September 21, 2018
Here's an alternative method for preparing the percutaneous balloon compression apparatus. Please refer to the details on the accompanying chapter in the article. 15-gauge needles used to create the stab incision for the trocar. Typically, the ISOVUE contrast agent is used to fill the embolectomy Fogarty catheter balloon to assure correct location of the balloon within the Gasserian ganglion. Here is the 4 FR Fogarty embolectomy catheter. The stylet of the ventriculostomy catheter may be used to create the path for the balloon. However, I find its use rarely necessary. Here's the 14-gauge liver biopsy trocar with its stylet or needle. The needle typically goes way farther than the tip of the trocar. And we have to make sure to mark the stylet or the needle in the correct location, so the operator does not advance the needle too far beyond the tip of the trocar. So, we mark the location where the needle would be just barely beyond tip of the trocar and to assure the operator cannot advance the needle too far beyond the tip of the trocar. This areas was, is marked with Steri-Strips. So it creates a hurdle or obstruction for the needle to be advanced way beyond the tip of the trocar. Often, multiple pieces of Steri-Strips are necessary. Again, this creates that resistance point so that the needle does not advance too far beyond the tip of its trocar. As you can see where the needle sits, there's a locking mechanism, the Steri-Strips prevent advancement of the needle too far beyond the tip of the trocar, as you can see here, Similar technique is used to make sure that the balloon stays beyond the tip of the trocar and not being too close or too far away from it. Obviously, if the balloon is inflated and it's too close to the tip of the trocar, it would burst since the tip of the trocar is very sharp. Here, you can see the configuration and how far the balloon is beyond the tip of the trocar. Here's the final product. Now we have to make sure that all the air bubbles are removed from the volume of the contrast fluid. So when the balloons alone is inflated within the Gasserian ganglion, the accurate location of the balloon is assured. Here, you can see the 4-way stopcock, contrast agent is injected serially, and then removed from the balloon until the air bubbles are completely evacuated. You can see, there is some residual air bubbles in there and the syringe is elevated. So the air bubbles return to the syringe. The air bubbles are removed from the syringe, and again, cycle is repeated until all the air bubbles are removed from the balloon. The entire catheter is also filled with a contrast agent. Now the balloon appears to be nicely filled with only the contrast and not any significant air droplets. Here's the marking for the ventriculostomy stylet, so that this stylet can create adequate pathway, just enough so that the deflated Fogarty balloon can be inserted. And here you can see how far the stylet of the ventriculostomy catheter can it be advanced beyond the tip of the trocar Just enough, as far as the Fogarty catheter. Here's the complete set off instruments. Let's go ahead and put them to use. Here's the two and a half centimeter marking stab incision. The liver biopsy needle is now advanced into the Gasserian ganglion using standard techniques. You can see adequate location of the tip of the trocar within the Gasserian ganglion at the junction of the clivus and the petrous bone. It's not advanced too deeply. Here, you can see the Foramen Ovale using an AP view. Next, the locking mechanism is released and the needle is removed. The ventriculostomy stylet can be used to create the track for the balloon. Next, the Fogarty catheter is placed into the Gasserian ganglion and under life fluoroscopy. The balloon is inflated. You can see a adequate shape of the balloon and nice movement of the petrous ridge. I usually inflate the balloon with 0.6- 0.8 cc of contrast. In other words, I inflate the balloon until I feel some resistance to further injection of the contrast into the balloon. The balloon remains inflated for one and a half minutes and then is deflated. And the whole apparatus is removed. Here's the final step after one and a half minutes of balloon inflation, the balloon is deflated and the whole apparatus is removed in one piece. Thank you.
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