Evaluation of bail-out techniques for managing cerebral vessel perforation: An experimental study

Background Intracranial vessel perforation is a rare but life-threatening complication during endovascular neurointerventions. Despite several described bail-out strategies, there is no consensus on the most effective approach for rapid hemorrhage control. This study aimed to systematically compare common endovascular rescue techniques in a standardized experimental setting. Methods Patient-specific, 3D-printed vascular models of the anterior circulation were used to simulate standardized vessel perforations at two anatomical sites and three perforation sizes. The impact of the anterior communicating artery (AComA) crossflow was assessed. Proximal balloon guiding catheter inflation, local compliant balloon inflation, temporary coil deployment, and distal intermediate catheter insertion were evaluated against a non-intervention control. The primary outcome was the time it took for 50 ml of fluid extravasation to accumulate. Results As expected, extravasation time inversely correlated with perforation size ( ρ = –0.95, p < 0.001). Local balloon inflation at the rupture site most effectively halted leakage. Proximal balloon occlusion was only effective in the absence of an AComA crossflow ( p = 0.02). Temporary coil deployment modestly slowed bleeding, especially for small-to-moderate perforations. Distal intermediate catheter placement had no significant effect. Conclusion Managing iatrogenic intracranial vessel perforation is time-critical, as even a brief bleeding time can be fatal. The most effective hemostasis method is compliant balloon inflation at the rupture site. If unavailable, temporary parent artery coiling can reduce bleeding while maintaining perfusion, but it is less effective for larger perforations. Proximal balloon occlusion is only effective in the absence of collateral crossflow.