs best at the neck of the aneurysm. Any questions on that? Now, you hear companies talk about framing and filling and finishing coils. This is great. It's a great idea. It's a great concept. And it's a wonderful way to think of fixing aneurysms. You want to frame it first, then you want to fill it, and then you want to finish it off. It sounds great. It's wonderful. You can see here, you've got the frame, you've got the fill, you've got the extra soft filling coil. Wonderful. Although, I've never seen this happen in real life. It's a great picture. I don't know how that happens in glass models, but it never happens inside a blood vessel. So the whole frame, fill, finish is a good idea and a good theory and a place to start. But the goal is not to frame the aneurysm or even to fill it, but our goal is to finish off the aneurysm. So however you use coils to do that depends on your own style. Yesterday, the aneurysm I did yesterday, I moved back and forth between frame and fill throughout the entire case. I'd put in like a 14 millimeter frame, and then I'd put in a 16 millimeter frame, and then a 12 millimeter fill. And then I'd go back to a 14 millimeter fill. It just depends on what was working at the time. Ideally, if you had a nice round ball of an aneurysm, you put in a framing coil that the coil loops go around the surface of the aneurysm, and then you onion skin it in like that. That would be ideal, but it never happens that way. And so don't get bogged down into thinking I've got to frame it, then I've got to fill it, then I'm going to finish it off. It'd be wonderful if it worked that way, but the only time this really fits into that pattern is when you get to the end of the aneurysm cooling process. The softer the coil, the better. So that's when you're finishing coils really tend to kind of carry their weight. So you go back to foundations and fundamentals. I mean, look at what's going to work best for this aneurysm. If I'm in a pocket here, and let's say it's a 3 millimeter pocket, I'm going to use a 3 millimeter aneurysm even though I know I'm going to go back and use some 7 or 8 millimeters. So you don't always have to go 10, 9, 8, 7, 6. You can go back up, back down, frame, fill, finish, helical, whatever. So whatever's working for you right there, go back to that fundamentals and the foundations of doing this. But there's a lot of Fs with the frames and the fills and the finish and the foundations and the fundamentals, trying to get bogged down in all the Fing Fs. So as a general rule, start with the biggest size and length that should fit within the aneurysm. If you've got a 12 millimeter aneurysm, don't start with an 8 by 30. Start with a 12, and then work your way down. Now, when you get a choice between coils of equal diameter, say like a 515 versus a 5.5, always go shorter. The reason I mention that is because you can always put another one in. So here's Amen Corner, the Augusta National. Let's say you're in the final pairing, the final Sunday, the Masters Tournament, and you're coming in at 12. What's the last thing you want to do here? Anybody? Hit it in the water. The absolute last thing you want to do is find yourself here. So if you're coiling an aneurysm and you decide, OK, do I put a 515 or a 5.5, what's the last thing you want to do? Prolapse loops out of the aneurysm. So go with the shorter length. It may cost a little more, but it's going to cost a whole lot more if you put in too much coil and it prolapses and you get a cluster and then someone dies. So always keep that in mind. It's a very dynamic process. Don't be afraid to reposition your microcatheter, pull coils back, and then redeploy. And if something isn't working right, stop. Figure out why it's not doing it. Because it's not the coil's fault. It's not the catheter's fault. It's something you're not appreciating. Microcatheter shaping is very, very important. As a general rule, I like to use the 45 degree pre-shaped catheter just most of the time, even if it's a straight shot like a basilar aneurysm. I put those asterisks there because this varies from everybody here. You've got a bunch of different faculty members here. They're going to say different things and use different catheters. Different aneurysms require different shapes. But remember to use that shape in your favor. Again, a video that doesn't work. Now, a word about coil prolapse. As soon as you start to see a loop, begin to prolapse out of the aneurysm. Stop. Don't keep pushing, but be aware that you're having a loop go out. What I normally do in that circumstance is I'll pull the coil back into the microcatheter until I see at least a loop go like that within the aneurysm. I'll see either a microcatheter reposition or I'll see a loop reposition. And that way, it tells me that the catheter is now in a slightly different position than it was when I deployed it and it started to prolapse. Then I'll start to go forward slowly again. And the vast majority of the time, the coil will then seek out a different space and the prolapse won't happen again. So I redeploy, I reposition. But as a last resort, sometimes I will go and push and let that loop completely come out and form. And sometimes it will slap itself back into the neck of the aneurysm as a last resort. But I don't do that unless I know that that's what's going to happen. The fine line here also is sometimes as you get further and further into coiling an aneurysm, the loops that you put out get tangled and you cannot pull it back. That's why we have stretch resistance. And even then, sometimes it doesn't work. So it's a fine line there. Any questions on that? Any comments on that, faculty guys, about prolapsing loops? Nobody? Now, who has seen waves or buckling in your coil as you're putting it in? Just a show of hands. So everybody knows what that means. It means you're hitting resistance. So that should tell you, ease up a little bit. But also, you can use that resistance in your favor. Because what's happening is the coil is wanting to go and you're pushing it. And sometimes it will make its own path because it needs that little bit of a push to make it get where it needs to go. And so use resistance in your favor, but also be aware of it. Don't over-push. Jay. Yes. Lucas, I would say one thing also. When you see those waves, consider what coil you're pushing, how stiff it is. Because it's one thing to push, let's say, a hyper soft and see some waves versus a stiff 18 framing coil. It's a totally different situation. You may get away with the soft coil with a little bit of advancement. Because sometimes those really soft coils, you do need that extra push. You almost need the buckling to make them go where you want them to go. So don't be afraid to use the microwire again to reposition. A lot of times, you're putting coils in and it doesn't go where you want to go. Sometimes I'll take that coil out, re-sheath it, put a microcatheter back up there, and reposition the microcatheter within the aneurysm in a better spot. And then go back to coiling. And you mentioned this, but you can also reposition the microcatheter over the coil, moving it around. For those of you all that weren't paying attention, like Dr. Maca was five minutes ago when I made that comment. I said you mentioned it. I heard it. I just thought it was worth re-emphasizing. And then this talk is not about using toys. But they're there for your enjoyment. They're there for your help. They're there to bring things to bear that you can't do just with straightforward aneurysm coiling. So remember that those are there for you. But try to avoid them if you can, if you can, because you don't always need to put a stent in every aneurysm. You don't need to balloon remodel every single one. And then be wary of what's going on down below. I cannot emphasize this enough. I can't tell you how many times I've seen fellows working on an aneurysm and struggling and struggling. And something's not going quite right. And all of a sudden, you pan down. And you've got a microcatheter or a guide catheter that's been shoved down into the common carotid artery. And the microcatheter is now looped into the external while the tip of the catheter is still in the aneurysm. You've lost so much control with that. The horse is so far out of the barn. So when they get technically difficult, don't forget to pan down. See what's going on. See where your guide tip is. See what the microcatheter is doing. Make sure it's not looping out somewhere. A lot of times, I've even seen it happen where you're in an ACOM aneurysm. And you're trying to push that last bit in to get catheterization. And you're just so focused on the tip of the aneurysm that you don't realize the microcatheter is prolapsed out into the MCA. Again, you've lost control. You don't realize the one-to-one motion is gone. So you've got to be very, very cognizant of that as we move forward. And then spasm can do a whole host of things. If it's not moving, spasm can just grip down on a microcatheter like you wouldn't believe, where you can't move it at all. And so if it's not moving, keep that in mind. Do a puff. Don't be afraid to give some mitroglycerin. And then finally, the number one rule, I'll go back to this. When you're putting coils in the aneurysm, I cannot emphasize this enough. It is to go slow. Yeah, we'd all love to do our case in 30 minutes and be done and pat ourselves on the back and blah, blah, blah. But you're not doing the patient any favors. The coils work best when you give them time to do what they're supposed to do, and that is seek out the space they need to fill. And you do that best by going slow. Thank you.

aneurysms

coilable

anatomy

catheterization techniques

coil placement techniques

CSF diversion

proximal anatomy

coil prolapse