Cardiac Catheterization in Congenital Heart Disease: Pediatric and Adult - Part 8 doc

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CHAPTER 25 Coarctation and systemic arterial stents
654
over the wire. If an adequate angiogram cannot be
obtained by either of these techniques, a second, small ret-
rograde catheter should be introduced. A freeze-frame
“road map” of this angiogram of the ductus is stored for
reference use.
After the angiogram has been obtained, an end-hole
catheter with a smooth tip is advanced over the wire
very gently, through the ductus and into the distal branch
pulmonary artery. Once the catheter is in the distal
pulmonary artery, the original ﬂoppy, torque-controlled,
guide wire that was used to manipulate across the ductus
is replaced with the stiffest possible exchange length
guide wire that the delivery balloon/stent that will be
used to deliver the stent to the ductus, will accommodate.
The exact length of the stent used in the PDA is deter-
mined from the angiogram of each particular ductus.
Ideally the stent must cover, and extend slightly past both
ends of the ductus but, at the same time, should not extend
too far into the lumen of either the pulmonary artery or
the aorta. Once the delivery wire is secure through the
ductus and well into a distal pulmonary branch, the sec-
ond angiographic catheter is positioned adjacent to the
aortic end of the ductus. The correct stent/balloon is
chosen and prepared on the catheterization table and the
prostaglandin infusion is stopped. The patient is observed
closely for at least 30 minutes, and assuming no acute or
severe deterioration of the patient during that time, the
aortogram is repeated. Usually the ductus constricts and
changes in conﬁguration rapidly once the infusion of

prostaglandin is stopped. Occasionally the rebound con-
striction of the ductus is very severe and very rapid which,
in turn, necessitates either the reinstitution of the pro-
staglandin infusion or the rapid introduction of, and the
implant of, the stent. The ductus tissues are friable, so
the balloon/stent introduction must be very gentle and
very precise, and the stent must pass easily through the
ductus. Because of these factors, some operators prefer to
prepare the balloon stent and position the stent/balloon
across the ductus before stopping the prostaglandin infu-
sion and then wait for the prostaglandin to wear off with
the deﬂated balloon/stent already in place across the duc-
tus. The second catheter adjacent to the aortic end of the
ductus is essential at this stage of the procedure in order to
allow very rapid and precise ﬁnal positioning of the stent
within the ductus just before deployment.
With any deterioration of the patient, or after 30 min-
utes, the angiogram is repeated, the stent/balloon posi-
tion adjusted, and the balloon/stent is inﬂated to its
advertised pressure or until all indentations in the bal-
loon/stent have disappearedawhichever comes ﬁrst. The
balloon is deﬂated immediately and rapidly. With a pro-
perly implanted stent, the patient immediately will oxy-
genate better and stabilize as soon as the balloon is
deﬂated. The balloon is withdrawn carefully out of the
stent/ductus and with the wire still through the stent and
ductus, the aortogram is repeated to visualize the ad-
equacy of the coverage of the stent in the ductus and the
new ﬂow to the pulmonary arteries. If there are any areas
of the ductus, particularly at either end of the ductus,

which are not covered by the stent, a second (or more)
stent(s) is/are implanted during the same catheterization.
The additional stent(s) is/are placed overlapping the ﬁrst
stent and covering all of the ductal tissues entirely. Any
“exposed” ductus tissue is notorious for constricting and
closing completely, even with a stent in the remainder of
the ductus. For the implant of an additional stent immedi-
ately after the implant of the ﬁrst stent, all of the catheters
and wires are already in place and minimal further
manipulation or time in the catheterization laboratory is
necessary for the implant of an additional stent. Once the
ductus is covered adequately and the patient is stable, the
delivery wire is withdrawn from the stent and the catheter
withdrawn. The infants are maintained on 21 mg aspirin
per day.
Stenting of the ductus in patients with
pulmonary atresia with intact ventricular septum
In infants with pulmonary atresia and intact ventricular
septum, along with the opening of the pulmonary valve, a
systemic to pulmonary “shunt” can be performed in the
catheterization laboratory by implanting a stent in the
ductus arteriosus. The stenting of the ductus is addressed
after the pulmonary valve has been perforated and dilated
successfully. This allows the delivery and implant of the
stent into the ductus arteriosus through a venous route
and the use of a smaller catheter system in the artery.
When a stent is to be implanted in the ductus during the
catheterization, before any intervention on the ductus and
if not administered earlier when the lines were estab-
lished, the patient is administered heparin systemically.

After the pulmonary valve has been perforated and
dilated, the ﬁnal balloon dilation catheter for the pul-
monary valvotomy is removed over the guide wire.
Following the perforation and balloon dilation of an
atretic pulmonary valve, a long guide wire usually has
already been advanced through the ductus creating
a “through-and-through” route from a femoral vein,
through the right heart and ductus, down the descending
aorta and out through a femoral artery sheath/catheter.
If the through-and-through “rail” wire was not estab-
lished during the valve perforation/dilation, the “rail” is
established at this time with an exchange length wire
which the proposed balloon catheter for stent delivery
will accommodate. The balloon dilation catheter used for
the pulmonary valve is replaced with a long 4- or 5-French
end-hole catheter, which is advanced through the venous
sheath, over the original guide wire and into the pulmonary
CHAPTER 25 Coarctation and systemic arterial stents
655
artery or ductus (wherever the end of the wire is posi-
tioned). If the tip of the prograde venous catheter is in the
pulmonary artery, it is manipulated through the ductus
into the descending aorta and maneuvered through and
out of the femoral artery sheath with the help of a torque-
controlled wire. Occasionally the prograde catheter in the
pulmonary artery cannot cross the ductus easily into the
descending aorta. In that circumstance a ﬂoppy tipped
wire and then a snare catheter is maneuvered from the
aorta, through the ductus and into the pulmonary artery.
A soft tipped wire is advanced through the venous

catheter prograde into the main pulmonary artery and is
snared with a Microvena™ snare (ev3, Plymouth, MN),
which has been passed through the retrograde catheter
into the main pulmonary artery. The snared prograde
wire and the prograde venous catheter are withdrawn
through the ductus and out through the femoral arterial
sheath with the retrograde snare. Once both ends of the
catheter are available outside of the body, the original
ﬂoppy tipped exchange wire is removed and replaced
with a stiff exchange wire of the maximum wire diameter
that the particular coronary stent/balloon catheter or
other pre-mounted stent/balloon that will be used for
implanting the stent in the ductus, requires. This wire is
secured outside of the body at both the arterial and
venous ends.
An equally effective alternative is to advance the ﬂoppy
tipped wire from the retrograde catheter through the duc-
tus and into the main pulmonary artery and to introduce
the snare catheter into the pulmonary artery from the
venous route. The retrograde wire then is withdrawn
through the right heart and out through the venous sheath
to complete the through-and-through wire.
Even when previously visualized very adequately, a
repeat aortogram with the injection adjacent to the ductus
is performed either through a Tuohy™ adapter attached
to the hub of the catheter over the through-and-through
wire or through a separate prograde or retrograde
catheter positioned in the descending aorta adjacent to the
ductus. This angiogram of the ductus is imperative
because of spasm or distortion of the ductus caused by the

various wire/catheter manipulations through it. The
diameter and length of the ductus are remeasured very
accurately. As with the implant of a stent in any other duc-
tus, the goal is to “line” the entire lumen of the ductus,
including covering both ends of the ductus with the stent.
Similarly to the patients with pure ductus-dependent pul-
monary circulations, a 4 mm diameter stent is used in
these patients. Once the through-and-through wire is
established and the appropriate balloon/stent for the
particular ductus is chosen and prepared for delivery, the
prostaglandin infusion is discontinued. Assuming no
acute or sudden deterioration in the infant’s saturation/
hemodynamics, the infant is observed for at least
30 minutes while off the prostaglandin infusion and the
aortogram repeated. Often the combination of the irrita-
tion of the through-and-through wire/catheter, the pre-
ceding manipulations during the balloon dilations of
the valve, and the discontinued prostaglandin infusion
distorts the ductal anatomy signiﬁcantly. The ductus
anatomy is re-examined carefully and the measurements
repeated.
If the ductus acutely goes into spasm or the infant dete-
riorates signiﬁcantly when the prostaglandin infusion is
stopped, the prostaglandin infusion is restarted and the
stent is delivered to the ductus before re-stopping the
prostaglandin as described previously.
The pre-mounted stent on a 4 mm balloon dilation
catheter is introduced over the venous end of the through-
and-through wire and advanced over the wire, through
the right ventricle, pulmonary valve and into the ductus

arteriosus. Although small stents notoriously are poorly
visible, or even invisible in large adult patients, in small
infants they are seen clearly in both the collapsed and the
expanded states. Once the balloon/stent combination is in
position in the ductus, and before the stent is expanded in
the ductus, the anatomy of the whole ductus and, in par-
ticular, the exact location and diameter of the areas of min-
imal ductal diameter are re-imaged angiographically. If
there is not a second catheter in the aorta, the aortogram is
accomplished by advancing a 4- or, preferably, a 5-French,
end and side-hole catheter retrograde over the arterial
end of the through-and-through wire. The catheter is
advanced just to the aortic end of the ductus and a pres-
sure, Tuohy™ “Y” adaptor is attached over the wire at the
proximal end of the retrograde catheter. An angiogram is
performed over the wire through this retrograde catheter,
the tip of which should be adjacent to the ductus and the
stent/balloon catheter coming from the other end of the
wire. With the anatomy precisely identiﬁed and recorded,
the retrograde catheter is withdrawn back into the des-
cending aorta as the stent/balloon catheter is positioned
exactly in the ductus.
The stent should cover both ends of the ductus com-
pletely including, in particular, the area of the narrowest
portion of the ductus, which usually is at the pulmonary
end of a long tortuous ductus. When satisﬁed with the
stent length and location, the stent is expanded by
inﬂation of the balloon to its full diameter or to the recom-
mended maximum pressure of the balloonawhichever
comes ﬁrstafollowed by a rapid deﬂation. A repeat

angiogram is recorded with injection through the aortic
catheter before the deﬂated balloon is withdrawn from the
stent positioned in the ductus. When satisﬁed that the
stent is fully inﬂated and ﬁxed in the ductus, the deﬂated
balloon is withdrawn cautiously out of the stent, over the
wire and out of the body. The retrograde catheter is re-
advanced to the aortic end of the stent and a ﬁnal repeat
CHAPTER 25 Coarctation and systemic arterial stents
656
angiocardiogram is recorded through this catheter before
the wire is withdrawn. Similarly to the other stents in the
neonatal ductus, if there is an area of the ductus which
is not covered completely, a second, overlapping stent
should be implanted at that time.
When satisﬁed with the position, the adequacy of
expansion of the stent and the “lining” of the entire ductus
by the stent(s), an end-hole catheter is introduced over the
venous end of the wire and advanced into the pulmonary
artery. The wire is carefully withdrawn out of the stent
through the venous catheter.
The hemodynamics and anatomy are carefully re-
assessed and a decision is made whether an atrial sept-
ostomy is to be performed. Hemodynamically, an atrial
communication in the presence of some elevation of the
right atrial pressure enhances left ventricular ﬁlling and
systemic output, albeit with some systemic desaturation
and at the expense of some forward ﬂow through the right
ventricle/pulmonary arteries. On the other hand, with at
least a moderate sized right ventricle, the right ventricular
pressure near normal, and even in the presence of signi-

ﬁcant tricuspid valve regurgitation, a restrictive atrial
communication and the associated elevated right atrial
pressure should enhance right ventricular ﬁlling and, in
turn, encourage forward blood ﬂow through the right
ventricle, pulmonary artery, and lungs. Until more
deﬁnitive data are available on which ventricles will grow
with adequate ﬂow, and with what type of stimulus, this
remains an on the spot judgment decision, which must be
made in the catheterization laboratory, during each indi-
vidual case.
Stenting of the ductus in the hypoplastic left
heart syndrome
The patent ductus is essential for the systemic output in
the infant with severe left heart obstructive lesions and,
particularly, an associated “hypoplastic left heart” syn-
drome. In most cases, the open ductus is maintained with
prostaglandins until the infant undergoes the ﬁrst stage
“Norwood” surgical palliation. In that surgery, the entire
ductal tissue is excised purposefully and widely when
the distal pulmonary artery is anastomosed to the aorta
and no catheter intervention on the patent ductus should
be considered when a “Norwood” surgical palliation is
considered.
An alternative approach to the “Norwood” and “single
ventricle” approach to the patient with a hypoplastic
left heart is an orthotopic cardiac transplant. However,
when the infant is “listed” and awaiting the transplant,
the ductal patentcy must be maintained until the trans-
plant is performedaoften for weeks or months. To main-
tain the patency of the ductus medically requires a

continuous, precisely controlled, intravenous (IV) infusion
of prostaglandin. The maintenance of the IV and the
precise control of the rate of the prostaglandin in a
neonate require a 24/7 neonatal intensive care environ-
ment. Even in this environment the infant is in a very pre-
carious situation. An alternative technique is to maintain
the ductal patency with an intravascular stent
20,21
.
Once the decision is made to “list” the patient for a
transplant, then the implant of a stent in the ductus should
be considered immediately. The longer the patient waits,
the lower the pulmonary resistance becomes and the
sicker the infant becomes. The longer the patient remains
on prostaglandin, the greater the likelihood of systemic
infection and the more friable the ductal tissues become.
The infant with a “hypoplastic left heart” who is to
undergo the implant of a stent in the ductus is taken to the
catheterization laboratory with the ductus patency main-
tained with the prostaglandin infusion. The infant is intub-
ated and ventilated on 17–18% oxygen. If the patient does
not have an indwelling arterial line, a femoral artery is
cannulated with a 20-gauge Quick-Cath™, and a multi-
purpose, end and side-hole catheter is introduced through
a sheath in the femoral vein. This catheter is manipulated
through the right ventricle to the pulmonary artery and to
the ductus arteriosus. A biplane angiogram is recorded
in the PA and lateral views with the injection directly into
the ductus. This angiogram is to visualize the exact dia-
meter, length and conﬁguration of the ductus. If necessary,

the X-ray tubes are re-angled to “cut the ductus on edge”
more precisely and the angiogram repeated. Precise meas-
urements are made of the length and diameter of the duc-
tus from the views that elongate the ductus optimally.
Freeze-frame images of the desired views are stored
for use as “road maps” during the implant of a stent into
the ductus.
The end and side-hole catheter is advanced through the
ductus into the distal descending aorta. A 0.018″ or 0.035″
exchange length guide wire (depending upon which stent
and which balloon catheter is to be used), is advanced far
into the distal aorta, the tip of the wire is ﬁxed in the ilio-
femoral artery, and the catheter is removed over the wire.
If there appears to be any distortion of the pulmonary
artery–ductus–descending aorta anatomy by the wire, a
repeat angiogram is recorded over the wire and through
the catheter in the ductus before the catheter is removed.
This angiogram performed with the catheter over the
wire is accomplished by injecting the contrast through
a Tuohy™ high-pressure “Y” adaptor attached to the hub
of the catheter while the catheter is still positioned over
the wire.
A stent is chosen that is as large in diameter as the duc-
tus/descending aorta can accommodate and long enough
to extend completely through the ductus. The expanded
stent must extend from well within the pulmonary artery,
through the ductus, to well into the descending aorta.
CHAPTER 25 Coarctation and systemic arterial stents
657
Unlike the stents in the ductus for pulmonary atresia

patients, where a very controlled ﬂow using a small stent
(3– 4 mm) is desired, in patients with hypoplastic left
heart, the stent must be large enough to accommodate all
of the cardiac output and not create any resistance to this
ﬂow because of restriction from a limited diameter of the
stent. Depending upon the patient’s size, this usually
requires an 8–12 mm diameter stent. The pre-mounted
standard “Large” Genesis™ stents (Johnson & Johnson–
Cordis Corp., Miami Lakes, FL) are satisfactory for this
use up to 10 mm in diameter. The Genesis™ stents are
available pre-mounted in diameters up to 9 mm and in
lengths of 19, 29 and 39 mm. These stents can be intro-
duced through a short, 6-French sheath and advanced
over a 0.035″ guide wire without the necessity of pre-
positioning a long sheath across the lesion. “Large”
Genesis™ stents are very ﬂexible and conform to the cur-
vature of the ductus. None of the coronary artery stents
are suitable for this use because of the maximum diameter
of 4 to 5 mm. The Express™ Biliary LD stents (Medi-Tech,
Boston Scientiﬁc, Natick, MA) are available pre-mounted
in similar sizes, but have larger side “cells” as a conse-
quence of their open-cell design, which may be a problem
for any use in the ductus because of the propensity for
rapid ingrowth of the ductal tissues through any space.
Once the wire is in place and the stent is ready for deliv-
ery, the prostaglandin infusion is stopped. The stent is
advanced over the wire and positioned across the ductus.
The balloon/stent is maintained in this position while
monitoring the patient’s distal arterial pressure and sys-
temic saturation for 30 minutes or until the patient’s

hemodynamics begin to deteriorate. The idea is to allow
the large diameter, often patulous, ductus to constrict
enough after the prostaglandin is stopped to hold the
stent in place. The blood pressure and systemic saturation
decrease as the prostaglandin wears off and the ductus
begins to close. Unless a second venous catheter has been
introduced into the pulmonary artery or the stent/balloon
was delivered to the ductus through a long sheath, an
angiogram in the pulmonary artery to verify the status of
the ductus and the stent position is not possible at this time.
After the 30 minutes or with any deterioration of the
patient, the stent’s position is compared to the freeze-
frame “road map” images of the ductus, and when in the
appropriate position, the balloon is inﬂated slowly to
deploy the stent precisely in the ductus. Once fully
inﬂated, the balloon is deﬂated rapidly. The large dia-
meter stent should ﬁx very securely in place in the ductus.
The inﬂation/deﬂation is repeated one, or more, times
and then the balloon is removed from the body over
the wire.
An end- and side-hole catheter is advanced over the
wire and into the stent. An angiogram is recorded within
the ductus (stent), injecting over the wire with the use of a
Tuohy™ “Y” connector on the catheter. If the stent is not
fully expanded, if it is at all unstable, or if there are areas of
ductal tissue that are “exposed” or “uncovered” by the
stent, a further dilation of the stent or the implant of an
additional stent will be necessary to cover the ductal tis-
sue completely. If a second stent is necessary and the
wire still is in place, the additional stent can be implanted

during this same procedure without any signiﬁcant
further or repeated manipulations through the freshly
implanted stent.
Once satisﬁed with the location and expansion of
the stent(s), the wire is removed from the catheter and
the catheter withdrawn. The infant is maintained off the
prostaglandin infusion. Depending upon the status of the
pulmonary vascular resistance, the infant usually can
be discharged and observed as an outpatient until a
donor heart becomes available. Even with a very satisfac-
tory stent in the ductus, the infant still needs very close
follow-up. As the pulmonary vascular resistance falls
signiﬁcantly, the infant’s lungs can become ﬂooded, with
a proportionate decrease in the effective systemic cardiac
output through the ductus.
The presence of the stent in the ductus does not interfere
with a cardiac transplant procedure since the stented duc-
tus and the adjacent tissues are removed at the time of the
transplant. The main disadvantage to stenting the ductus in
an infant with hypoplastic left heart syndrome is when a
donor heart does not become available of for some other
reason, the decision for the course of treatment is reversed
and a “Norwood” procedure is required. A large stent in
the ductus arteriosus complicates, or even possibly ren-
ders impossible, the usual “Norwood” surgery.
Complications of arterial stents
Complications of systemic arterial stents include exagger-
ation or extension of any of the complications of balloon
dilation of any vessel including, particularly, coarctation
of the aorta or dilation of other arterial lesions. At the

same time, since the implant of a stent requires no over-
dilation of the artery, complications related to dilation with
the balloons are very rare.
Iatrogenic obstructions caused by the implant of stents
that have a maximum diameter that will be too small for
the eventual size of the adult aorta, should be a totally
avoidable “complication” of stents used in the treatment
of coarctation of the aorta and other arteries. There now
are stents available that can be dilated to 25+ mm, which
makes these stents large enough in diameter for any adult
proximal descending aorta. These potentially larger dia-
meter stents should be used in any growing patient with
even the potential of having the aorta in the area of coarc-
tation grow to larger than 16–18 mm in diameter. A stent
CHAPTER 25 Coarctation and systemic arterial stents
658
with a limited diameter, which creates an obstruction
because it is too small for the aorta, creates an obstruction
that is much more difﬁcult to repair than the usual native
or “residual” post-operative obstruction. When the patient
is too small to implant a stent that can be dilated to the
anticipated diameter of the adult aorta, it is preferable to
treat the patient with balloon dilation without a stent or
with surgical repair initially. A stent can be implanted
later to “ﬁnalize” the correction of any residual lesion fol-
lowing prior dilation or surgery.
A very serious complication of the catheter treatment of
coarctation of the aorta using balloon dilation with or
without stent implant is injury to the central nervous sys-
tem (CNS) during the catheterization procedure. CNS

injury most likely occurs from air and/or clot emboliza-
tion coming from catheters, sheaths or wires that are pre-
sent in the systemic circulation proximal to the carotid
and vertebral vessels. Meticulous attention to clearing
ﬂuid lines, catheters and sheaths of any air and/or clot,
keeping guide wires in the circulation “covered” with a
catheter that is maintained on a continual ﬂush for as long
as possible, the continual ﬂushing of all catheters and
sheaths that are positioned in the heart, and the routine
use of systemic heparin, particularly during “left heart”
procedures, should reduce or eliminate CNS problems.
Direct injury from the tip of a wire positioned in a cranial
artery has been implicated in central nervous system
injury. Never positioning a wire tip in either a carotid or a
vertebral artery eliminates this particular possibility.
Probably the most common complication of the use of
stents in the arteries is injury to the local artery at the site
of catheter/stent introduction with subsequent compro-
mise of arterial blood ﬂow in the involved extremity.
These injuries occasionally are unavoidable because of the
necessarily very large sized balloon catheters/sheaths
that are used to deliver stents to the aorta. Meticulous care
of the arteries, which was discussed earlier in this chapter
and in Chapter 4, is the best prevention and, in turn, best
treatment of this problem. Local anesthesia is used liber-
ally and repeatedly around the artery and surrounding
tissues before, during, and at the end of the procedure.
Local anesthesia is administered even if the patient is
receiving general anesthesia. A precise, single-wall punc-
ture is utilized for the entrance into the artery. Although

an indwelling sheath often is as much as 2–3 French sizes
larger than the dilation balloon or balloon catheter that
is used for the stent delivery, an indwelling sheath, which
is relatively ﬁxed in the artery, is always less traumatic to
the artery than a constantly moving catheter or a bare,
rough, “folded” balloon/stent being introduced into
and withdrawn out of the artery. When the sheath is
removed from the artery, the puncture site is compressed
manually and personally while continually monitoring
the puncture site for bleeding and, at the same time, the
artery distal to the puncture for a pulse. This hemostasis
can take 30, 60, or more minutes, but should be accom-
plished before the patient leaves the observation and care
of the catheterizing physician!
Stent displacement is relatively common during the
implant of stents in coarctation of the aorta. There often is
a large discrepancy in diameter between the aorta prox-
imal to the coarctation and the aorta distal to the coarcta-
tion. A stent that is expanded to a diameter that is
calculated to ﬁx the stent in the aorta proximal to the
coarctation, can easily become free-ﬂoating in the much
larger distal aorta. At the same time, expanding the stent
to a diameter satisfactory for the diameter of the aorta dis-
tal to the coarctation would split the smaller-diameter
aorta that is proximal to the obstruction. In order to avoid
displacement, the stent is implanted with the majority of
the stent positioned in the aorta proximal to the narrow-
ing and no attempt is made at “approximating” the distal
end of the stent to the larger distal aorta during the initial
implant procedure. If a stent dislodges and moves further

distally in the aorta, the stent is purposefully repositioned
in the distal aorta so that it does not compromise vital side
branches, and then it is expanded and ﬁxed in the more
distal location.
Tears in the arterial wall or ﬂaps off the intima/media
are less common, or at least, less recognized, during stent
implants in systemic arteries, including congenital coarc-
tation of the aorta, than with balloon dilation alone of
these same lesions. When the proper sized stents are used
after the artery is measured properly and very accurately,
the adjacent aorta should not be “over-dilated” at all and,
at the same time, any slight disruption of the intima/
medial tissue within the area of the stent is compressed
back against the wall of the aorta by the stent. As the
endothelium and neointima develop over and around
the stent, the combination of the wall “thickening” by the
“new endothelial tissues”, the scarring as a consequence
of any tears that did occur, and the “metal scaffolding” of
the stent within the area, all together create a very solid
arterial wall. The artery in the precise area of the stent is
very non-compliant, but no more so than a surgical scar
involving the same area!
Aneurysms have occurred acutely during the implant
of stents in coarctations of the aorta. These occurred more
commonly with the use of the larger Palmaz™ stents
( Johnson & Johnson, Warren, NJ) and occurred predomin-
antly (only?) when the stents were dilated acutely to
their ﬁnal large diameters with a single inﬂation of a
large diameter balloon. Acute aneurysms are not reported
with the sequential dilation of stents to their precise,

eventual large diameters, or with the use of stents that do
not develop sharp tips at their ends as they expand.
Aneurysms following the implant of stents in coarctation
of the aorta are still being studied, and should be looked
CHAPTER 25 Coarctation and systemic arterial stents
659
for in every patient who undergoes a stent implant in
the aorta.
Tears or ruptures of the aorta occur with dilation of
native coarctation, re-coarctation of the aorta, and middle
aortic syndrome, but should not occur with the conserva-
tive implant of the correct size stent in coarctations.
Meticulous, accurate measurements of the lesion itself
and the adjacent vessels, and avoiding oversized dila-
tions/stents compared to the size of the lesion itself and
the adjacent vessel, presumably should prevent this com-
plication during stent implant. In cases of very severe
stenosis of classic coarctation or middle aortic stenosis,
a staged dilation/implant during several sequential
catheterizations is utilized to avoid splitting very nar-
rowed vessels by a single dilation to a very large diameter.
A stent that is still narrowed within a vessel can always be
dilated further at a later date. Once the artery/aorta is
split or torn, there is little or no “turning back”, although
several operators have reported on the successful use of a
covered stent as an emergency “bail-out” therapy in the
catheterization laboratory
22,23
.
Stents implanted in coarctation of the aorta have been

reported to fracture or kink
24
. This probably is a result of
the type of stent used in the area. There have been no
adverse events from these ﬁndings and a recurrent nar-
rowing as a result of a fracture or kink can be treated with
the implant of an additional stent within the original stent.
The implant of stents into the patent ductus of newborn
infants has its own speciﬁc complications. These compli-
cations are in addition to the inherent complications of
extensive catheter manipulations in very sick newborn or
small infants. As with all complications, the best treat-
ment is prevention by paying meticulous attention to the
details of the procedure and the use of known, established
techniques until newer/better techniques are proven.
Irritation and spasm of the ductus is a potential problem
with any manipulation around or through the ductus.
This spasm is not always responsive to prostaglandin
infusion or re-infusion. Should intractable ductal spasm
occur, having the equipment ready for immediate deploy-
ment of a stent is the best treatment. This, however, is not
a guarantee of successful recovery since the “mass” of
even the “tiny” stent/balloon occasionally cannot be
advanced through the ductus once it begins to spasm.
Disruption/tears of the ductal tissues is another potential
with stent implant into the patent ductus, particularly
when the stent delivery is rushed. The tissue is inherently
very friable and cannot tolerate rough handling.
When disruption of the ductus does occur, it usually is
catastrophic.

Stent displacement during implant into the “patulous”
ductal tissue in an infant is a real problem. Prevention, by
the use of a slow meticulous positioning and by waiting
for the prostaglandin to wear off before deploying the
stent, is the best treatment. When a stent displaces from
the ductus, an attempt is made to capture the stent on a
balloon and reposition it back into the ductus. A new bal-
loon which is at least 1 mm larger than the maximum
diameter of the stent is more effective for “capturing” an
errant coronary stent. When a coronary stent becomes dis-
placed from the ductus and is positioned or implanted in
any other artery (even very peripherally), the coronary
stent, unequivocally, eventually will produce a very
signiﬁcant stenosis in that vessel because of its very small
maximum diameter. If a displaced stent cannot be cap-
tured and reimplanted successfully in the ductus or
removed from the patient with a catheter, the stent should
be removed surgically from the errant vessel within a few
days after the attempted implant procedure, unless the
errant vessel is considered “expendable”.
The majority of the complications of stent implants in
arterial locations are eliminated by the use of extremely
accurate measurements, a conservative diameter at the
initial implant, and by paying meticulous attention to the
details of every step of the procedure. The morbidity and
complications of dilation with intravascular stent implant
for systemic arteries appear to be comparable to or even
less than surgical therapy of these same lesions. Dilation
with stent implants in coarctation and other congenital
systemic arterial lesions still represents a “new” treat-

ment, which requires decades of follow-up to determine
its real efﬁcacy and safety.
References
1. Dotter CT et al. Transluminal expandable nitinol coil
stent grafting: preliminary report. Radiology 1983; 147(1):
259–260.
2. Palmaz JC et al. Atherosclerotic rabbit aortas: expandable
intraluminal grafting. Radiology 1986; 160: 723–726.
3. Shaffer KM et al. Intravascular stents in congenital heart dis-
ease: short- and long-term results from a large single-center
experience. J Am Coll Cardiol 1998; 31(3): 661–667.
4. Morrow WR et al. Balloon angioplasty with stent implanta-
tion in experimental coarctation of the aorta. Circulation 1994;
89(6): 2677–2683.
5. Grifka RG et al. Balloon expandable intravascular stents:
aortic implantation and late further dilation in growing
minipigs. Am Heart J 1993; 126(4): 979–984.
6. Suarez de Lezo J et al. Balloon-expandable stent repair of
severe coarctation of the aorta. Am Heart J 1995; 129(5):
1002–1008.
7. Rosenthal E, Qureshi SA, and Tynan M. Stent implantation
for aortic recoarctation. Am Heart J 1995; 129(6): 1220–1221.
8. Bulbul ZR et al. Implantation of balloon-expandable stents
for coarctation of the aorta: implantation data and short-term
results. Cathet Cardiovasc Diagn 1996; 39(1): 36–42.
9. Cheatham JP. Stenting of coarctation of the aorta. Catheter
Cardiovasc Interv 2001; 54(1): 112–125.
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10. Mendelsohn AM et al. Stent redilation in canine models of

congenital heart disease: pulmonary artery stenosis and
coarctation of the aorta. Cathet Cardiovasc Diagn 1996; 38(4):
430– 440.
11. Cheatham J et al. Early experience using endovascular stents
in children with coarctation of the aorta: promising results
. . . but proceed with caution (abstr). Cardiol Young 1998;
9(Suppl 1:11): (abstr).
12. Suarez de Lezo J et al. Immediate and follow-up ﬁndings
after stent treatment for severe coarctation of the aorta. Am J
Cardiol 1999; 83(3): 400–406.
13. Sapin SO, Rosengart RM, and Salem MM. Chest pain dur-
ing stenting of a native aortic coarctation: a case for acute
intercostal muscle ischemia and rhabdomyolysis. Catheter
Cardiovasc Interv 2002; 57(2): 217–220.
14. Thanopoulos BV et al. Long segment coarctation of the thor-
acic aorta: treatment with multiple balloon-expandable stent
implantation. Am Heart J 1997; 133(4): 470–473.
15. Tyagi S et al. Percutaneous transluminal angioplasty for
stenosis of the aorta due to aortic arteritis in children. Pediatr
Cardiol 1999; 20(6): 404–410.
16. Redington AN and Somerville J. Stenting of aortopulmonary
collaterals in complex pulmonary atresia. Circulation 1996;
94(10): 2479–2484.
17. El-Said HG et al. Stenting of stenosed aortopulmonary
collaterals and shunts for palliation of pulmonary atresia/
ventricular septal defect. Catheter Cardiovasc Interv 2000;
49(4): 430–436.
18. Gibbs JL et al. Stenting of the arterial duct: a new approach to
palliation for pulmonary atresia. Br Heart J 1992; 67(3):
240–245.

19. Michel-Behnke I et al. Stent implantation in the ductus arte-
riosus for pulmonary blood supply in congenital heart dis-
ease. Catheter Cardiovasc Interv 2004; 61(2): 242–252.
20. Ruiz CE et al. Brief report: stenting of the ductus arteriosus as
a bridge to cardiac transplantation in infants with the
hypoplastic left-heart syndrome. N Engl J Med 1993; 328(22):
1605–1608.
21. Slack MC et al. Stenting of the ductus arteriosus in hypoplas-
tic left heart syndrome as an ambulatory bridge to cardiac
transplantation. Am J Cardiol 1994; 74(6): 636–637.
22. Khan MS and Moore JW. Treatment of abdominal aortic
pseudoaneurysm with covered stents in a pediatric patient.
Catheter Cardiovasc Interv 2000; 50(4): 445–448.
23. Tyagi S, Rangesetty UC, and Kaul UA. Endovascular treat-
ment of aortic rupture during angioplasty for aortic in-stent
restenosis in aortoarteritis. Catheter Cardiovasc Interv 2003;
58(1): 103–106.
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661
Introduction
Occlusion of abnormal or persistent arterial or arterioven-
ous structures or vessels feeding vascular leaks or tumors
by catheter embolization techniques has been utilized for
over thirty years
1
. The embolization techniques were
developed and perfected primarily by the vascular radi-
ologists working in the abdominal viscera, gastrointestinal
areas and the central nervous system, particularly in “end

artery” vessels. Many materials and devices, including the
patient’s own clotted blood, Gelfoam™, colloidal plugs,
“glues”, detachable balloons and coil occlusion devices
have been used for these peripheral occlusions
1– 6
.
In the pediatric and congenital heart population there
are numerous abnormal congenital and acquired vascular
communications and intravascular “leaks” which require
or, at least, can be beneﬁted by transcatheter occlusion.
The occlusion of these vascular lesions in pediatric and
congenital heart patients has been performed in the cath-
eterization laboratory for over two decades. The abnor-
mal ﬂow through these communications usually results
in signiﬁcant abnormalities of the underlying hemody-
namics and compromises the patient’s symptomatic and
hemodynamic status. The abnormal vascular communica-
tions which are encountered in pediatric and congenital
heart patients include traumatic ﬁstulae, systemic to pul-
monary artery collaterals, systemic arteriovenous ﬁstulae,
pulmonary arteriovenous ﬁstulae, coronary arterial-cameral
ﬁstulae, perivalvular leaks and a variety of residual, surgi-
cally created systemic to pulmonary artery communica-
tions including Blalock–Taussig, modiﬁed Blalock–Taussig,
Potts, and Waterston/Cooley shunts.
There are numerous different catheter-delivered devices
and techniques available for the occlusion of these abnor-
mal vascular structures. There is no single device applic-
able for every lesion and multiple devices may be suitable,
and used, for any one lesion. These devices/materials are

used either by themselves or (frequently) in combination
with one or more of the other devices. The speciﬁc occlu-
sion device used depends upon the type, size and location
of the communication/leak as well as the availability of
a particular device either locally or as approved, in the
particular country. Some of these devices are designed
speciﬁcally for a particular lesion and are discussed in
detail in other chapters in the description of the occlusion
of the speciﬁc intracardiac defect. These same descriptions
are not repeated in this chapter.
Since most of the devices can be utilized for the occlu-
sion of multiple different structures and many of the
abnormal vascular communications can be occluded with
several different devices, each of these miscellaneous vas-
cular lesions and the separate vascular occlusion devices
that are used for that lesion are included in the discussion
of the particular lesions in this chapter. The multiple
devices themselves that are available for these occlusions
are discussed initially in this chapter, before the details of
their use in the various lesions for which they can be used.
Devices/equipment for vascular
occlusions
Occlusion coils
Stainless steel occlusion coils are the most widely used
of the catheter-delivered occlusion devices and have had
the longest continued use in pediatric and congenital
heart lesions. They are particularly useful for small or tor-
tuous vessels and have gained enormous popularity and
use for the catheter occlusion of the patent ductus arterio-
sus (PDA). The speciﬁc coils used for PDA occlusion

and the modiﬁcations of the delivery system/techniques
speciﬁcally for the PDA are discussed separately and in
detail in Chapter 27 (“PDA Occlusion”). Many of these
modiﬁcations, which were developed speciﬁcally for
PDA occlusions, are useful for the occlusion of general
vascular structures.
26
Occlusion of abnormal small vessels,
persistent shunts, vascular ﬁstulae
including perivalvular leaks
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
662
Occlusion coils are available as speciﬁc lengths of vari-
ous sizes (gauges) of stainless steel, spring guide wire. The
“guide” wires are pre-formed during manufacturing so
that they will coil into a cylindrical tube of a speciﬁc dia-
meter of the wire in their “resting” state. The number of
loops of coil and the length of the “tube” of coils depends
upon the original length of the straightened wire. Most
of the “occlusion coils” have multiple tiny threads or ﬁla-
ments of nylon fabric intertwined within the windings
of the spring wires to promote better thrombosis within
a vessel.
Occlusion coils are best suited for the occlusion of long
and/or tortuous vessels with irregular internal diameters,
and especially those which have a signiﬁcant narrowing
somewhere along the course of the vessel. Since a success-
ful occlusion is expected to cut off all blood ﬂow through
the vessel, the vessels being occluded should not be the
sole blood supply to a particular area of tissue unless

necrosis of the tissues that are supplied by the vessel is
desired.
Gianturco™ coils and 0.052
″
stainless steel coils
The coil occluder with the most extensive use in pediatric
and congenital heart patients is the standard Gianturco™
coil. The Gianturco™ coil is a length of special stainless
steel spring guide wire in which the stiffening “core” wire
is pre-formed to curl into a “coil” or “wire cylinder” of a
speciﬁc diameter in its “free” or “resting” state. These
coils are available in multiple sizes of the spring wire,
multiple diameters of the coil (“cylinder”) and multiple
lengths of the coil wire. The Gianturco™ coil has multiple
ﬁne nylon ﬁber segments embedded within the windings
of the spring wire in order to increase the thrombogenicity
of the implanted coil. Gianturco™ coils are available in
spring wire diameters of 0.025″, 0.035″, 0.038″ and now, an
additional coil of 0.052″ wire diameter, in lengths between
1.2 and 15 cm and in coil diameters from as small as 2 mm to
as large as 20 mm in diameter. The very smallest diameter,
short coils are available only in the 0.025″ diameter wires
while very large diameter coils are available only in the
more recently available 0.052″ wires. The total length of
the straightened segment of coil wire in conjunction with
the particular diameter of the preformed loops of the coils,
determine the number of loops which are formed by any
particular length of coil. Each Gianturco™ coil comes
from the manufacturer in a straight metal introducer tube.
The internal lumen and the length of the introducer tube

are speciﬁc for the diameter of each wire and the straight-
ened length of the wire.
The mass of the wire of the coil itself creates a mechan-
ical occlusion and the embedded nylon ﬁbers add to the
thromboses in the area where the coil is deposited and, in
turn, occlude the vessel or communication. The coils are
best suited for deposit into tubular vessels that have
some length and vessels that have an area of narrowing
somewhere within the channel of the vessel or the abnor-
mal communication. A stenosis distally in the channel of
the vessel prevents even coils that are undersized from
migrating out of the target vessel and embolizing to an
area or vital organ distally beyond the vessel.
The coils are delivered through polyethylene, end-hole
only, catheters, which have an internal diameter which
is just slightly greater than the diameter of the wire of the
spring coil. Other end-hole only catheters manufactured
from materials that impart a smooth or slick inner surface
and that are slightly larger in their internal diameters
than the wire of the coil can be used for coil delivery. The
catheter for coil delivery must not have side holes. Side
holes allow the potentially curved tip of the coil to catch
in, or pass into, a side hole of the catheter as the tip of the
coil crosses the side hole. The tip of a coil catching in a side
hole of the catheter will prevent the coil from being deliv-
ered through the tip of the catheter. Since the standard
Gianturco™ coils have no attachment to the delivery wire,
the coil catching in a side hole also prevents any retrieval
of the coil without totally removing the delivery catheter.
Both the material of the catheter and the internal diameter

of the catheter are critically important in order to prevent
the coil from “binding” within the lumen of the catheter
during the delivery through the catheter.
A catheter that is smaller in internal diameter than the
coil wire obviously does not allow the coil with its imbed-
ded ﬁbers to be introduced into, or advanced through,
the catheter. A catheter with an internal diameter signiﬁc-
antly larger than the diameter of the wire of the coil allows
the coil to bend and partially “coil” within the catheter or
allows the pusher wire to push past the coil instead of
actually “pushing” the coil through the catheter. Either
occurrence will cause the coil to bind within the catheter.
The delivery catheters are available with many pre-
formed tip conﬁgurations in order to facilitate entry into
speciﬁc areas. Straight delivery catheters, which the
operator can pre-shape to suit his particular needs, are
also used to deliver coils. End-hole, only, ﬂoating balloon
catheters can be used to deliver the coils to certain
locations or in particular circumstances. The inﬂated
balloon helps to ﬁx the tip of the catheter in place and/or
prevents portions of the coil from extending back into
a more proximal main vascular channel. The catheter
lumen of the ﬂoating balloon catheter obviously must be
of a slightly larger internal diameter than the diameter of
the coil wire that is being delivered through the balloon
catheter.
The coil is introduced into the proximal hub of the
delivery catheter through the straight metal “loader” as a
straight length of wire. The straightened coil is pushed out
of the loader, into the delivery catheter and through the

CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
663
delivery catheter with a teﬂon-coated, spring guide wire
of the same or similar wire size as the coil wire. The coil is
delivered by pushing it completely through and out of the
distal end of the delivery catheter. As the coil is extruded
out of the delivery catheter, it immediately begins to form
the small loop of its predetermined “coil” diameter as it
opens into its coiled conﬁguration. Once the extrusion
from the catheter starts with the standard Gianturco™ or
the 0.052″ coils, there is no way of withdrawing the coil
back into the catheter or stopping or reversing the deliv-
ery. Even if the coil is noted to be in an unsatisfactory posi-
tion as it starts to extrude from the catheter, it can only be
extruded completely and then retrieved with a separate
retrieval catheter and system.
When choosing the appropriate occlusion coil, the
diameter, the length and the general conﬁguration of
the vessel to be occluded are imaged angiographically.
The length and diameters of the vessel are measured
very accurately on the angiograms. The Gianturco™ coil
occludes the vessel by the creation of an irregular mass of
the coil wire and the nylon ﬁber strands that are incorpor-
ated within the wire in which a thrombus forms. The coil
used should be 1–2 mm larger in diameter than the vessel
that is to be occluded. The slightly larger diameter results
in the coil unraveling in an irregular conﬁguration within
and across the vessel lumen rather than into a neat
“donut” like cylinder or smoothly coiled conﬁguration.
If the diameter of the coil is far larger than the diameter of

the vessel, the coil does not “coil” at all, but rather tends to
align straight within the vessel lumen and, in turn, does
not form an effective occlusive mass in the vessel. When
the coil is extruded from the catheter, it not only must
have the appropriate diameter and length to ﬁx to the
walls of the vessel, but also must not be excessively long.
When the coil is too long, it can extend proximally out of
the target vessel and into the more central feeder vessel,
which potentially can be back into the normal circulation
and interfere with vital structures. If, at the other extreme,
the diameter of the formed coil is too small for the vessel,
the coil rolls up into a tight “donut”, does not occlude the
entire vessel, and is likely to tumble distally or even out of
the desired vessel. Once one coil is secured within a ves-
sel, additional coils of different sizes and/or diameters
can, and frequently are, intertwined within or deposited
proximal to the original coil to complete the occlusion.
Even when used in tandem, but without a distal narrow-
ing or some other type of device for ﬁxation, the standard
Gianturco™ coil generally is only usable in tubular struc-
tures of no more than 7–8 mm in their distended diameter.
For larger vessels and vessels without an area of discrete
stenosis, either the standard Gianturco™ coils are used in
conjunction with other intravascular occlusion devices or
the 0.052″ coils are used initially to begin the occlusion
of the vessel.
Occlusion coils can be deposited into long vessels that
have a discrete distal narrowing, where the coil then
lodges in place at the narrowing, although it is not “ﬁxed”
against the wall. In that circumstance, coils can be

“ﬂoated” into the vessel, one after another to create a mass
of coils, proximal to the stenosis in the vessel. When this
technique is used, the ﬁnal coil in the vessel should be of a
slightly larger diameter then the diameter of the vessel in
order to wedge the last coil against the walls of the vessel.
The one “ﬁxed” coil assures that the “loose” coils packed
within the vessel do not “ﬂoat” back out of the vessel into
the vital circulation.
Currently, by far the most common use of the
Gianturco™ coil in congenital heart lesions is for the clo-
sure of the patent ductus arteriosus. This is an entirely
separate subject and is discussed in detail in Chapter 27
and is not covered in this chapter at all. There are many
abnormal vessels, collaterals and persistent surgically cre-
ated systemic to pulmonary artery shunts, which fre-
quently are associated with more complex lesions. These
vessels require occlusion when the additional systemic
ﬂow competes with normal pulmonary ﬂow, particularly
when the abnormal communication persists after the
major intracardiac defect has been corrected. These
communications traditionally required surgical division
during the corrective procedure or as a separate, later,
surgical procedure. When the occlusion of these defects
is performed surgically during the intracardiac repair, it
signiﬁcantly prolongs or complicates the surgery. Most of
these abnormal communications now are occluded with
Gianturco™ coils either before or shortly after the major
surgery
7
. With the use of coils, further extensive extra

surgery or repeat surgery is unnecessary for the elimina-
tion of persistent systemic to pulmonary artery collaterals
or for any surgically created systemic to pulmonary artery
shunts that are present at the time of, or following, the
“total” correction.
Other lesions in which the coils are useful are arterio-
venous ﬁstulae, including systemic coronary-cameral,
peripheral arteriovenous ﬁstulae as well as pulmonary
arteriovenous ﬁstulae. These lesions can produce either
left to right or right to left shunts. In these lesions it is
critical to identify a stenotic or “end” vessel into which the
device can be ﬁxed very securely in order to reduce the
dangers of embolization to an essential more distal vessel
or vital structure in the systemic circulation.
The 0.052 inch stainless steel coil
In order to provide a more robust coil, a more occlusive
coil and a coil particularly for use in the patent ductus
arteriosus, the 0.052″ stainless steel coil was developed.
The 0.052″ coil is a larger, stiffer version of the standard
Gianturco™ coil with the wire of the coil being the heavier
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
664
gauge 0.052″ diameter. The 0.052″ coil provides a much
sturdier occluding device for the miscellaneous vessels
and is particularly useful for the occlusion of much larger
vessels with higher pressures and higher ﬂows
8
. The use
of the 0.052″ coils for the occlusion of the patent ductus
arteriosus for which they were developed, is discussed in

detail in Chapter 27.
In an end vessel or in a vessel with deﬁnite distal
stenosis, the 0.052″ coils are delivered with a “free release”
technique exactly like the standard, smaller sized,
Gianturco™ coils. However, when choosing the diameter
of the 0.052″ coil for a particular constrained vessel, the
diameter of the coil used should be no more than 1–1.5 mm
larger than the stretched diameter of the vessel being
occluded. The 0.052″ coils are very rigid and have a much
greater tendency to form into a symmetrical “donut”
shape after they are extruded, and they have very little
tendency to form into irregular or elongated shapes. In a
vessel that is signiﬁcantly small in diameter for the coil
and non-elastic, the 0.052″ coil is likely to elongate into
an almost straight wire rather than to bunch up into an
irregular coil.
Because of the larger wire size alone, the 0.052″ coil
requires a delivery “catheter” of a larger internal diameter
for implant than the standard Gianturco™ coils. The
necessity of using the larger delivery catheters can pro-
hibit the use of the 0.052″ coils in infants and very small
children. This becomes an even greater problem when the
0.052″ coil embolizes away from the implant location and
must be retrieved. To overcome the necessity of using
the larger French sized delivery catheters, the 0.052″ coil is
usually delivered through a 4- or 5-French, long, transsep-
tal type sheath with a radio-opaque band at the tip rather
than through a separate delivery catheter. This allows the
delivery of the larger diameter coil wire without an over-
all increase in outside diameter of the delivery system. The

long sheaths have the disadvantages of having less ﬂex-
ibility, less ability to bend at acute angles and, as a con-
sequence, a greater tendency to kink than most “delivery
catheters”. This tendency to kink compromises the access
to vessels or lesions arising at acute angles off the major
vessel (aorta). When the long 4- or 5-French sheath is used
to deliver the 0.052″ coil, it is advisable to introduce the
long sheath into the peripheral entry vessel through a
short, 6- or 7-F sheath. Then, if the totally extruded coil
needs to be withdrawn, it can be withdrawn into the
larger, short 6- or 7-French sheath, which is already in the
vessel. In the larger patient, the 0.052″ coil, of course, can
be delivered through a 6- or 7-French guiding catheter.
The “bioptome controlled” delivery technique is prefer-
able to the “free release” technique for the delivery of the
0.052″ coils to all locations, but particularly when there are
any concerns about the proper “seating” or possible distal
embolization of this coil. Bioptome-controlled delivery is
described in detail, later in this chapter and in Chapter 27
on “PDA Occlusion”.
Delivery techniques for the Gianturco™
and the 0.052
″
stainless steel coils
“Free-release” technique for coil delivery
An end-hole only delivery catheter is chosen with a shape
of the tip of the catheter that will facilitate entry into the
speciﬁc area to be occluded and of an internal diameter to
match the diameter of the coil wire being used. The deliv-
ery catheter/sheath is manipulated and advanced as far

as possible into the vessel to be occluded. The tip of the
delivery catheter/sheath is ﬁxed securely in the vessel at,
or distal to the site for, implant of the occlusion device.
Extra effort should always be made to ensure that the
delivery catheter/sheath is positioned very deep into the
vessel that is to be occluded. Often during the process of
advancing the coil through the catheter or extruding the
coil wire out of the tip of the delivery catheter/sheath,
the tip of the delivery catheter/sheath can be pushed
backward in the vessel. The catheter/sheath must be far
enough into the vessel initially to allow for this.
Once the catheter is positioned properly, the thin tubu-
lar end of the coil introducer is introduced into the prox-
imal hub of the pre-positioned delivery catheter or sheath.
The coil introducer should be introduced through a wire
back-bleed/ﬂush device that previously was attached to
the proximal hub of the coil delivery catheter/sheath. The
back-bleed/ﬂush device allows a continual ﬂush of the
delivery catheter or sheath during the introduction of
the coil and during any exchange of pusher wires, which, in
turn, “lubricates” the lumen of the catheter. The stiff end
of a straight teﬂon-coated spring guide wire (of the same
size as the internal diameter of the delivery catheter/
sheath and the same size or slightly larger [if possible]
than the wire of the coil itself) is introduced into the prox-
imal end of the straight tubular coil introducer. As the
straight spring guide wire is introduced into the proximal
end of the coil introducer, the coil is pushed through and
out of the distal end of the introducer tube and into the
delivery catheter/sheath by the “pusher” spring guide

wire. The coil wire has no attachment or connection to the
pusher wire so that once the introduction of the coil into
the catheter has begun, the coil can be advanced only within
the catheter. Standard Gianturco™ or 0.052″ coils cannot
be withdrawn at all! Once the coil is completely within
the proximal end of the delivery catheter/sheath, the
coil introducer is withdrawn from the catheter over the
“pusher” wire and pulled back to the proximal end of, or
off, the pusher wire. The teﬂon-coated spring pusher wire
is reversed and the soft end of the wire is advanced within
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
665
the catheter, which, in turn, pushes the coil (still as
a straight segment of wire) through the length of the
delivery catheter/sheath. Once the wire and coil are
well within the catheter, the catheter, pusher wire and
enclosed coil wire are observed carefully on ﬂuoroscopy
as the coil is advanced within the catheter or long sheath.
The coil is distinguishable from the pusher wire by its
slightly “undulating” conﬁguration and the different dens-
ity of the wire of the coil compared to the pusher wire. As
a check of the two wires, a small radiolucent “interspace”
can be created between the proximal end of the coil and
the distal end of the pusher wire by withdrawing the
pusher wire several millimeters while observing under
ﬂuoroscopy.
Once the distal end of the coil has reached the tip of the
catheter/long sheath, the coil begins to extrude from the
tip of the catheter/sheath by continuing to advance
the “pusher” wire. As the coil is extruded from the tip of

the catheter or sheath, the “coil wire” immediately begins
to curl into its pre-formed coiled conﬁguration and/or
push the tip of the delivery catheter/sheath away from
the site. Exactly how the coil positions itself within the
vessel depends upon the size relationship of the diameter
of the pre-formed coil and the internal diameter of the ves-
sel at that particular location.
It is important to choose a coil diameter of the standard
Gianturco™ coil that is 15–20% larger than the stretched
or expanded internal diameter of the vessel at the area
where the coil is to be implanted. If the coil diameter is
smaller than the vessel diameter, the coil wire “coils” into
a tight, smooth circular coil with the appearance of a small
“donut” and is likely to embolize further along in the ves-
sel. When it tumbles and if it does become lodged in the
more distal vessel, the lumen within the “donut” of the
coiled wire can line up with the vessel lumen and prevent
effective occlusion. On the other hand, when the diameter
of the coil is much larger than the diameter of the vessel
lumen, then the coil cannot “coil” on itself at all and
stretches out longitudinally in the lumen of the vessel and
again, probably will not occlude the vessel. When the coil
diameter is so large that the coil cannot “coil” at all, as the
pusher wire and coil wire are advanced through the
catheter or sheath and as the coil wire is pushed out of
the tip of the delivery catheter or sheath, the coil wire re-
mains straight and actually pushes the tip of the delivery
catheter/sheath back in the vessel. The catheter or sheath
tip can be pushed completely back out of the vessel into
which the coil is being delivered. This leaves some, or all,

of the coil extending proximally out of the target vessel.
The ideal coil/vessel size relationship allows the coil to
partially coil on itself yet partially stretch out into a very
irregular shape or mass. When the coil is to be delivered
into a very critical and short segment of vessel, the “dis-
tensibility” of the particular vessel can be tested precisely
at that location by a low-pressure inﬂation of a small
angioplasty balloon that is slightly larger in diameter than
the vessel at that area.
After the successful implant of a coil, a small injection of
contrast is performed through the delivery catheter or
sheath to verify the degree of occlusion. Often, it is neces-
sary to deposit more than one coil, and often even mul-
tiple coils of different sizes, in any single vessel to complete
the occlusion. As long as there is room in the vessel, addi-
tional coils are deposited at the same location, through the
same delivery catheter or sheath, and during the same
procedure until the vessel is occluded completely.
In most cases of the occlusions of discrete vessels, stand-
ard coils are extruded into a conﬁned segment of the ves-
sel and are released automatically by the “free-release”
technique as they exit the delivery catheter. The majority
of vessels that are occluded (except the PDA), have some
distal tortuosity or narrowing on which the extruded coil
becomes trapped. The very accurate “teetering” across the
narrowest segment of a vessel that is required for coil
occlusion of the PDA, seldom is encountered in the major-
ity of other vascular/small vessel occlusions. With accur-
ate information about the size of the vessel to be occluded
and when the proper size and type of coil is used for the

occlusion of discrete vessels, there is full expectation that
the coil will “fold up” into a compacted, irregular shape,
reorient and move (usually distally) after its release and
then lodge securely in the vessel. When there is a high
likelihood of this type of seating in an appropriate vessel
there is little need for the more complicated and expensive
detachable/retractable coils. Although unnecessary for
the majority of coil deliveries for vascular occlusions, con-
trol of the release and retrievability of the coil, however,
does become essential in some circumstances.
Special techniques for the delivery or
modiﬁcation of the Gianturco™ and 0.052″ coils
to improve the safety of their delivery
When the coil must be delivered in a very speciﬁc site in
order not to occlude adjacent or branching vessels that are
critical for the supply of essential viable tissues (e.g. coron-
ary branches adjacent to a coronary-cameral ﬁstula),
then a controlled release/retrievable system must be
used. When the vessel more proximal to the area being
occluded is signiﬁcantly wider than the area of the vessel
where the coils are being implanted or when the coils are
delivered near to the aortic entrance of the vessel and as
the vessel becomes full of coils, then a retractable or con-
trolled release coil is desirable or even essential. Similarly,
if the vessel has only minimal length or the coil is at all
large in diameter relative to the vessel diameter, there is
a high probability that the coil will elongate too much dur-
ing delivery and will extend back into the central vessel
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
666

(aorta!) as it is extruded from the delivery catheter, and a
control of the release of the coil is essential. Even when
multiple coils are being “wadded” into a long vessel, easy
and immediate retrievability of the last and most prox-
imal coil always is desirable.
When the free-release coil is too small in diameter for
the vessel, it “balls-up” into its “donut” conﬁguration,
“bounces around” in the vessel, which is too large, and
easily can embolize backward and out of the vessel into
the central, critical vessel. With standard free-release
Gianturco™ coils, there is absolutely no control over this
tumbling, once the extrusion of the coil has started.
“Retrieval” of a free-release Gianturco™ coil after the
extrusion of the coil has started, thereafter, represents a
“foreign body” retrieval of a coil which has embolized to a
distal location from the site of implant!
Special techniques to achieve control over
standard Gianturco™ and 0.052″ stainless
steel coils
In order to overcome the non-retrievability, “all or noth-
ing” delivery of standard Gianturco™ and 0.052″ coils,
multiple modiﬁcations of the delivery system/technique
have been developed. With a controlled attach/release coil,
the ﬁt and ﬁxation of the completely extruded coil can be
tested once the coil is extruded completely into the vessel
before the coil is released from the attached delivery
wire/cable. If the position/ﬁxation is not satisfactory, the
coil can be withdrawn back into the delivery catheter and
repositioned before it is released, or the coil can be with-
drawn totally out of the body and the procedure restarted

with a more appropriately sized coil. When there is a
residual leak through the coils and even when the vessel
proximal to the coils is short or otherwise not ideal, by
using a controlled-release coil system, an additional coil
can be extruded safely into earlier coils in the vessel and
tested for both occlusion and ﬁxation before release. If
either ﬁxation or occlusion is not satisfactory, the addi-
tional coil can still be withdrawn from the original coil(s),
although care must be taken because each successive coil
tends to become entangled with any previous coil(s).
The various commercially available and the self-made
techniques for controlled release of the coil, all are effect-
ive to some degree at accomplishing retrievability of the
coil during delivery. The minute details of all of these
modiﬁcations are described in detail in Chapter 27 on
“PDA Occlusion”, where these coil “control” systems
are more of a necessity. The speciﬁc uses of the various
“controlled-release” systems for general vascular occlu-
sions are discussed here.
Because of the problem of a “no-return” delivery once
the extrusion of standard Gianturco™ and 0.052″ coils
is started and, in the long absence of a commercially
available and viable “detachable coil” in the United States,
there have been several very innovative techniques devel-
oped in order to overcome this shortcoming and make the
Gianturco™ and 0.052″ coils safer and more reliable.
Latson catheter modiﬁcation for Gianturco™
coil delivery
The Latson™ modiﬁcation of the delivery catheter provides
some degree of control and retrievability for the standard

Gianturco™ coil
9
. The tip of the delivery catheter is heated
and then pulled into a tapered tip over a short, solid,
smooth wire or “mandril” of exactly the diameter of the
bare coil spring wire of the particular coil. The mandril is
removed and the pulled tip of the catheter is cut off at the
narrowest area of the “pulled taper” on the catheter. This
creates an opening in the tapered tip of the catheter, which
is tight around the bare spring wire of the coil and very
tight around the coil wire when the nylon fabric is embed-
ded in the wire of the coil. This modiﬁed tip conﬁgura-
tion is now available commercially as the Latson™
multipurpose catheter: #248498 (Cook Inc., Bloomington,
IN) and as the modiﬁed Vertebral catheter: #WN27750
(Mallinckrodt Inc., St. Louis, MO).
As a result of the narrowed oriﬁce of the tip of the
catheter, the coil now is gripped very tightly as it passes
through the narrowed oriﬁce of the tightened, modiﬁed
tip of the catheter. As a consequence of the tight grip
on the wire, it is necessary to apply considerable force
to the delivery/pusher wire to extrude the standard
Gianturco™ coil through the tip of the Latson™ catheter.
Because of this tight grip on the coil created by the
modiﬁed tip of the catheter, and unless the coil has
become entrapped on something in the vessel (a previous
coil!), the now “dangling” coil, which has been extruded
almost entirely but is now gripped tightly by the tip of the
modiﬁed catheter, can be withdrawn from a vessel and
out of the body along with the catheter when the delivery

catheter is withdrawn through a peripheral introductory
sheath.
During the withdrawal of the Latson™ catheter, the coil
cannot be withdrawn back into the Latson™ catheter but
rather the coil, which is now mostly extruded, will be
“dangling” at the tip of the catheter, exposed in the circu-
lation and not “protected” as it is being withdrawn within
the circulation. The coil cannot be repositioned or reused
with this catheter while it still is within the circulation. To
start over, the coil and delivery catheter are withdrawn
completely out of the body through the peripheral intro-
ductory sheath, and a new coil is introduced through the
same delivery catheter.
The technique for the delivery of a Gianturco™ coil to a
vessel using the Latson™ modiﬁcation is almost identical
to the delivery of the “free-release” coils. Usually, but not
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
667
necessarily, the retrograde approach is used with the
Latson™ catheter. Once in position the coil is pushed out
of the catheter with the pusher wire, but now with the nec-
essary considerable additional force on the pusher wire.
Because of the force required, more attention must be paid
to the extrusion process in order to extrude the coil in
small, controlled increments in order to deliver the coil to
the precise location. The grip on the coil by the tip of
the catheter is dependent completely on the very accurate
“tolerances” of the internal diameter of the tip of the
catheter whether the catheter is built by hand or by com-
mercial manufacturers. The Latson™ catheter tip is not as

strong or dependable as any of the other attach/release
mechanisms and does not allow the reuse of the coil
during the same procedure without ﬁrst withdrawing the
coil out of the body completely. Although the Latson™
catheter does provide some extra safety in the delivery of
a standard Gianturco™ coil, the necessary tolerances and
the inability to withdraw the coil into the catheter are dis-
advantages to this catheter modiﬁcation for coil delivery.
Balloon-assisted coil delivery to branch vessels
Floating end-hole balloon catheters occasionally are used
to deliver any 0.035″ or smaller Gianturco™ coils to abnor-
mal branch vessels. Balloon catheters are used with
several different techniques for the delivery of the coils.
The end-hole, ﬂoating balloon catheter may be the only
catheter that can be manipulated into the vessel by the
particular operator. In that circumstance, usually, once in
the vessel, the balloon is deﬂated within the vessel and the
end-hole balloon catheter is used like any other end-hole
catheter for the delivery of the coil. Because of the “ragged”
surface of the deﬂated balloon over the tip of the catheter,
extra attention is necessary during the withdrawal of the
catheter after the coil has been delivered to prevent the
balloon from snagging on the fabric strands that are dang-
ling from the freshly implanted Gianturco™ coil.
The end-hole ﬂoating balloon catheter is also used with
the balloon inﬂated securely in the vessel in order to wedge
coils forcibly into distal locations or to keep the coils from
extruding back out of the target vessel. For these pur-
poses, the balloon catheter is manipulated into the vessel
to be occluded and then the balloon is inﬂated tightly

against the walls within the particular vessel. With the
balloon catheter ﬁxed tightly within the vessel, the “free-
release” Gianturco™ coil is extruded into the vessel distal
to the balloon. When the inﬂated balloon is ﬁxed tightly
enough in the vessel, the coils can be pushed into the
vessel with some force to “pack” them more tightly in the
vessel. This usually represents a delicate balance between
the ﬁxation of the balloon in the vessel and the force used
against the pusher wire. If too much force is applied, the
inﬂated balloon can be pushed out of the vessel along
with the coils that are being packed into the vessel. If
the entrance of the vessel being occluded is close to the
entrance of a vital branch vessel, some of the coils can
extend into the adjacent vessel or the entire coil can
embolize distally into the more central circulation!
Bioptome-assisted coil delivery
The bioptome-assisted delivery of coils for PDA occlu-
sion, and in particular the 0.052″ coils, is discussed in
detail in Chapter 27 (“PDA Occlusion”)
8
. The bioptome-
assisted technique is effective for the precise control of
the delivery of any Gianturco™ coil to locations other
than the PDA where the exact localization of the coil is
extremely critical. Bioptome-assisted delivery is equally
as effective when using the more frequently used 0.038″
coils as it is with the 0.052″ coils. Bioptome-controlled
delivery is offered an alternative to the commercially
manufactured, detachable coils, which in their more robust
form are only available outside of the USA. The bioptome

technique allows complete retrievability of the coil at any
time until the purposeful release of the grasp with the
bioptome. The bioptome technique is used as an adjunct
technique to the “free-release” technique in the placement
of the coils into very speciﬁc locations or the “ﬁnal” coils
in more critical or precarious locations.
The bioptome attachment to the coil requires the lumen
or internal diameter (ID) of the delivery system to be at
least 1.3 mm (4-French ID). A 4-French long sheath with
a back-bleed valve and distal radio-opaque marker is
used as the minimum sized delivery system for bioptome-
controlled delivery. However, a 5-French sheath allows
a “more comfortable” delivery and more reliable with-
drawal of the coil/bioptome back into the delivery system
when necessary particularly with the 0.052″ coils. As a
consequence, a 5-French sheath with distal radio-opaque
marker is usually used with bioptome-controlled coils
except in the very smallest infants.
An end-hole catheter is introduced through a 6- or
7-French short sheath and advanced well into the vessel
to be occluded. The end-hole catheter is replaced with
a stiff, exchange length wire. The 4- or 5-French long
sheath/dilator that is to be used to deliver the coil/biop-
tome is introduced over the wire and through the short
introductory sheath and advanced until the tip of the
sheath is signiﬁcantly past the “target” area within the ves-
sel to be occluded. Because of the use of a sheath for the
delivery and the stiffness of the bioptome itself, bioptome-
controlled delivery does have some limitations as to
which vessels it can be used in. Often, if there is signiﬁcant

tortuosity of the vessel proximal to the implant site, the
bioptome-controlled technique cannot be used.
The bioptome technique requires a special prepara-
tion of the occlusion coil, which is used in order for the
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
668
coil to be grasped with the bioptome. All Gianturco™
and 0.052″ coils consist of a very ﬁne stainless steel wire
tightly wound to form the larger “spring guide” type
wire of the advertised coil “wire” diameter. One end of
the “spring” wire is sealed and polished with a small
“weld”, while the opposite end is open with a very
tiny hollow tube created by the ﬁne wires. The coils,
including the 0.052″ coils, come loaded in a metal “loading
tube” with the welded end of the coil at the distal end of
the loader.
The stiff end of a separate 0.038″ spring guide wire
is introduced into the proximal end of the coil holder/
loader and advanced until just 1–2 mm of the distal, closed
(welded) end of the coil is exposed exiting the distal end of
the metal loading tube. This exposes the tiny welded tip,
which seals the end of the ﬁne coiled “wire tube” of which
the “spring coil” is made. While holding the short more
proximal and exposed portion of the coil tightly between
the ﬁngers, the small welded tip (only) is grasped tightly
with a forceps and pulled 0.25 to 0.5 mm away from the
remainder of the spring coil which is held by the ﬁngers
of the other hand. This maneuver separates the small
welded ball approximately 0.5 mm away from the wind-
ings of the coiled portion of the “spring wire”, but still

attached by a single, stretched-out, strand of the ﬁne, very
stiff wire. This separation of the welded “ball” allows the
bioptome to grasp the “ball” ﬁrmly while at the same time
allowing the bioptome jaws to close almost completely
over the stretched out strand of ﬁne wire. This allows the
outside diameter of the combination of the closed, 3-
French bioptome jaws, over and holding the welded
“ball” of even the 0.052″ coil, still to be less than 4-French
in outside diameter.
The closed bioptome jaws over the tip of the coil,
however, do not ﬁt back within the original metal loader.
The combination must be withdrawn into a separate
slightly larger “loader” in order to be front-loaded into the
delivery sheath. Before the coil is grasped with the biop-
tome, the bioptome is passed through the separate slightly
larger metal loading tube (which comes with the 0.052″
coils) or through a segment of a 4-French short sheath
which can be used as a loader equally as well as the new,
larger metal loading tube which is provided only with the
0.052″ coils. The 4-French sheath must be long enough
to contain the entire straightened length of whichever coil
is being used. After the bioptome is passed through the
separate metal loading tube or the 4-French sheath and
during the attachment to the “prepared coil”, the metal
loading tube or length of sheath is withdrawn on the biop-
tome shaft back to its proximal control handle. Once the
new “loading tube” is back on the shaft of the bioptome
catheter, the bioptome jaws are opened and then closed
tightly around the “prepared” separated, welded ball at
the end of the coil.

With one operator/assistant holding the bioptome
jaws closed tightly over the “ball” at the tip of the
coil, the “new”, larger diameter “loading tube” through
which the bioptome was previously passed, is advanced
over the bioptome jaws which now have the tip of the
coil grasped within them. The entire coil is drawn out
of the original metal loading tube directly into the new
larger “loading tube” or segment of short sheath. The
coil is withdrawn completely into this new tube until
the now distal (originally proximal) end of the coil is just
within the tip of the new loading tube. The bioptome-
controlled coil is now ready to be delivered from the new
loading tube into the pre-positioned delivery sheath. The
distal end of the loading tube is introduced into the back-
bleed valve at the hub of the pre-positioned delivery
sheath and the bioptome catheter (with the attached coil)
is advanced into the loader/sheath and the shaft of the
delivery sheath.
The bioptome jaws are held closed very tightly while
the coil is advanced to the end of the delivery sheath. The
entire delivery is observed closely on ﬂuoroscopy. The
coil and the bioptome jaws can be visualized very clearly
on ﬂuoroscopy. The sheath is withdrawn slightly until the
tip of the sheath is exactly in position for implanting
the coil. The bioptome catheter and coil are advanced
together, extruding the coil out of the tip of the sheath. The
combination bioptome/coil is advanced together with
the sheath held in position until the bioptome jaws with
the grasped coil are just 1–2 mm within the tip of the sheath.
At this point the security of the extruded coil is tested by

very slight, gentle, to-and-fro movement of the sheath
and bioptome catheter together. The degree of occlusion
can be tested by a contrast injection into the involved ves-
sel through a second catheter. This obviously can only be
accomplished if such a catheter is in place. If not satisﬁed
with the ﬁxation of the coil in the vessel or the degree of
occlusion, the coil can easily be withdrawn into (and, if
desired, out of) the sheath, and the procedure restarted in
a new location of the delivery sheath or with a different
coil. When satisﬁed with the ﬁxation in the vessel and the
degree of occlusion, the bioptome catheter is advanced
until the jaws have advanced completely out of the tip
of the sheath. The bioptome jaws are opened, releasing
the coil.
The advantages of the bioptome-controlled delivery of
coils are the obvious complete control over the actual
release of the coil and the complete retrievability of the
coil until the moment of its purposeful release. The major
disadvantages to this technique are the requirement for
a slightly larger delivery system, the lower ﬂexibility of
the long sheath delivery system for entering more tortu-
ous locations or vessels arising at acute angles off the
major feeding vessel (aorta), and the added expense of the
bioptome.
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
669
Special commercial modiﬁcations of the delivery
system or the coil to control the delivery of the
Gianturco™ type coil
Detachable™ coils: Jackson™ coils, Cook detachable

and Flipper™ coils
Outside the United Statesai.e. in countries not under US
FDA jurisdictionathe Jackson™ (or Detachable™) coil is
available commercially from Cook™ Inc., Europe. This is
a safe, detachable or controlled-release variation of the
standard Gianturco™ coil. The Detachable™ coil is in
widespread, standard, use for PDA occlusion as well as all
other types of vascular occlusions, particularly in Europe
10
.
The European Detachable™ coil is not available in the
United States. The Detachable™ coil is slightly less robust
than the standard Gianturco™ coil, however, for the
occlusion of most vascular lesions other than the PDA,
this relative ﬂimsiness is of little consequence. The relat-
ively simple attach/release mechanism of the Detachable™
coil gives complete control over the release and retract-
ability of the coil, making vascular occlusions in even the
most precarious vessels a safer and more effective pro-
cedure. The Detachable™ coil, with its speciﬁc pusher/
delivery wire is, however, slightly more expensive than
the standard “free-release” Gianturco™ coil.
The Detachable™ coil essentially is a standard
Gianturco™ coil that has been ﬁtted with a screw mechan-
ism for the purposeful attachment and release from the
delivery or “pusher” wire. The European Detachable™
coil comes from the manufacturer as a “set” containing the
coil, a special clear loader, a special delivery/pusher wire
and a ﬁne movable mandril, which passes through the
delivery wire and the coil. The clear loader has a slight

funnel at the proximal end where the “female” screw
mechanism in the coil is located. The Detachable™ coil
itself outwardly has the same appearance as a standard
Gianturco™ coil, with the distal end of the occlusion coil
sealed with a rounded, smooth and polished “weld”
while the proximal end of the coil is hollow. The open,
proximal end of the straightened occluder coil is “squared
off”, hollow and appears slightly irregular on very close
inspection. The ﬁne wire windings within the proximal,
hollow end of the coil form a “female screw thread” for
the attachment of the “pusher” wire. The special attach/
release delivery or “pusher” wire consists of a spring
guide wire of the same diameter as the coil to be used. The
pusher wire has a long, tapered “male” screw mechanism
as an integral part of its distal end and comes with a
removable “torquing” device for purposeful rotation
of the wire/screw tip. The coil attaches to the delivery/
pusher wire with this very simple screw mechanism.
In addition, the special delivery/pusher wire has no
ﬁxed “core” wire, but is hollow throughout its entire length,
including through the ﬁne screw at the distal end. The
small lumen throughout the wire allows a very ﬁne,
smooth, steel “mandril” or stiffening wire to pass com-
pletely through, out of the end of the pusher wire and
through the coil. The ﬁne, totally removable “mandril”
wire, which is approximately 10 cm longer than the com-
bined pusher wire and the straight coil wire, comes pack-
aged within each pusher wire. The mandril passing
within the delivery/pusher wire and the coil acts as a stiff-
ening “core” wire. The mandril has a short segment of

“spring” wire attached at its proximal end to serve to
identify the proximal end and as a “hub” for moving and
torquing the mandril. Detachable™ coils commercially
come stretched out as a straight spring wire positioned
within a thin, clear, straight loading tube of approximately
the same ID as the OD of the coil.
Once the delivery catheter is positioned properly and
secured in place, the coil is attached to the pusher wire.
The clear loader containing the occluder coil is inspected
very carefully. Each end of the occluder coil is positioned
slightly more than one centimeter within the ends of the
loader. The proximal and distal ends of the occluder
coil/loader are identiﬁed. The screw end of the deliv-
ery/pusher wire is introduced into the proximal (fun-
neled) end of the loader. The mandril wire is advanced
through the delivery/pusher wire and 8–10 mm beyond
the distal tip of the “screw” mechanism of the delivery/
pusher. Very carefully and without pushing the coil for-
ward in the loader, the mandril is introduced into the
proximal end of the coil by gentle trial and error probing
and then advanced 8–10 mm into the hollow coil. The
delivery/pusher wire is advanced over the mandril until
the screw at the tip of the delivery/pusher wire enters
into the proximal end of the coil. When the screw tip has
engaged in the proximal end of the coil, the coil and
pusher wire are attached by two and a half clockwise
turns on the pusher wire or on the coil loader when it is
gripped facing the pusher wire. The screw at the tip of the
pusher wire enters and engages with the proximal end
of the coil. Once the screw has tightened within the coil,

the delivery/pusher wire is turned counter-clockwise
one half turn to slightly loosen the attachment. Gentle, and
very slight to-and-fro motion of the pusher wire within
the loader is used to test the attachment of the coil to the
pusher wire. Holding the pusher wire, the core/mandril
wire is advanced the remainder of the way into the coil
until the mandril reaches the distal, closed tip of the
straightened coil within the loader.
The distal end of the clear coil loader is introduced
through a wire back-bleed/ﬂush device into the hub of
the previously positioned delivery catheter. The deliv-
ery/pusher wire with the enclosed mandril is advanced
into the loader, which, in turn, pushes the attached,
straightened Detachable™ coil out of the loader and into
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
670
the delivery catheter. The mandril remains in the deliv-
ery/pusher wire as the pusher wire is advanced. The
distal end of the catheter is observed continually on
ﬂuoroscopy as the coil advances through the catheter to
the tip of the catheter and as the coil is advanced out of the
tip of the catheter into the desired location for implant by
advancing the delivery/pusher wire further. The mandril
is maintained within the delivery wire and coil until the
coil is at least partially out of the delivery catheter and the
tip of the coil is in or slightly distal to the correct position
for implant. The mandril still within the coil keeps the coil
straight and allows easy adjustments in the position of the
coil. Once the coil is partially out of the catheter and in
proper position for implant, the mandril is withdrawn

slowly, allowing the coil to curl into its “coiled” conﬁgura-
tion in the vessel/lesion. The pusher catheter and coil are
advanced further while the mandril is withdrawn to just
within the proximal end of the coil and until the coil is totally
extruded from the catheter and formed into its full coil
conﬁguration. At this point the coil is tested for its proper
location and its ﬁxation in the vessel by slight to-and-fro
motion of the pusher wire or with an angiogram. When
satisﬁed with the ﬁxation of the coil and the occlusion of
the vessel, the small “vise” is attached to the proximal end
of the delivery/pusher wire and the vise with the pusher
wire/mandril is rotated counter-clockwise until the coil
detaches from the pusher wire. The release of the coil as
the coil is being detached is observed very closely under
ﬂuoroscopy to ensure a smooth “unscrewing”, and that
there is no binding or twisting of the still-attached coil.
If the Detachable™ coil is not in the exact, desired posi-
tion, at any time before it is purposefully “unscrewed”, it
can easily be withdrawn back into the delivery catheter.
As the coil is withdrawn into the catheter, the mandril
remains positioned proximal to and outside of the coil.
If the same coil is to be repositioned using the same
catheter, the mandril is re-advanced into the coil (which
now is straightened within the catheter) before the coil
is re-extruded into the vessel. This retrievability during
delivery adds total control and a signiﬁcant degree of
safety to the occlusion of any vascular structure. The total
European Detachable™ coil systems are slightly more
complicated and signiﬁcantly more expensive than the
standard Gianturco™ coils by themselves.

Flipper™ coils
The Flipper™ coil (Cook Inc., Bloomington, IN) is
an attempt in the US at a version of the European
Detachable™ coil. The earlier US version of a detachable
stainless steel coil of a size considered reasonable to use in
PDA occlusions was a catastrophe. The original “larger”
detachable coil which became available in the US was
made from a smaller, less robust spring wire, had far fewer
incorporated “thrombotic” ﬁbers, and had a bizarre,
unnecessarily complicated attach/release mechanism. As
a consequence this coil had very little use. The Flipper™
coil is a revised version of the Cook, Inc., US detachable
coil, which became available in 2001 with an attach/release
mechanism similar to the European Detachable™ coils.
The Flipper™ coil wires are 0.035″ wires and still do not
have comparable robustness nor the occlusive capabilities
of the 0.038″ standard Gianturco™ coils. Flipper™ coils
are available in 3–12 cm lengths and with coil diameters
between 3 and 8 mm. Current Flipper™ coils have more
ﬁber strands embedded in the coil wire than the original
US version of the detachable coil, and for a 0.035″coil do
seem to have comparable occlusive properties to the
smaller 0.035″ standard Gianturco™ coils. Flipper™ coils
require a delivery catheter with a 0.041″ inner diameter,
which generally is a 5-French catheter.
The lack of robustness of the 0.035″ coil compared to the
0.038″ coil is a limitation of this coil for its use for primarily
closing a patent ductus arteriosus, but the controllabil-
ity and retrievability of the Flipper™ coil make it very
appealing for most other vascular occlusions or for the

implant of additional coils for the “ﬁnal and total” occlu-
sion of a patent ductus which already has a larger, secure
coil in place.
The packaging, attaching, loading, delivery and release
of the Flipper™ coils are all similar to the European
Detachable™ coils described above.
Alternative occlusion coils including “Micro” coils
In addition to the standard and large sized Gianturco™
type coils, there is a large variety of other small coils avail-
able for small vessel occlusion. The alternative coils are
delivered through signiﬁcantly smaller and more ﬂexible
catheters, and as a consequence can be placed in more
circuitous and distal locations. None of the smaller alter-
native coils are as robust as the stainless steel Gianturco™
coils.
Target™ platinum coils and their delivery technique
Target™ Coils (Target Therapeutics, Fremont, CA)
are similar in concept to the Gianturco™ coils. They are
segments of very ﬁne spring guidewire-like wires with
thrombogenic ﬁbers intertwined in the spaces between
the wire coils of the spring wire. There, the similarity
ends. Target™ coil wires are made of very small diameter
0.014″ and 0.018″ platinum wires. In spite of their very
small diameters, and because of the platinum material,
these coils are very radio-opaque and easily visible under
ﬂuoroscopy in the catheterization laboratory. Because of
the material and tiny size of these coils, they are more
ﬂexible and pass through tortuous catheters/vessels eas-
ier than Gianturco™ coils. Target™ coils do not open into
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae

671
a cylindrical “coil” in their relaxed state but rather, into
complex “helix” conﬁgurations which vary between 4
and 7 mm in diameter. Because of their size and less
“ﬁber material”, these coils are more compressible in a
particular vessel and, in turn, not as occlusive as the larger
stainless steel Gianturco™ coils.
Target™ coils are delivered through speciﬁc, very
small (3-French), very ﬂexible Tracker™ delivery catheters
(Target Therapeutics, Fremont, CA). The Tracker™
catheters are small and “trackable” but are non-radio-
opaque throughout their entire length except for a tiny
radio-opaque marker at the very tip of the catheter. This
tip marker identiﬁes the most distal location of the tip
but, once the delivery/pusher wire is removed from the
Tracker™ catheter, the course of the catheter proximal to
the tip is invisible! Tracker™ catheters are advanced to the
oriﬁce of the vessel to be occluded through a larger torque-
controlled 5-French, guiding catheter. From the guiding
catheter, the Tracker™ catheter is advanced through
the vessel over a special, very ﬁne, Dasher™ guide wire
(Target Therapeutics, Fremont, CA). The Dasher™ guide
wire is pre-positioned in the target vessel. Because of its
torque control, its very ﬂoppy tip and its very small size,
this wire can be manipulated very readily to very distal
locations and through very tortuous and long vessels.
To deliver the Target™ coils, a pre-formed, torque-
controlled, 5-French guiding catheter which accommodates
the Tracker™ catheter is positioned in the oriﬁce of the
vessel to be occluded or, alternatively, into a trunk vessel

off of which the target vessel arises. The special Dasher™
tracking wire, which is 0.014″ in diameter and 175 cm long
with a very ﬂexible tip, is passed through the guiding
catheter and into the target vessel. The speciﬁcally curved
ﬂoppy tip of the Dasher™ wires can be manipulated select-
ively through very tortuous and very circuitous, distal
vessels using a “torquer vice” on the stiff shaft of the
wire to help to direct the tip of the wire to the speciﬁc loca-
tion. An appropriately sized Tracker™ (“Tracker™-18”,
150 cm) catheter (Target Therapeutics, Fremont, CA) is
then advanced over the Dasher™ wire and through the
guiding catheter to the oriﬁce of the target vessel. As the
Tracker™ catheter is being advanced over the wire a
continual ﬂush is maintained through the guide catheter
and the Tracker™ catheter through the special double
“Y” adaptors attached to the proximal ends of both the
Tracker™ and the guiding catheters.
When the Tracker™ catheter is being advanced over the
wire beyond the tip of the guiding catheter and through
the more tortuous areas of the vessel, the Tracker™
catheter is advanced several centimeters at a time while
alternately withdrawing or tightening the Dasher™
wire very slightly. In this way the Tracker™ catheter is
“inched” along the Dasher™ wire without displacing the
wire. All of this time, only the tip of the Tracker™ catheter
is visible over the wire. Occasionally the Tracker™
catheter does not follow over the Dasher™ wire and the
wire is pulled out of position. In that circumstance, often
the very ﬂimsy Tracker™ catheter with just the tip of
the exposed, very ﬂoppy Dasher™ wire maintained just

beyond the tip of the catheter can be advanced (manipu-
lated) together as a unit back to the appropriate location.
Once the Tracker™ catheter has reached the desired loca-
tion, the Dasher™ wire is withdrawn very carefully and
very slowly from the Tracker™ catheter. The Tracker™
catheter is maintained on a slow constant ﬂush while the
opaque tip of the catheter is observed continuously on
ﬂuoroscopy to be sure that the tip is not being displaced
during the removal of the wire. Once the wire is removed,
again, only the opaque marker at the tip of the Tracker™
catheter will be visible. A small, slow hand injection of
contrast is performed through the Tracker™ catheter and
recorded on biplane angiography or stored ﬂuoroscopy in
order to “road map” the actual “course” of the Tracker™
catheter for future reference. After the “road map” is
recorded, the Tracker™ catheter is ﬂushed very slowly but
very thoroughly to clear it of all contrast material. A rapid
or forceful ﬂush of the Tracker™ catheter can easily “blow”
the tip of the Tracker™ catheter back out of the vessel.
Each Target™ coil comes straightened in a separate,
tiny, metal tubular holder/introducer. The introducer
tube is ﬂushed gently and the end, which does not have a
hub, is ﬁtted into the straight segment of the “Y” connec-
tor at the proximal end of the Tracker™ catheter. The coil
is pushed out of the introducer and into the proximal end
of the Tracker catheter with the short “plunger tool”
which comes with the coil. Once the plunger tool has been
advanced to the “hilt”, the coil is completely within the
Tracker™ catheter as a short, straight, free segment of
wire. Target™ coils fortunately are very radio-opaque.

The plunger tool and the introducer tube are removed.
The stiff end of the special “coil pusher wire” is introduced
into the proximal end of the Tracker™ catheter and
advanced approximately 30 cms. This “pre-advances” the
coil that distance within the Tracker™ catheter. The stiff
end of the coil pusher is withdrawn, the pusher wire
reversed, and the soft nylon distal end of the pusher
“wire” introduced into the Tracker™ catheter. All of this
time the Tracker™ catheter and guiding catheter are main-
tained on a slow continuous ﬂush. As the coil pusher (soft
nylon end ﬁrst) is advanced in the Tracker™ catheter, the
coil is advanced proportionately through the catheter.
This part of the delivery is observed particularly carefully
on the ﬂuoroscopy. Extreme care is taken as the coil is
advanced within the Tracker™ catheter to ensure that
the tip of the Tracker™ catheter is not withdrawn even
slightly by inadvertent traction applied to it. When the
advancing coil and coil pusher wire begin to enter curves
and bends in the course of the Tracker™ catheter, the
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
672
advancing coil and coil pusher wire tend to “straighten”
the Tracker™ which, if not compensated for by advancing
the proximal end of the Tracker™ catheter, can pull the tip
of the Tracker™ catheter back out of the desired position.
The course of the coil, which now is visible through
the “invisible” catheter, is compared to the previously
obtained angiographic “road map” of the catheter course.
This is to help ensure that the coil and pusher are not dis-
placing the “invisible” catheter during the introduction

of the coil.
When the coil reaches the tip of the Tracker™ catheter,
by further advancing the coil pusher, the coil is extruded
from the distal end of the catheter and is free in the vessel
to be occluded. Like the standard Gianturco™ coils, the
Target™ coils have no attachment to the pusher wire
and once extrusion begins, the coil cannot be withdrawn.
Also like the Gianturco™ coils, the way the coils unwind
and coil in the vessel depends upon the relative size of the
coil compared to the vessel size. In order to accomplish
complete occlusion of a vessel, usually many coils or mul-
tiple sizes of the coils are used. As with other occlusions
and whenever possible, the total occlusion of the vessel
should be accomplished completely before the procedure
is abandoned.
Controlled release micro coils
There are two varieties of controlled release systems for
the “micro” coils, which do provide retrievability of the
coils even after they have started to be extruded. The two
mechanisms are entirely different, but both are manu-
factured by Target™ Therapeutics (Target Therapeutics,
Fremont, CA). Although the primary use of these coils is
by neuroradiologists, they are equally suitable for small
vessel occlusions in the pediatric/congenital population.
The ﬁrst of these controlled release micro coils is
the Guglielmi™ electrolytically detachable coil (GDC)
(Target Therapeutics, Fremont, CA). These are, as the
name implies, released from the delivery wire by a micro
current delivered through the wire, which, in effect, melts
a connection between the delivery/pusher wire and the

coil. The second type of controlled release coil is the
Interlocking Target™ coil (Target Therapeutics, Fremont,
CA). These coils have a unique system of micro machined,
overlapping pins or “couplers” which are compressed
within a tiny delivery catheter until the ﬁnal millimeter of
the coil is extruded from the tip of the catheter. Both of
these controlled release micro coils otherwise are used in
similar circumstances to the other micro coils.
Tornado™ coils
The Cook Tornado™ coils (Cook Inc., Bloomington, IN)
functionally are almost a cross between the standard
Gianturco™ coils and the Target™ coils. As their name
implies, these coils are shaped like a tiny tornado “funnel”
which along with their size and material gives them more
compressibility and, supposedly, more coil “exposure” to
the lumen of the vessel. These coils are constructed of plat-
inum wire, which is more radio-opaque than stainless
steel wire of comparable size. The coil wires are available
in both 0.018″ and 0.025″ spring wire sizes, which, in turn,
are less robust than the standard Gianturco™ coils. Each
coil has multiple strands of tiny synthetic ﬁbers embed-
ded along the coil wire to facilitate thrombosis. The
Tornado™ coil sizes are labeled corresponding to the
largest and the smallest diameters at the ends of the “fun-
nel”. For example, a 6/2 coil has a 6 mm diameter large
end, which tapers down to a 2 mm diameter small end.
The 0.018″ Tornado™ coils are available in sizes from 3/2
to 10/4 with lengths of the straightened coil varying from
2 to 14 cm, while the 0.025″ Tornado™ coils come in sizes
from 5/3 to 10/5, with lengths of the straightened coil

from 4 to 12 cm. From the standard packaging of the
Tornado™ coils, the small end of the “funnel” is delivered
ﬁrst from the “coil” holder and loads ﬁrst. By special order
the Tornado™ coils can be packaged so the large end is
delivered ﬁrst. Tornado™ coils are delivered through
catheters with internal diameters of 0.025″ or 0.032″,
which allow the use of very small, trackable catheters.
The 3-French Slip-Cath™ (Cook Inc., Bloomington, IN)
is ideal for the delivery of these coils. The Slip-Cath™ is
very ﬂexible and has a very slick hydrophilic coating,
which allows it to track through very circuitous and small
vessels. Its small outer diameter allows it to be advanced
to the oriﬁce of the vessel that is to be occluded through a
torque-controlled, 5- or 6-French guiding catheter. The
nylon 3-French infusion catheter (Cook Inc., Bloomington,
IN) with a radio-opaque tip is less ﬂexible than the Slip-
Cath™ but also makes a good delivery catheter for delivery
to more proximal areas in small, but less tortuous vessels.
The technique for loading and delivering the
Tornado™ coil is similar to the delivery of a “free-release”
Gianturco™ coil. There is no attach/release mechanism.
The coils are introduced into the pre-positioned delivery
catheter from their loader and advanced through the
catheter with a 0.025″ pusher wire. When there is a very
tortuous vessel proximal to the site of delivery, a very soft
tipped pusher wire is used. A concomitant slow, continu-
ous ﬂush through the delivery catheter assists in advanc-
ing the coil through the catheter. The smaller Tornado™
coils occasionally can be advanced through the delivery
catheter by a strong ﬂush on the catheter alone. The strong

ﬂush, however, may cause the tip of the catheter to recoil
out of position, making the “ﬂush” delivery much less
reliable and less precise. As with other micro coil occlu-
sions, usually more than one coil essentially is always
required to complete the occlusion. After one or more
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
673
coils are delivered, a small hand angiogram is performed
through the delivery catheter to check the degree of occlu-
sion. If there still is any residual leak, additional coils are
delivered until the vessel is occluded or there is no more
space in the vessel for additional coils.
Nester™ coils
The Nester™ coils (Cook Inc., Bloomington, IN) are still
another variety of coil for vascular occlusions. These are
0.035″ platinum coils with synthetic ﬁbers entwined in the
coil wire. In their relaxed, free shape, the coils have a
cylindrical conﬁguration. Nester™ coils are all 14 cm in
length and available in 4–12 mm diameter “cylinders”.
These coils are softer than even the comparable diameter
Tornado™ coils. The Nester™ coils are designed to
occlude by bunching up and packing into a relatively
large (1–2 cm) mass within the vessel.
The Nester™ coils are delivered through a catheter with
a 0.035″ or 0.038″ inner diameter and advanced through
the delivery catheter with a 0.035″ teﬂon-coated spring
guide “pusher” wire identically to the delivery of the
Gianturco™ free-release coils. The standard Nestor™
coils have no attach/release mechanism so, like the
Gianturco™ coils, once extrusion of the coil begins, there

is no turning back. Because they are so soft and ﬂimsy,
these coils are used mostly as additional or supplemental
“stufﬁng” coils rather than primary occlusion devices.
They are added as “packing” to complete the occlusion
within a previous, stiffer coil or other device already
placed in a vessel.
Particulate materials and non-coil intravascular
devices available for vascular occlusions
There are several materials and intravascular devices in
addition to the intravascular coils that are available and
occasionally used for the occlusion of abnormal vascular
communications.
Particulate materials
Vascular radiologists use particulate materials exten-
sively for the acute occlusion of vessels and abnormal
communications. These materials usually are used to
control bleeding from a speciﬁc vessel and/or to totally
occlude vessels with the intent of necrosing the tissues
“downstream” from the occlusion (tumors, neoplasms).
The particulate materials are useful mostly for very dif-
fuse, but, at the same time, “end artery” lesions. The mater-
ials used include autologous blood clots, pieces of
Gelfoam™ and pieces of Polyvinyl Alcohol (Ivalon™).
The autologous blood clots and Gelfoam™ usually only
provide a temporary occlusion and for that reason seldom
are used in congenital vascular lesions where a more “per-
manent” occlusion is desired.
The autologous clots are just thatasmall solid particles
of the patient’s recently clotted blood, which are injected
from a syringe through a catheter that is pre-positioned

in the culprit vessel
1
. The “clot particles” that are used
should be slightly larger than the vessel that is to be
occluded. The already clotted blood acts as a temporary
occlusive mass to occlude the small, preferably “end” ves-
sel. The clot usually thrombolyses over a short period of
time, however, it usually remains in place long enough to
allow acute bleeding from the vessel to stop and occasion-
ally long enough for the vessel to thrombose.
Gelfoam™ is an insoluble material made from dried
pork skin gelatin and formed into porous foam sheets. The
foam material can absorb many times its own weight
in blood and/or other ﬂuids. When left in the tissues
it resorbs into the body within 4–6 weeks. Gelfoam™ is
approved to enhance coagulation on the surface of bleed-
ing tissues but is not “approved” for intravascular use. It
comes in sterile sheets, which can be cut to any desired
size or shape, and the pieces can be compressed into very
small particles.
Very small, cut and compressed pieces of Gelfoam™
are soaked in a dilute solution of contrast and then are
forced into the end vessel that is to be occluded through a
catheter by a strong ﬂush with a syringe
2
. In the vessel, the
“wad” of Gelfoam™ expands and absorbs blood to create
an occlusive mass. Gelfoam™ is useful to “complete” or
“ﬁnalize” the occlusion of a vessel/ﬁstula which has
been started with another occlusion device. Obviously,

this soft gelatin like material cannot be used to occlude
high-ﬂow and/or high-pressure vessels, and like autolog-
ous clot, the Gelfoam™ itself may not create a permanent
occlusion. The Gelfoam™ particles themselves are not
radio-opaque, so embolization to distal locations is only
apparent from any contrast solution that might be
retained in the particles and/or signs or symptoms that
are produced by the embolized particles.
Ivalon™ (Polyvinyl-alcohol or PVA) foam particles
are available for a similar use to the autologous clots or
Gelfoam™ pieces. The Ivalon™ does provide a more per-
manent occlusion but, as small soft particles, still is useful
only for end vessel and/or “completion” of other vessel
occlusions. Ivalon™ particles are available commercially
from Cook Inc. (Bloomington, IN) as dried particles in
multiple different particle sizes between the smallest
50–100 micron and the largest 2000–2800 micron sizes to
accommodate multiple different vessel sizes. The dried
Ivalon™ particles are mixed with contrast material to
soften them and give them some radio-opacity for injec-
tion into the circulation. The particles mixed with dilute
contrast are drawn out of their sterile container into
a syringe and injected with the same syringe into the
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
674
desired site through a pre-positioned catheter. Similar to
the autologous clots and Gelfoam™, there is little control
over the location where the particles are delivered and
essentially, no retrievability.
“Intravascular” glues

There was a transient interest by several different
investigators for the use of the tissue adhesive isobutyl
2-cyanoacrylate (Bucrylate™) as an occlusive/embolic
material to occlude large vessels/vascular communica-
tions
4
. The Bucrylate™ polymerizes into a solid mass
instantaneously on contact with blood. The area for
deposit of the Bucrylate™ must be “isolated” from the
surrounding circulating blood and/or the Bucrylate™
must be injected very speciﬁcally into the area.
Bucrylate™ was very difﬁcult to handle and to control
during delivery both during animal testing and during
several clinical uses. If injected too fast it embolized dis-
tally and/or backward into proximal branches and, in
doing so, occluded all areas that it entered. If injected
too slowly, it occluded the injecting catheter when only
partially extruded. The difﬁculties with delivery of
Bucrylate™ compared to other occlusion materials/
devices, and the unknowns about long-term carcinogenic
effects of Bucrylate™ in humans, led to it being aban-
doned for human trials in the United States.
Occlusion devices for large vascular
communications
Gianturco-Grifka Vascular Occlusion Device™
(GGVOD™)
Although it does contain spring guide wire and is ap-
proved for use in the US as a variation of the Gianturco™
coil, the Gianturco-Grifka Vascular Occlusion Device™
(GGVOD™) (Cook Inc., Bloomington, IN) has little resem-

blance in either appearance or use to the Gianturco™
coils. The GGVOD™ is a nylon bag or sack of a predeter-
mined ﬁxed diameter into which a speciﬁc length of
spring wire is wadded to achieve a tense, ﬁxed diameter,
mass of spring wire
11
. The wire for the packing of the bag
of the GGVOD™ is a spring guide wire with the stiffening
core and safety wires removed. The bag only serves to
contain the mass of wire within the ﬁxed diameter of the
bag. The bags are available in diameters of 3, 5, 7 and
9 mm, each coming with a speciﬁc length of “packing”
spring guide wire. The bags are somewhat ﬂattened and
elongated so that they do not form a circular or spherical
conﬁguration in their length or cross section. The stated
diameter is the largest measured cross-section of the par-
ticular bag and not the actual circumferential diameter
of the bag.
The GGVOD™ is usable only in tubular vascular struc-
tures that are at least 1.5 times longer than their respective
diameters. The GGVOD™ is held in the vessel by the
radial force created by the wad of spring wire within
the bag and exerted against the surrounding vessel wall.
The bag diameter should be at least one millimeter larger
than the diameter of the vessel to be occluded. If the par-
ticular vessel is very distensible, then a larger diameter
bag to vessel ratio is used.
The technique for delivery of the GGVOD™ to most
abnormal vascular communication is similar to the deliv-
ery of the GGVOD™ to the PDA (as described subse-

quently in Chapter 27) with one major exception. When
delivering the GGVOD™ to a collateral or branch vessel
compared to the delivery to the PDA, the delivery sheath
initially and, in turn, the bag is delivered exactly to the
implant site and all of the wire extrusion into the bag is
directly into the site where the bag is to be implanted. This
is in comparison to the delivery to the usual patent ductus,
where the sheath and the bag are advanced beyond the
implant location and some of the ﬁller wire is extruded
into the bag in this distal location before the bag/delivery
catheter is withdrawn back into the speciﬁc site within the
ductus for the implant. The ﬁxation of the bag and/or the
ability to push all of the ﬁller wire into the bag depend(s)
upon a relatively precise and, at the same time, tight ﬁt of
the ﬁlled bag into the vessel/channel. As with the delivery
of coils to critical locations, the vessel/channel can be
“sized” with a small angioplasty balloon that is slightly
larger than the vessel/channel and inﬂated at a low pres-
sure in the vessel/channel.
Because of the complexity of the delivery and release
of the GGVOD™ and the critical importance of each indi-
vidual step, the details of the GGVOD™ delivery to vas-
cular communications other than the PDA are listed here
in a tabular, “cook book” form.
Components of the GGVOD™ system
• A long, 8-French, valved outer delivery sheath with a
distal marker band.
• The nylon “sack” or “bag”: in 3, 5, 7 and 9 mm sizes
(diameters).
• An inner, stiff walled, pusher catheter to which the bag

is attached.
• A long variable length (according to bag size) detach-
able, coiled spring ﬁller wire within the pusher catheter.
• A stiffer pusher wire (attached to the proximal end of
the ﬁller wire and extending out of the proximal end of the
pusher catheter).
• A second, stiff, middle, “bag release” catheter which is
pre-positioned over the pusher catheter.
• A complex attach/release system which joins all of
these components.
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
675
• A short length of 8-French “peal away” sheath which
comes over the distal ends of the two catheters and the
attached “bag”.
Six major steps in the implant of a GGVOD to an
abnormal vascular communication (except a PDA)
• The long delivery sheath is advanced into the abnormal
vascular communication until the sheath tip is just within
the area where the “sack” is to be implanted.
• The “sack” is introduced into the long sheath through
the “peal away” sheath.
• The “sack” is positioned precisely in the area to be
occluded and the sheath is withdrawn off the sack.
• The ﬁller wire is pushed into the sack.
• The pusher wire is separated from the ﬁller wire.
• The ﬁlled “sack” is separated from the pusher catheter.
Details of the six major steps for the GGVOD
delivery to an abnormal vascular communication
Step 1: The long delivery sheath is positioned in

vascular communication with the tip of the sheath
1–2 cm beyond the area where the sack is to be
implanted
• The abnormal vascular channel is entered with an end-
hole catheter which is advanced as far beyond the area to
be occluded as possible.
• A second catheter from a second vascular entrance site
is placed adjacent to the proximal (in the direction of ﬂow)
end of the communication.
• The end-hole catheter is replaced with a 0.035″ stiff
exchange wire.
• The special 8-French, valved delivery sheath/dilator
set with a marker band at the distal tip of the sheath is
advanced over the wire into the abnormal channel until the
tip of the sheath is just beyond the area of the channel where
the GGVOD™ is to be implanted. Unless the delivery
sheath tip can be advanced just distal to the location for
occlusion, the GGVOD™ cannot be used.
• The dilator and wire are removed, the system is
cleared of air and clot and then the sheath is ﬂushed
thoroughly.
Step 2: The “sack” and delivery system introduction
into the long sheath
• All of the components of the GGVOD system are
inspected carefully.
• The “sack”, which is attached to the pusher catheter
and the wire/delivery/release system, is introduced into
the pre-positioned long sheath as a single unit through the
short “peal away” sheath.
• The short “peal-away” sheath is removed after the

“sack” is completely within the sheath.
• The “sack” is advanced with the attached delivery system
to the tip the sheath (but still within the sheath tip) to the
exact location where the GGVOD™ is to be implanted.
Step 3: The “sack” is positioned in the vessel/
channel
• With the pusher catheter held in place, the sheath is
withdrawn off the “sack” which now is in the precise
position for implant. The “sack” itself is invisible, but
the attaching band on the proximal neck of the “sack” is
visible and deﬁnes the proximal limit of the “sack”.
• While observing on ﬂuoroscopy, several loops of the
“ﬁller” wire are advanced very loosely into the “sack” by
advancing the stiff pusher wire 5–10 cm. The “sack” is not
packed tightly with the ﬁller wire at this point.
• The position of the “sack” is checked with a small
angiogram through the second catheter positioned in or
adjacent to the proximal end of the channel.
Step 4: The ﬁller wire is pushed into the sack
• With the “sack” in the proper position, the remainder
of the ﬁller wire is fed completely into the “sack”. This is
checked on ﬂuoroscopy being sure that the connection
point of the ﬁller wire with the pusher wire is within the
sack. This is identiﬁed by a difference in X-ray densities at
the connection point.
• The exact “sack” position in the vessel and the degree of
occlusion are checked by another angiogram through the
second catheter.
Step 5: The pusher wire is separated from the ﬁller
wire

• When sure the ﬁller wire is completely within the
“sack” and while observing on ﬂuoroscopy, the wire
release mechanism is activated by pushing forward
on the two side “loops” of the special attach/release
handle. This detaches the pusher wire from the ﬁller wire.
• The pusher wire is withdrawn into the pusher catheter
athis releases and separates the pusher wire from the
“sack”. This withdrawal of the pusher wire should be
very slowa until absolutely sure that the pusher wire is
separated from the ﬁller wire.
Step 6: The pusher catheter is separated from the
sack
• The stiffer, middle, release catheter, which is over the
pusher catheter but within the sheath, is advanced snugly
against the neck of the “sack”.
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
676
• With the tip of the release catheter held exactly in place
against the sack, the inner “pusher” catheter is withdrawn
forcibly from within the neck of the “sack”. (If the release
catheter moves at all, the position of the “sack” very likely
will move with it!!)
• The forceful withdrawal of the “pusher catheter”
releases the “sack” in the channel entirely free from the
delivery system.
The advantages of the GGVOD™ for vascular occlusions
are the same as its advantages for occlusion of the PDA.
The GGVOD™ is excellent for the occlusion of relatively
large and/or high ﬂow vascular channels or structures
that have any associated length. In this type of lesion, the

GGVOD™ usually produces immediate, complete occlu-
sion. Even the largest “sack” is delivered through only an
8-French sheath, which is reasonable in all patients past
infancy. Once delivered and before it is released purpose-
fully, if the “ﬁlled bag” does not ﬁt in the vessel, is loose
in the vessel or otherwise does not occlude the vessel, the
wire can be withdrawn and the bag repositioned or even
replaced with a bag of a different size. The larger diameter
GGVOD™ devices also are applicable to some larger,
high ﬂow vessels and channels where coils alone are not
sufﬁcientafor example in large abnormal venous chan-
nels or large pulmonary arteriovenous malformations.
One of the greatest advantages of the GGVOD™ is that
it is approved for this use and is available in the United
States.
The GGVOD certainly is not a “universal” device,
only being applicable to tubular vascular lesions that are
somewhat longer than they are in diameter. Another dis-
advantage of the GGVOD for vascular occlusions relates
to the size and stiffness of the delivery sheath. Since most
small vessels requiring occlusion arise from the aorta and
require arterial access, the 8-French delivery sheath repres-
ents a signiﬁcant disadvantage for use in infants or small
children. In addition to its diameter, the GGVOD™ is
delivered through a long sheath which is not as ﬂexible as
most delivery catheters, so delivery of the device into
acutely angled and/or tortuous vessels is difﬁcult, if not
impossible. Replacing the delivery sheath that comes with
the GGVOD™ with a Flexor™ type sheath overcomes
some of this problem. A ﬁnal disadvantage is that the

GGVOD™ is quite complicated to use and when used
infrequently, the delivery/release technique must be
“relearned” with each use.
There have been rare complications encountered with
the use of the GGVOD™ even in the occlusion of vascular
structures other than a PDA. On several occasions the
ﬁller wire either could not be or was not pushed entirely
into the “sack” and/or was pulled partially out of the
“sack” as the pusher wire was withdrawn (incompletely
released?), resulting in a segment of the ﬁller wire extend-
ing into the lumen of the vascular channel after the release
of the “sack”. In most occlusions other than the PDA, this
creates little or no problem since the goal is to occlude the
entire channel. If the ﬁller wire extends back into a neces-
sary or vital feeding channel and cannot be “wadded”
back into the channel that is being occluded, the wire can
be captured with a vascular snare. The wire can be bent
back and forth repeatedly against the oriﬁce of the target
vessel and, in doing so, broken off from the more distal
wire, which is within the target vessel. If the wire cannot
be broken, the entire wire can be withdrawn from the sack
and out of the body. This, unfortunately, leaves the “sack”
empty and often destined to embolize to a more distal
location. Under these circumstances and before with-
drawing the wire completely out of the “sack”, the “sack”
should be grasped with a separate retrieval device and/or
the vessel distal to the “sack” selectively occluded with a
temporary occlusion balloon unless it is determined that
the more distal vessel is expendable if permanently
occluded with the embolized empty sack.

When undersized and/or in a very compliant vessel,
the entire, full “sack” can embolize distally from its
desired site in the abnormal channel. Occasionally this
merely occludes the desired channel in a different, but
still effective location. If, however, the embolized “sack”
migrates into the central or other vital areas of the circula-
tion, the embolized sack must be removed, which cannot
be accomplished as a full sack. First, the full bag is snared
to hold it in position. If the neck of the sack can be snared,
it should not be pulled with any force. Unusual tension on
the neck can detach the only radio-opaque part of the bag
itself!! Once the bag is grasped, a hole is “chewed” in the
bag with a bioptome forceps introduced from a separate
vessel and through a slightly larger sheath. Once a hole
is created in the full “sack”, loops of the packed ﬁller
wire usually will extrude immediately through the hole,
and/or while “chewing” the hole, a loose portion of the
ﬁller wire becomes exposed and is grabbed. The grasped
wire then is carefully withdrawn with the forceps while
the “sack” is held with the snare or other retrieval device.
The emptied bag is then withdrawn utilizing the device
that is holding the sack.
In spite of the disadvantages and rare complications,
the GGVOD™ has some very speciﬁc uses and it should
be available to any laboratory heavily engaged in thera-
peutic catheterizations.
Spring wire alone
The steel wire of a spring guide wire itself is thrombo-
genic. This property of the wire causes unwanted throm-
bosis on the wires within the blood stream and within

sheaths and catheters. Thrombosis on spring guide wires
represents a continual potential for embolic complications.
This same property of the wire can be used purposefully
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
677
to promote thrombosis and/or occlusion in very large
abnormal chambers (aneurysms) or channels, either alone
or packed on top of other occlusion devices. In order for a
spring guide wire to be used as a stimulant to thrombosis
and vascular occlusion, the wire should be capable of being
wadded into a fairly compact mass. Flexibility of the
wire is accomplished by removing the straight, stiffening
safety core wire(s) from inside of a standard stainless steel
spring guide wire. Once the safety core is removed from a
spring guide wire, the remaining spring wire becomes
very soft and can be compacted easily into a tight mass.
Once a guide wire has the core wire removed, several
meters of 0.025–0.038″ spring wire can be delivered into a
2–3 cm diameter space. Once packed within any conﬁned
area that has little or no ﬂow within it, such as a peduncu-
lated aneurysm, thrombosis and obliteration of the area
occur very effectively.
Like a “free-release” coil, long spring wires used in this
fashion cannot be retracted back into the delivery catheter
once the extrusion of the wire has started. If part of the
wire inadvertently protrudes out of the speciﬁc area being
“packed”, usually the loose end of the wire can be recap-
tured with a snare catheter and can be withdrawn com-
pletely if it cannot be positioned ideally.
Amplatzer™ Vascular Plug

The Amplatzer™ Vascular Plug (AGA Medical Corp.,
Golden Valley, MN) is the latest addition to the armamen-
tarium for the occlusion of abnormal vascular commun-
ications and is available even in the United States. This
unique device is still another modiﬁcation of the Nitinol™
wire weave or “basket-like” occlusion devices already in
common use for the occlusion of the patent ductus, atrial
septal defects, patent foramen ovale and ventricular sep-
tal defects. The Amplatzer™ Vascular Plugs are small,
cylindrical, Nitinol™ wire mesh “plugs”, which are avail-
able in various diameters, but have no ﬂanges or retention
disks at either end of the “plug”. The plugs are manufac-
tured of 144 strands of a ﬁner, 0.004″ Nitinol™ wire.
Unlike most of the other Amplatzer™ occlusion devices,
the vascular plugs have no polyester disks within them
and, in turn, rely on the ﬁne mesh of the Nitinol™ metal
mesh for occlusion of the vascular structure. Similar to
the other Amplatzer™ devices, the plugs do have similar
metal posts or markers at the center of each end of the
plug, with a female micro screw within the post at
the proximal end of the device. The female micro screw
allows attachment with an identical screw mechanism to a
standard Amplatzer™ delivery cable. The plugs achieve
their ﬁxation in the particular vessel by the tension against
the wall of the vessel by the expansion of the device
against the wall of the vessel/structure similarly to the
other Amplatzer™ devices.
The plugs are available in diameters from the smallest
of 4 mm increasing in 2 mm increments up to a maximum
of 16 mm in diameter. The 4–10 mm plugs are 7 mm long

while the 12–16 mm plugs are 8 mm in length. The ﬁner
metal wires and the lack of polyester disks allow the plugs
to be implanted through smaller delivery systems than
the comparably sized Amplatzer™ PDA and VSD occlu-
sion devices. The 4–8 mm diameter devices are delivered
through a 5-French, 0.056″ internal diameter sheath, the
10 & 12 mm devices through 6-French, 0.067″ internal
diameter sheaths and the 14 & 16 mm devices are deliv-
ered through 8-French, 0.088″ internal diameter sheaths.
The Amplatzer™ Vascular Plugs are usable for the
occlusion of multiple different venous and arterial struc-
tures, all of which, however, must have some “tubular”
conﬁguration. This includes residual Blalock–Taussig
type shunts, the tubular PDA, systemic to pulmonary
collaterals, systemic to pulmonary vein communications,
pulmonary arteriovenous ﬁstulae, and even some peri-
valvular leaks. The diameter of the plug that is used
should be 2–3 mm larger than the diameter of the lumen
that is to be occluded. The Amplatzer™ Plugs, like the
other Amplatzer™ devices, have the advantage of being
fully retrievable until they are purposefully released,
which makes a test occlusion with the device possible
before the operator is committed to releasing the plug.
In addition to “the tubular” characteristics of the lesion,
the use of the Amplatzer™ Vascular Plug depends upon
the ability to maneuver the delivery catheter into (and
past) the lesion that is to be occluded. The current deliv-
ery sheath along with the relatively stiff delivery cable
precludes the use of the plugs distally in very tortuous
locations, while, at the same time, the retrievability of the

plug allows its placement more proximally in tortuous
vessels where other non-controlled release devices would
be inappropriate.
PFM Nit-Occlud™ device for occlusion of abnormal
vascular channels
Although designed speciﬁcally for the occlusion of the
PDA, the Nit-Occlud™ device (PFM, Cologne, Germany)
is another effective tool for the occlusion of certain abnor-
mal vessels and vascular channels where precise control
over the release is an issue. The Nit-Occlud™ device
is discussed in detail for its use for PDA occlusion in
Chapter 27. Unfortunately, this device is only available
outside of the United States and in a limited clinical trial in
the US. Nit-Occlud™ devices are tightly wound coils of
Nitinol™ wire, which are pre-shaped to conform to sev-
eral different shapes of “typical” conical PDAs. Like its
predecessor, the Duct-Occlud™ device, the Nit-Occlud™
devices have no ﬁbers intertwined in their coil windings
to help promote thrombosis/occlusion. Nit-Occlud™
CHAPTER 26 Vascular occlusions—miscellaneous vessels, ﬁstulae
678
devices depend entirely on the tightness of the coil con-
ﬁgurations, the mass of Nitinol™ wire, and the thrombo-
genicity of the metal itself to occlude the vessels. The
precise control/release mechanism of the Nit-Occlud™
device makes it useful in situations in vascular channels
where a precise and very controlled positioning is essen-
tial. Like the bioptome control for the delivery of standard
stainless steel coils, the attach/release system for the Nit-
Occlud™ makes the delivery system somewhat stiffer

than the usual Gianturco™ type coil delivery catheters
which, in turn, makes these devices less useful for lesions
in more tortuous vessels and/or circuitous locations. Where
it is available outside of the US (and hopefully sometime
eventually in the US) the Nit-Occlud™ device should be
considered for the occlusion of larger and unusual and/or
abnormal vessels/vascular communications/leaks where
the placement of the occluder is very precarious.
Catheter delivered detachable vascular occlusion
balloons
Several types of detachable occlusion balloon were avail-
able around the world and even in the United States in the
past. Although still available in some locations around the
world, none of the detachable occlusion balloons are
available any longer in the US market.
B-D Mini-Balloon™
The B-D Mini-Balloon™ occlusion device (Becton Dickson
Co.) probably had the widest use in congenital heart
defects when it was available
12
. These were very tiny
occlusion devices. The balloons were 1 mm in diameter
when deﬂated and up to 5.3 mm in diameter when
inﬂated. They were delivered “hydraulically” by a unique
(and complex) delivery system. The deﬂated balloon came
attached to the tip of a very soft, ﬂexible, 1 mm diameter
delivery catheter. This catheter, with the attached deﬂated
balloon, was coiled into a spherical “delivery chamber”.
These delivery chambers were ﬂattened at two opposite
ends, giving the chamber the appearance of a toy “rotat-

ing top”. The delivery chamber had an inlet and outlet
port at the opposite ﬂatter ends of the chamber.
A larger, more maneuverable, guiding catheter, which
accommodates the 1 mm delivery catheter, is maneuvered
into the origin of the vessel to be occluded. The outlet port
of the delivery chamber which contained the delivery
catheter and attached balloon was attached to the prox-
imal end of the guiding catheter with a Lure-lock connec-
tion. By a rapid, forceful, hand ﬂush into an inlet port
in the chamber, the delivery catheter with the deﬂated
balloon attached at the tip was hydraulically forced into
and through the guiding catheter, and from there into the
vessel. The catheter with the deﬂated balloon actually
ﬂoated along with the ﬂow of the ﬂuid and blood in the
vessel. With this delivery technique, the tiny deﬂated bal-
loon and catheter would traverse almost any bend, curve
or loop throughout the course of the vessel. Usually the
catheter with the deﬂated balloon traveled completely
through the vessel to, or even past, the end of the vessel.
There was, however, no way to direct the course of the bal-
loon/catheter purposefully if there was a branch or bifur-
cation in the vessel. Once delivered, the ﬁne soft, delivery
catheter with the attached deﬂated balloon was with-
drawn slowly until the deﬂated balloon reached a position
precisely at the site within the vessel where the occlusion
was to occur.
The balloon then was inﬂated with a predetermined
amount of contrast solution, which was diluted to be
exactly isotonic. With this inﬂation and with the balloon
still attached, the degree of occlusion and, of more import-

ance, the tightness of the ﬁxation of the balloon within the
vessel were tested. If the balloon migrated distally and/or
did not ﬁx securely in a suitable position in the vessel, it
was deﬂated and withdrawn to a different more proximal
area or withdrawn completely. If the ﬁxation and occlu-
sion seemed satisfactory, then the balloon was further
inﬂated with several tenths of a ml more of the dilute
contrast, which, in turn, ﬁxed the balloon in place more
securely and occluded the vessel. The delivery catheter
was pulled away forcefully from and out of the “neck” of
the “ﬁxed” balloon, hopefully leaving the balloon in place.
The B-D Mini-Balloon™ had a self-sealing valve in the
neck of the balloon, which kept the balloon inﬂated after
the delivery catheter was pulled out of the valve. The iso-
tonic contrast within the balloon would neither leach in
nor out of the balloon, once the balloon was inﬂated in
position. Occasionally, even with this technique, the tiny
balloons would work loose and migrate (embolize) more
distallyausually with no consequences as long as they
remained in the same vessel. A 10 mm occlusion balloon
on a 2 mm diameter catheter, which was delivered with
the same system, was developed at about the time the
entire system/concept was abandoned.
The B-D Mini-Balloon™ had the capability of being able
to be delivered through very tortuous channels to other-
wise inaccessible locations. At the same time, the delivery
technique was quite complex and initially was difﬁcult
for many operators to master, so most operators would
choose an alternative device (coil) unless the location
mandated the use of the occlusion balloon. In addition,

because of the balloon material, these occlusion balloons
had a deﬁnite and relatively short (one year) shelf life
before the materials of the balloon deteriorated and
became unusable. There have been other detachable
“mini-balloons” used sporadically and in isolated cases
for the occlusion of congenital heart lesions, but like the
B-D Mini-Balloon™ they have been withdrawn from the

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