Early experience with a temporary bridging device (Comaneci) in the endovascular treatment of ruptured wide neck aneurysms

Treatment of Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage Using the Compliant Manually Adjustable Mesh Comaneci

Background and purpose: Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Compliant and noncompliant balloons and manually adjustable mesh may be used in this indication. We describe our initial experience with the Comaneci (Rapid Medical, Yokneam, Israel) in cerebral vasospasm treatment following aSAH. Methods: All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Comaneci device for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details, and outcomes were obtained from electronic medical records. Results: Between February 2022 and June 2023, seven consecutive patients underwent CV treatment with the Comaneci. Angioplasty of 37 arterial segments (supraclinoid internal carotid artery, A1, A2, and A3 segments of the anterior cerebral artery and M1 and M2 segments of the middle cerebral artery) was attempted, and 35/37 (95%) were performed. The vessel diameter improved significantly following angioplasty (+64%), while brain hypoperfusion decreased (-45% of the mean T Max). There was no long-term clinical complication, and 6% per-procedural complications occurred. Conclusions: The Comaneci is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device in the armamentarium of the neurointerventionalist to perform intracranial angioplasty.

Endovascular Treatment of Wide-Neck Bifurcation Aneurysm: Recent Trends in Coil Embolization with Adjunctive Technique

Wide-neck bifurcation aneurysms (WNBAs) are sometimes challenging to treat. During endovascular treatment, it is important to prevent coil deviation and preserve normal vessels. Adjunctive balloon- and stent-assisted techniques have been developed. A meta-analysis of endovascular treatments of WNBAs revealed that only 40% of patients had complete occlusion. Recently, novel devices have been developed to expand the range of treatment options. Flow-diverter stents and intra-aneurysmal flow disruption devices do not require coils; however, coil embolization remains the standard procedure used by many neurointerventionists. This review describes the recent trends in adjunctive techniques for supporting coil embolization for WNBAs. We referred to literature on balloon-assisted techniques, stent-assisted techniques, Y-stenting, PulseRider, Barrel stents, Comaneci temporary stents, pCONUS, and eCLIPs. These reports showed that adequate embolization rates were generally greater than 80%, and the complete occlusion rate was as high as 94.6%. All devices had a relatively high occlusion rate; however, it may be inaccurate to simply compare each device because of the heterogeneity of the studies. It is important to select the best treatment for each individual case by considering not only literature-based efficacy and safety but also patient background, aneurysm characteristics, and operator experience.

Comaneci-assisted coiling of a right posterior communicating artery aneurysm: an unusual case of coil retention

Although endovascular embolization has become the main treatment option for intracranial aneurysms,1 2 wide-necked intracranial aneurysms remain difficult to coil.3 Both stent- and balloon-assisted coiling are used for wide-necked aneurysms because they provide a scaffold that protects the parent vessel during coiling.4 5 However, stent-assisted coiling requires dual antiplatelet therapy, which increases the risk of bleeding, whereas balloon-assisted coiling temporarily obstructs blood flow.4 6 7 The Comaneci device (Rapid Medical, Yokneam, Israel) has recently received US Food and Drug Administration approval as a 'temporary coil embolization assist device'.5 It temporarily covers the aneurysm neck and allows safe coiling, avoiding the disadvantages mentioned above.6-8 A potential complication of Comaneci-assisted coiling is coil retention when it adheres to the device on recapture; this complication should be promptly recognized and managed.5 9 10 In this video, we present an unusual case of coil retention with the Comaneci device (Video 1). neurintsurg;15/12/1286/V1F1V1Video 1 .

Endovascular treatment of wide-necked intracranial aneurysms using the Nautilus Intrasaccular System: initial case series of 41 patients at a single center

BACKGROUND

Endovascular treatment of intracranial wide-necked and bifurcation aneurysms (WNBA) is technically challenging. The Nautilus Intrasaccular System is designed to provide a mechanical barrier at the aneurysm neck to support coil embolization. We report the results of a single-center series of patients treated for intracranial aneurysms with the Nautilus.

METHODS

Clinical and radiological data were retrospectively collected for all patients treated with the Nautilus for an unruptured or ruptured intracranial aneurysm at our center between March 2021 and March 2022. Clinical outcomes (modified Rankin Scale (mRS) scores), Raymond-Roy angiographic occlusion, recanalization, and complications were measured immediately post-procedure and at 3-6-month follow-up.

RESULTS

A total of 41 patients of mean age 56.7 years (range 37-83 years) were treated with the Nautilus, with 41 saccular aneurysms (18 (43.9%) unruptured and 23 (56.1%) ruptured). The majority of aneurysms (39/41 (95.1%)) were located in the anterior circulation. We experienced no technical complications. One patient had an asymptomatic post-procedural minor stroke related to the procedure. Immediate Class I occlusion was achieved in 30 (73.1%) patients. The rate of all-cause mortality was 7.3% (3/41). One patient was lost to follow-up. At follow-up, 94.5% (35/37) of patients achieved Class I occlusion and 94.5% (35/37) had an mRS score of 0. There were no procedural-related deaths or permanent morbidities at discharge or follow-up.

CONCLUSION

This study demonstrates good safety and effectiveness using the Nautilus Intrasaccular System to treat both ruptured and unruptured intracranial aneurysms. Larger studies are needed to confirm these findings.

A systematic review and meta-analysis of Comaneci/Cascade temporary neck bridging devices for the treatment of intracranial aneurysms

Background

The temporary neck bridging devices represented by Comaneci and Cascade are a type of promising endovascular device for the treatment of intracranial bifurcation or wide-necked aneurysms. This systematic review and meta-analysis aim to assess the efficacy and safety of Comaneci/Cascade devices for the treatment of intracranial aneurysms.

Methods

We performed a systematic literature search on articles in PubMed, Embase, and Web of Science that evaluated the efficacy and safety of Comaneci/Cascade devices for endovascular treatment of intracranial aneurysms, based on the Preferred Reporting Items for Systematic Reviews and Meta Analytics (PRISMA) guideline. We extracted the characteristics and treatment related information of patients included in the study, recorded the rate of technical success, procedural related complications, and angiographic outcomes. The angiographic outcome was evaluated based on Raymond Roy classification, and adequate occlusion was defined as Raymond Ray I + II.

Results

Nine studies comprising 253 patients with 255 aneurysms were included. Among them, eight studies were conducted in Europe, one study was conducted in the USA. All these studies were retrospective. 206 aneurysms (80.78%) were ruptured. The vast majority of patients with ruptured aneurysms did not receive antiplatelet therapy. The rate of technical success was 97.1% (95% CI, 94.9 to 99.3%, I2 = 0%). The rate of periprocedural clinical complications was 10.9% (95% CI, 5.4 to 22.1%, I2 = 54%). The rate of complete occlusion (RR1) and adequate occlusion (RR1 + RR2) on immediate angiography after the procedure were 77.7% (95% CI, 72.7 to 83.2%, I2 = 35%) and 98% (95% CI, 95.9 to 100%, I2 = 0%) respectively. The rate of complete occlusion (RR1) and adequate occlusion (RR1 + RR2) on the last follow-up angiography were 81.2% (95% CI, 69.2 to 95.2%, I2 = 81%) and 93.7% (95% CI, 85.6 to 100%, I2 = 69%) respectively, with follow-up range from 3 to 18 months. 22/187 (11.76%) cases of aneurysms progressed during the follow-up period. 39/187 (20.86%) cases of aneurysms received additional treatment during the follow-up period. No fatal complications occurred during the treatment.

Conclusion

The Comaneci/Cascade device can be used as an auxiliary treatment for intracranial aneurysms, with a good occlusion effect, but the incidence of complications still needs to be monitored.

Coiling Variations for Treatment of Ruptured Intracranial Aneurysms: A Meta-Analytical Comparison of Comaneci-, Stent-, and Balloon-Coiling Assistance Techniques

BACKGROUND

Wide-necked aneurysms represent a challenge for treatment in the setting of acute subarachnoid hemorrhage. Stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) are well-known techniques for treating wide-necked aneurysms. Comaneci-assisted coiling (CAC) is a newer technique involving temporary stent deployment to assist aneurysm coiling. We aim to present the first meta-analysis comparing these treatments of ruptured aneurysms.

METHODS

Following PRISMA guidelines, PubMed and Embase databases were queried from earliest records to July 2022 for literature reporting SAC, BAC, or CAC of ruptured intracranial aneurysms. A meta-analysis of identified articles was performed.

RESULTS

Of the 571 articles queried, 64 articles were included. One study reported BAC and SAC, 8 reported BAC, 52 reported SAC, and 3 reported CAC. These studies comprised 3153 patients with 3207 ruptured aneurysms treated with CAC (161 patients and aneurysms), BAC (330 patients and aneurysms), and SAC (2662 patients, 2716 aneurysms). Rates of periprocedural thromboembolic or hemorrhagic complications, overall or procedure-related mortality, immediate complete occlusion, retreatment, and length of angiographic follow-up did not differ significantly between SAC and BAC. Periprocedural thromboembolic (P = 0.03) and hemorrhagic (P = 0.01) complication rates were higher with BAC than CAC. Periprocedural thromboembolic (P = 0.03) and hemorrhagic (P < 0.0001) complication rates were higher with SAC than CAC. Complete aneurysm occlusion rates (P = 0.033) were higher with CAC than BAC. No significant differences were present in CAC versus BAC or SAC retreatment rates.

CONCLUSIONS

CAC was associated with lower hemorrhagic and thromboembolic complication rates and demonstrated similar complete occlusion and residual retreatment rates to those for BAC and SAC.

Endovascular Therapy Versus Microsurgical Clipping of Ruptured Wide Neck Aneurysms (EVERRUN Registry): a multicenter, prospective propensity score analysis

OBJECTIVE

Randomized controlled trials have demonstrated the superiority of endovascular therapy (EVT) compared to microsurgery (MS) for ruptured aneurysms suitable for treatment or when therapy is broadly offered to all presenting aneurysms; however, wide neck aneurysms (WNAs) are a challenging subset that require more advanced techniques and warrant further investigation. Herein, the authors sought to investigate a prospective, multicenter WNA registry using rigorous outcome assessments and compare EVT and MS using propensity score analysis (PSA).

METHODS

Untreated, ruptured, saccular WNAs were included in the analysis. A WNA was defined as having a neck ≥ 4 mm or a dome/neck ratio (DNR) < 2. The primary outcome was the modified Rankin Scale (mRS) score at 1 year posttreatment, as assessed by blinded research nurses (good outcome: mRS scores 0-2) and compared using PSA.

RESULTS

The analysis included 87 ruptured aneurysms: 55 in the EVT cohort and 32 in the MS cohort. Demographics were similar in the two cohorts, including Hunt and Hess grade (p = 0.144) and modified Fisher grade (p = 0.475). WNA type inclusion criteria were similar in the two cohorts, with the most common type having a DNR < 2 (EVT 60.0% vs MS 62.5%). More anterior communicating artery aneurysms (27.3% vs 18.8%) and posterior circulation aneurysms (18.2% vs 0.0%) were treated with EVT, whereas more middle cerebral artery aneurysms were treated with MS (34.4% vs 18.2%, p = 0.025). Within the EVT cohort, 43.6% underwent stand-alone coiling, 50.9% balloon-assisted coiling, 3.6% stent-assisted coiling, and 1.8% flow diversion. The 1-year mRS score was assessed in 81 patients (93.1%), and the primary outcome demonstrated no increased risk for a poor outcome with MS compared to EVT (OR 0.43, 95% CI 0.13-1.45, p = 0.177). The durability of MS was higher, as evidenced by retreatment rates of 12.7% and 0% for EVT and MS, respectively (p = 0.04).

CONCLUSIONS

EVT and MS had similar clinical outcomes at 1 year following ruptured WNA treatment. Because of their challenging anatomy, WNAs may represent a population in which EVT's previously demonstrated superiority for ruptured aneurysm treatment is less relevant. Further investigation into the treatment of ruptured WNAs is warranted.

Comaneci plus Balloon-assisted Embolization of Ruptured Wide-necked Cerebral Aneurysms

BACKGROUND AND PURPOSE

Recently, avant-garde combinations of ancillary devices as an adjunct to coil embolization for acutely ruptured and wide-necked cerebral aneurysms have emerged. This study sought to investigate the feasibility, safety and durability of the simultaneous combination of temporary neck-bridging devices plus balloon-assisted coiling (BAC) to treat acutely ruptured and wide-necked cerebral aneurysms.

METHODS

A retrospective review was performed of patients with ruptured and wide-necked intracranial bifurcation aneurysms treated with temporary stent plus balloon-assisted coiling. Anatomical features, technical details, intraprocedural complications, clinical and angiographic results were reviewed. Preprocedural and follow-up clinical statuses were evaluated using the modified Rankin scale (mRS).

RESULTS

A total of 21 patients (mean age 54.5 years, range 37-72 years) were identified. The immediate postprocedural angiography revealed complete aneurysm occlusion in 85.7% (18/21) of the cases. A periprocedural complication developed in 9.5% of the cases. There was no mortality in this study. The permanent morbidity rate was 4.7%. Long-term follow-up angiography was performed in 18 of 21 patients (85.7%) (the mean follow-up period was 21 months). The rate of complete aneurysm occlusion at final follow-up was 89.4%.

CONCLUSION

The results of this study confirmed that temporary stent plus balloon-assisted coiling is a durable and relatively safe endovascular technique for the treatment of ruptured wide-necked bifurcation aneurysms located in both the posterior and anterior cerebral circulation.

Comprehensive review of the recent advances in devices for endovascular treatment of complex brain aneurysms

The International Subarachnoid Aneurysm Trial (ISAT) showed superiority for endovascular treatment of ruptured aneurysms and technology has since moved on rapidly. Many approaches and technology now exist for the endovascular management of ruptured and unruptured intracranial aneurysms, which reflects their varied nature - there is no one-size-fits-all technique. We aim to provide an overview of the various classes of device and the major developments over the past decade. Coiling is the oldest of the technology and continues to demonstrate high levels of occlusion and acceptable risks, making it the default treatment choice, particularly in the acutely ruptured aneurysm setting. Advances on coiling include the use of adjuncts such as balloons, stents and fully retrievable temporary neck-bridging devices, which have facilitated the treatment of more complex aneurysms. Flow divertors have also revolutionised complex aneurysm treatment with small added risk in acute aneurysm treatment and seek to remodel the aneurysm-vessel interface without accessing the aneurysm sac. The latest development and most promising avenue appears to be intrasaccular flow disrupting devices like WEB, Contour and Neqstent that provide excellent opportunities to treat wide neck complex aneurysm with minimal mortality and morbidity and good occlusion rates and may in future replace a significant number of stent-assisted coiling too.

Early Experience with Comaneci, a Newly FDA-Approved Controllable Assist Device for Wide-Necked Intracranial Aneurysm Coiling

BACKGROUND

Comaneci (Rapid Medical) is a compliant, adjustable mesh that provides temporary scaffolding during coiling of wide-necked intracranial aneurysms (WNAs) that preserves antegrade flow. We report our early multi-institutional experience with the Comaneci device in the USA.

METHOD

We reviewed all patients with WNAs that were treated using the Comaneci device for coil remodeling of ruptured and unruptured aneurysms at 4 institutions between July 2019 and May 2020. Clinical characteristics, angiographic variables, and endovascular results were assessed.

RESULTS

A total of 26 patients were included (18 women). The mean age was 62.7 years (range 44-81). Fifteen patients presented with ruptured aneurysms and 11 with unruptured aneurysms. The mean aneurysm neck width was 3.91 mm (range 1.9-6.5) with a mean dome-to-neck ratio of 1.57 (range 0.59-3.39). The mean maximum width was 5.80 mm (range 3.0-9.9) and the mean maximum height was 5.61 mm (range 2.0-11.8). Successful aneurysm occlusion was achieved in 25 of 26 patients. Complete occlusion was achieved in 16 patients, near-complete occlusion was observed in 9 patients, and 1 patient demonstrated residual filling. The mean time of device exposure was 24 min (range 8-76). No vasospasm was observed at the device location. Clot formation on the device was noted in 2 separate cases, but there were no clinical sequelae. There was 1 intraprocedural complication in a case that involved the simultaneous use of 2 Comaneci devices.

CONCLUSIONS

Our initial experience shows that the Comaneci device is a promising and reliable tool that can safely support coil remodeling of WNAs.

Comaneci Device for Temporary Coiling Assistance for Treatment of Wide-Necked Aneurysms: Initial Case Series and Systematic Literature Review

BACKGROUND

Coiling of wide-necked aneurysms requires high-density packing of coils within the aneurysm, which necessitates adequate microcatheter access and navigability. The Comaneci device, introduced in the United States in 2019, is a retrievable stent that can be used as an adjunct to coiling of a wide-necked aneurysm without limiting flow. We present a case series and systematic review of use of this device.

METHODS

All cases involving use of the device at our institute between May 1, 2019, and April 30, 2020, were reviewed. A comprehensive systematic review of the literature was conducted using PubMed and EMBASE and a review of eligible article bibliographies.

RESULTS

Five patients underwent Comaneci-assisted wide-necked aneurysm coiling during the study period; 4 were treated via a radial artery approach, and 1 was treated via a femoral artery approach. Two patients presented with subarachnoid hemorrhage: 1 had a ruptured posterior inferior cerebellar artery aneurysm (Hunt-Hess 5, Fisher 4), and 1 had a ruptured middle cerebral artery aneurysm (Hunt-Hess 2, Fisher 1). Mean aneurysmal neck size was 4.4 ± 0.8mm; mean aspect ratio was 1.2 ± 0.3. Raymond-Roy 1 occlusion was achieved in all aneurysms except the posterior inferior cerebellar artery aneurysm. Systematic literature review identified 4 articles that found use of the Comaneci device to treat wide-necked aneurysms to be effective.

CONCLUSIONS

This device can be used with transfemoral and transradial approaches, allowing for continued flow through the parent vessel during the coiling procedure while providing a scaffold for dense coiling of the aneurysm and its neck.

Comaneci device-assisted embolization of wide-necked carotid aneurysms with an unfavorable ratio

Background

Endovascular treatment is the technique of choice for most intracranial aneurysms. However, the treatment of morphologically complex wide-necked aneurysms with an unfavorable anatomy is still a therapeutic challenge.

The purpose of the study is to describe the initial experience with the Comaneci embolization assist device for the treatment of wide-necked aneurysms with an unfavorable ratio for direct embolization.

Methods

We report a retrospective single-center analysis taken from a prospective database of consecutive aneurysms of the anterior circulation treated using the Comaneci device in the period from March 2017 to March 2019.

Results

Eighteen aneurysms were collected from 16 patients (9 women and 7 men) treated using the Comaneci device. The mean age was 48.4 years (range 36–81). Twelve patients had SAH, three were incidental aneurysms and one had compressive symptoms. A complete asymptomatic occlusion rate of 88.8% was obtained. The major complication rate was 5.55%.

Conclusion

The Comaneci embolization assist device is a safe, effective option for endovascular treatment of complex aneurysms with an unfavorable ratio.

Treatment of cerebral vasospasm secondary to subarachnoid hemorrhage utilizing the Comaneci device

Delayed cerebral ischemia due to vasospasm following subarachnoid hemorrhage continues to have high morbidity and mortality despite current treatments. This report highlights the use of the Comaneci (Rapid Medical, Yokneam, Israel), a device FDA approved for temporary coil embolization assistance, for the treatment of symptomatic vasospasm. Ten days post subarachnoid hemorrhage, a patient developed acute left-sided hemiparesis with angiographic vasospasm. Through a Headway 17 microcatheter, a Comaneci 17 was deployed in the right ICA terminus, M1, M2, A1, and, A2 segments resulting in improvement of angiographic vasospasm and the patient's left-sided hemiparesis. On the following day, a repeat angiogram demonstrated no recurrence of vasospasm. The patient had complete return on neurologic function by post bleed day 18 continuing to her four-week follow-up appointment. This case demonstrates the feasibility of the Comaneci device as an effective tool in the treatment of vasospasm following subarachnoid hemorrhage.

Endovascular treatment of patients with intracranial aneurysms: feasibility and successful employment of a new low profile visible intraluminal support (LVIS) EVO stent

BACKGROUND AND PURPOSE

Low-profile self-expandable stents have increased the number of intracranial aneurysms treated by endovascular means. The new low-profile visible intraluminal support device LVIS EVO (Microvention), the successor of LVIS Jr, is a self-expandable and retrievable microstent system, designed for implantation into intracranial arteries with a diameter up to 2.0 mm. In this retrospective study we aimed to elucidate the technical feasibility and clinical safety of the novel LVIS EVO stent for stent-assisted coil embolisation of intracranial aneurysms.

MATERIALS AND METHODS

A single centre technical report of the first six consecutive cases of stent-assisted coil embolisation with the novel LVIS EVO stent for the treatment of unruptured or recanalised intracranial aneurysms. Records were made of basic demographics, aneurysmal characteristics, device properties and related technical details, adverse events, clinical outcomes and occlusion rates on available radiological follow-up.

RESULTS

Six LVIS EVO devices were successfully implanted in all subjects to treat a total number of six intracranial aneurysms. No device-related intraprocedural complications were seen. At early clinical follow-up six out of six (100%) patients had a modified Ranking score of 0-1. Early angiographic and cross-sectional radiological follow-up, available in five out of six (83.3%) of the patients confirmed unchanged aneurysmal occlusion rates. A minor, transitory neurological deficit was recorded in one of the six (16.6%) patients. Mortality was 0%.

CONCLUSIONS

Preliminary experience in this subset of our patients confirms a notably improved technical behaviour of the novel LVIS EVO stent system when compared to its ancestor LVIS Jr. The enhanced visibility of the stent and the refined delivery/retrieval capabilities of the stent further increase the safety margins of the devices profile, especially in cases of tortuous anatomy.

Acutely ruptured basilar artery bifurcation aneurysm, treated with simultaneous Cascade and Comaneci temporary-assisted coiling

Temporary stent-assisted coiling is an eligible approach for the treatment of acutely ruptured complex cerebral aneurysms. Improved material properties and industrial advances in braiding technology have led to the introduction of new stent-like devices to augment endovascular coil embolization. Such technology includes the Cascade and Comaneci neck-bridging devices. Both devices are manually controlled, non-occlusive and fully retrievable neck-bridging temporary implants. The braided nature and the ultra-thin wire, compliant structure of their bridging meshes helps maintain target vessel patency during coil embolization. In this video (video 1) we demonstrate the straightforward combination of two temporary neck-bridging devices for the embolization of an acutely ruptured aneurysm of the basilar artery. Technical success and complete embolization of the aneurysm were recorded at the final angiography. In this technical video we discuss the technical nuances of the Comaneci and Cascade coil embolization. neurintsurg;13/2/196/V1F1V1Video 1.

The Comaneci Device for Entering an Acute-Angled Small Feeder during Cerebral Arteriovenous Malformation Embolization: A Novel Technique to Support Microcatheterization

In this report, we describe the use of the Comaneci device to support microcatheterization in a small branch arising from a parent artery during embolization. In 2 cases, arteriovenous malformations presented with intracranial hemorrhage. A microcatheter was navigated into a small feeder while the Comaneci device was deployed just distal to the feeder with an acute angle from the parent artery. Our technical note represents an alternative option of catheterization in cases with difficult access to small feeders originating from higher flow arteries at a sharp angle while maintaining continuous flow in the parent artery.

Recent advances in stent-assisted coiling of cerebral aneurysms

INTRODUCTION

Stent-assisted coiling (SAC) of intracranial aneurysms paved the way for endovascular coiling of wide-neck and bifurcation aneurysms, improving rates of aneurysm obliteration and recurrence. In this review, we provide a comprehensive review of the most recent advances related to stent-assisted coiling of intracranial aneurysm.

AREAS COVERED

The authors have made an attempt to cover the inception, applications, and limitations of SAC of intracranial aneurysms. Special focus is given to 1) the current and recently introduced SAC techniques, 2) most recent advances in device technology, and 3) outcome data for the discussed techniques and devices. The authors also discuss the potential future direction of SAC.

EXPERT OPINION

technical refinements in the field of SAC should continue to focus on device development and addressing the limitations of SAC, namely aneurysm recurrence and need of antiplatelet agents. Although the recurrence rate of SAC has not been shown to be inferior to flow diverters, the use of intrasaccular and intravascular flow diverters are likely to expand in the future at the expense of SAC.

The Cascade device - In vitro tests to assess coil protrusion into the parent vessel

BACKGROUND

Balloon and stent-assisted coiling of aneurysms have increased the number of aneurysms available for endovascular treatment. Newer devices that allow flow within the parent vessel but coverage at the neck have recently entered the market. The Cascade is a new non-occlusive fully retrievable neck-bridging support device that has been designed to provide temporary support during coil embolisation of intracranial aneurysms.

METHODS

Using a silicone aneurysm model three different aneurysms were catheterised with the coiling microcatheter placed in three different positions within each aneurysm - at the neck, centrally, and looped within the aneurysm. Multiple different coils were then deployed within each aneurysm with the Cascade device deployed across the neck to provide protection. In total 480 attempted coilings were performed. Aneurysm flow was used to calculate the change in intra-aneurysmal flow with the Cascade device deployed across the neck of the aneurysm.

RESULTS

We did not observe a single episode of coil protrusion through the Cascade mesh nor did we observe any coil protrusion into the parent vessel when the Cascade was deployed across the neck. There was an average flow velocity reduction of 23% with the Cascade device deployed across the neck of the aneurysm.

CONCLUSION

The Cascade device offers robust protection of the aneurysmal neck and parent vessel as well as inducing significant intra-aneurysmal flow velocity reduction.

Advances in endovascular aneurysm management: coiling and adjunctive devices

Endovascular coil embolisation continues to evolve and remains a valid modality in managing ruptured and unruptured cerebral aneurysms. Technological advances in coil properties, adjunctive devices and interventional techniques continue to improve long-term aneurysm occlusion rates. This review elaborates on the latest advances in next-generation endovascular coils and adjunctive coiling techniques for treating cerebral aneurysms.

Early clinical experience with Cascade: a novel temporary neck bridging device for embolization of intracranial aneurysms

Background

Temporary placement of a retrievable neck bridging device, allowing parent vessel flow, is an attractive alternative to balloon remodeling for treatment of ruptured intracranial aneurysms.

Objective

To present, in a single-center study, our initial experience with Cascade (Perflow, Israel) in the treatment of ruptured intracranial aneurysms.

Methods

During a period of 1.5 months, 12 patients with aneurysmal subarachnoid hemorrhage underwent coil embolization in conjunction with Cascade in our center. Retrospective analysis of prospectively collected angiographic and clinical data was conducted to assess the safety and efficacy of the device.

Results

Among all treated patients, 41.7% (5/12) were female, the median age was 55 (47–77) years, the median aneurysm dome size was 5.75 mm (3–9.1), and the median neck size was 3.55 mm (2.3–7.9). Complete obliteration (Raymond 1) was achieved in 75% (9/12) of cases, and intentional residual neck (Raymond 2) was left in three cases (25%). None of the patients received any oral or intravenous antiplatelet therapy perioperatively. No thromboembolic complications, device-related spasm, vessel perforation, or coil entanglement were detected in any of the treated patients.

Conclusions

In our initial experience, treatment of wide-neck ruptured intracranial aneurysms with Cascade is safe and effective, without the need for adjuvant antiplatelet therapy. Long-term follow-up data in larger cohorts are needed to confirm these preliminary findings.

Coiling of ruptured, wide-necked basilar tip aneurysm using double Comaneci technique

In this report, we present a novel technique of successful coil embolisation using temporary deployment of two Comaneci devices placed in Y configuration across a wide-neck ruptured basilar tip aneurysm. The placement of two devices across the wide aneurysm neck allowed optimal coverage for safe coil delivery, while maintaining parent vessel patency. This case highlights the unique and safe applicability of two crossed Comaneci devices in a ruptured aneurysm with unfavourable anatomy, ultimately resulting in complete aneurysm obliteration. To our knowledge, this is the first reported case of double Comaneci usage in a wide-neck ruptured aneurysm. This technique can be potentially applied in challenging wide-neck bifurcation aneurysms, particularly when double antiplatelet therapy is of concern.