Y-Stent-Assisted Coiling of Wide-Neck Bifurcation Intracranial Aneurysms: A Meta-Analysis

Low-Profile Visualized Intraluminal Support Device for Y-Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms: A Single-Center Experience

BACKGROUND

The Low-Profile Visualized Intraluminal Support (LVIS) device has been frequently used as an intracranial stent for treating intracranial aneurysms. However, the feasibility and efficacy of LVIS devices in Y-stent-assisted coiling (Y-SAC) have remained contentious. This study aimed to evaluate long-term angiographic and clinical outcomes of Y-SAC using LVIS devices.

METHODS

We retrospectively reviewed the clinical presentation and angiography data of patients treated with Y-SAC using LVIS stents. The vascular angle geometry between the parent and the 2 branch vessels, before and after stent deployment and after coiling, were analyzed. Based on the Raymond-Roy Occlusion Classification (RROC), aneurysm occlusion status was classified. Clinical outcomes were assessed using the modified Rankin Scale.

RESULTS

Forty patients with 40 aneurysms were included in this study. Immediate postprocedural angiograms showed complete/near-complete occlusion (RROC 1 and 2) in 31 aneurysms (77.5%). The long-term follow-up angiographic studies were available in 32 patients and showed RROC class 1 and 2 in 93.8% of patients. Y-SAC with LVIS devices significantly decreased the angle between the bifurcation branches from 171.90° ± 48.0° (standard deviation) to 130.21° ± 46.3° (standard deviation) (P < 0.0001). Periprocedural complications occurred in 5 patients (12.5%) including 4 in-stent thromboses (10.5%). Thirty-six patients (90.0%) had favorable clinical outcomes at the final follow-up. Univariate analysis showed that World Federation of Neurological Societies grade 3-5, thickness of subarachnoid hemorrhage on head computed tomography, intraprocedural complications, and in-stent thrombosis were predictors of poor outcome.

CONCLUSIONS

Y-SAC using the LVIS device for intracranial bifurcation aneurysms is a feasible and relatively safe procedure with favorable long-term angiographic and clinical outcomes.

A core-lab adjudicated analysis of single-stent assisted coiling of wide-neck bifurcation aneurysms

BACKGROUND AND PURPOSE

Core-lab adjudicated data regarding the efficacy of the single-stent assisted aneurysm coiling technique 'L-stenting' are lacking. We present a multicenter, core-lab adjudicated study evaluating the safety and effectiveness of single-stent assisted coiling in the treatment of wide-neck bifurcation aneurysms (WNBAs).

METHODS

Consecutive patients who underwent L-stenting for WNBAs at three academic institutions between 2015 and 2019 were included in this retrospective study. Clinical safety and efficacy outcomes were gathered from the patient chart, and angiographic imaging was evaluated by core lab analysis. Safety and efficacy outcomes were summarized and predictors of safety and efficacy were calculated.

RESULTS

Of 128 patients treated, 124 had angiographic outcome data at last follow-up. Of those, 110 had adequate (core-lab adjudicated modified Raymond Roy (mRR) score of 1 or 2) occlusion (88.7%). During follow-up, 19 patients (14.8%) required retreatment. There were 17 complications experienced in 12 patients: intraoperative (n=8, 6.25%), perioperative (n=5, 3.9%), or delayed (n=6; n=4 attributed to device/procedure, 3.1%). Significant predictors of complete occlusion were smaller aneurysm size and use of the jailing technique (P=0.0276). Significant predictors of retreatment were larger size, neck size, and larger dome to neck ratio (P=0.0008).

CONCLUSION

This study provides multicenter, core-lab adjudicated angiographic data regarding the efficacy of single-stent assisted coiling for WNBAs. This study acts as a validated comparator for future studies investigating novel devices or techniques for treating this challenging subgroup of aneurysms.

Efficacy and safety of low profile stents in Y-stent assisted coil embolization of wide-necked bifurcation aneurysms: a systematic review and meta-analysis

Low-profile stents may provide significant advantages in Y-stent-assisted coiling due to their miniaturized design and capability to be delivered through a 0.0165-inch microcatheter. We aim to investigate the safety and efficacy of using these newer versions of stents in Y-stent-assisted coiling for the treatment of wide-necked bifurcation aneurysms. We conducted a systematic review of the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2023, following the PRISMA guidelines. Eligible studies included  ≥ 5 patients with intracranial wide-necked bifurcation aneurysms treated with Y-stent-assisted coiling using low-profile stents, providing angiographic and clinical outcomes. Two authors independently handled the search and selection. Primary outcomes were immediate and follow-up aneurysm occlusion, procedure-related complications, aneurysm recanalization, and retreatment. Secondary outcomes included technical success, procedure-related morbidity, procedure-related mortality, procedure-related stroke, and in-stent stenosis at follow-up. We analyzed the data using random-effects meta-analysis. In total, 19 studies including 507 patients with 509 aneurysms were included. 95% of the treated aneurysms were managed using the crossing Y-configuration. Technical success rate was 99%. Immediate adequate aneurysm occlusion was 90%. Follow-up angiographies were available for 443 aneurysms. The mean angiographic follow-up duration was 15.6 ± 1.9 months. The rates for follow-up adequate aneurysm occlusion and complete occlusion were 98% and 89%, respectively. After a mean clinical follow-up of 15 ± 2.4 months, a good clinical outcome was observed in 98% of patients. Overall, procedure-related morbidity and mortality rates were 1.3%, and 0.4%, respectively. Low-profile stents in Y-stent-assisted coiling outperform previous stent versions in terms of safety, efficacy, and technical success rates.

Endovascular Treatments for Aneurysms Involving a Major Branch

Remarkable advances have been made in the endovascular treatment of intracranial cerebral aneurysms. These advances include various adjunctive techniques, increased indications for endovascular treatment, and improved treatment results. Furthermore, the number of cerebral aneurysm treatments using flow diverters (FDs) is expected to increase. However, the reported long-term rate of branch artery occlusion after FD treatment has been reported is 15.8%. Moreover, the complete aneurysm obliteration rate is low if normal branches arise from an aneurysm neck or dome. Flow diverter placement for ophthalmic artery, posterior communicating artery, and anterior choroidal artery aneurysms is often difficult because these normal branches often arise from the aneurysm neck or dome. Therefore, in many cases, coil embolization, which can occlude the aneurysm while preserving branch vessels, should be selected. Although not yet established, various adjunctive techniques and other endovascular treatments that can be performed safely have been reported. Treatment must be planned after understanding the advantages and disadvantages of each treatment method.

A new era in the treatment of wide necked bifurcation aneurysms: Intrasaccular flow disruption

Wide-necked bifurcation aneurysms (WNBAs) are challenging lesions to treat via both open surgical and endovascular techniques. Presently, there are 3 intrasaccular devices available to address many of the limitations of prior techniques, all of which are at different phases of approval for human use around the world. These devices include the Woven EndoBridge (WEB®) made by MicroVention, the Artisse™ Embolization Device made by Medtronic, and the Contour Neurovascular System™ made by Cerus Endovascular. Although heterogenous in design, these devices rely on the principle of using fine mesh overlying the aneurysm neck to slow blood inflow, promoting stagnation and thrombosis that ultimately leads to healing across the neck and exclusion from the circulation. While our understanding improves as long-term occlusion rates from these devices continue to be studied, the safety profiles and short-term success rates demonstrated in recent studies provide optimism for these innovative intrasaccular devices for the treatment of WNBAs. In this paper, we review these 3 intra-saccular flow disruption devices for use in WNBAs and summarize recent literature and studies of their effectiveness and safety.

The Safety and Efficacy of eCLIPs for Treatment of Wide-Necked Bifurcation Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND

Wide-necked bifurcation aneurysms (WNBAs) are challenging intracranial aneurysms. Several device and treatment approaches have been proposed for the treatment of WNBAs. The endovascular clip system (eCLIPs) is a newly developed endovascular device with flow diverter and flow disruptor features. This study aims to investigate the safety and efficacy of the eCLIPs for treatment of patients with WNBAs.

METHODS

This is a systematic review and meta-analysis study conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The electronic databases of PubMed, Embase, Scopus, and Web of Science were systematically reviewed from inception to June 19, 2023. The rate of complete and near-complete occlusion, successful device implantation, and serious adverse events were pooled using STATA, version 17.

RESULTS

A total of 5 studies with 110 patients with WNBAs were systematically investigated. Our findings show that the immediate successful implantation rate of eCLIPs was 0.93 (95% confidence interval [CI], 0.88-0.97). Moreover, the immediate postoperative complete occlusion rate was 0.34 (95% CI, 0.10-0.58), and the immediate postoperative near-complete occlusion rate was 0.35 (95% CI, 0.24-0.45). Also, the near-complete occlusion rate at the latest follow-up was 0.3 (95% CI, 0.16-0.44). The serious adverse event rate was 0.14 (95% CI, 0.05-0.22). Stroke was also reported in 2 studies, with 1 study reporting 1 patient who experienced stroke within the first 24 hours and 1 study reporting no patients with stroke.

CONCLUSIONS

Our findings document that the eCLIPs is a safe and effective device for treating patients with WNBAs and associated with favorable outcomes.

Long-term results of wide-necked intracranial bifurcation aneurysms treated with stent-assisted coiling using low-profile acandis acclino stents

PURPOSE

Little data exists on endovascular treatment of complex intracranial aneurysms with the Acandis Acclino low-profile self-expanding closed-cell stent systems and is mainly limited to short- or midterm results. We report our long-term, single-centre experience with three generations of Acclino stents treating complex intracranial aneurysms.

METHODS

62 wide-necked intracranial aneurysms were treated electively using 88 Acclino stent systems. Single stent-assisted coiling was the preferred treatment in 38 cases and the kissing-Y stenting technique in 24 cases. We analysed demographic data and long-term follow-up results.

RESULTS

All stents were successfully deployed with immediate complete (Raymond Roy occlusion classification, RROC I) or near-complete occlusion (RROC II) achieved in 93,5%. Follow-up was available in 55 cases with a mean follow-up of 36 months (range 9-80 months). Long-term RROC I or II was achieved in 49 cases (89,1%). Three cases of stable residual aneurysmal filling were observed (5,5%). Seven aneurysms (12,7%) demonstrated a worsening on follow-up leading either to a neck remnant (4 cases, 7,3%) or to an aneurysm recurrence (3 cases, 5,5%). One recurrent aneurysm was retreated with coilembolization (1,8%). The directly procedural-related complication rate was 4,8%. Seven cases of clinically silent in-stent stenosis (12,7%; morbidity n = 0) were detected on long-term follow-up, six of them using the kissing-Y stenting technique.

CONCLUSION

Endovascular treatment of various intracranial aneurysms using the Acandis Acclino stent systems is safe and efficient with high aneurysm occlusion rates combined with low complication rates on long-term follow-up. Overall, rates of in-stent stenosis are low but may depend on the treatment technique (single stent-assisted coiling versus kissing-Y stenting with coiling).

Six-month Outcomes after PulseRider- and Conventional Single Stent-assisted Embolization for Bifurcation Aneurysms: A Propensity-adjusted Comparison

Endovascular treatment of wide-necked bifurcation aneurysms (WNBAs) remains challenging despite using a stent. PulseRider is a novel device specifically designed to treat WNBAs, protecting both daughter branches, but the outcomes have not been compared with conventional single stent-assisted embolization. This study aimed to compare the six-month outcomes of PulseRider and single stent-assisted embolization for intracranial unruptured WNBAs using propensity score adjustment. Between February 2012 and October 2021, 46 unruptured WNBAs (34 basilar and 12 middle cerebral arteries) smaller than 10 mm in diameter were treated with PulseRider-assisted embolization (n = 17) or single stent-assisted embolization (n = 29). The immediate and six-month outcomes were compared using inverse probability of treatment weighting analysis. The immediate adequate occlusion rates for the PulseRider- and single stent-assisted embolization were similar (47.1% vs. 62.1%). At six months, adequate occlusion rates for the two groups were also similar (94.1% vs. 86.2%). However, the complete obliteration rate was significantly high after PulseRider-assisted embolization (88.2% vs. 41.4%, adjusted OR 10.54, 95% CI 1.93-57.63). The angiographical improvement rate was also significantly high after PulseRider-assisted embolization (70.6% vs. 37.9%, adjusted OR 6.06, 95% CI 1.54-23.76). The neurologic thromboembolic complication rate was 0% after PulseRider-assisted embolization and 3.4% after single stent-assisted embolization. PulseRider-assisted embolization of WNBAs smaller than 10 mm in diameter was associated with complete obliteration and angiographical improvement at six months. The unique shape of the PulseRider might contribute to the improved midterm aneurysm occlusion.

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.

Flow diversion for the treatment of intracranial bifurcation aneurysms: a systematic review and meta-analysis

BACKGROUND

Flow diversion (FD: flow diversion, flow diverter) is an endovascular treatment for many intracranial aneurysm types; however, limited reports have explored the use of FDs in bifurcation aneurysm management. We analyzed the safety and efficacy of FD for the management of intracranial bifurcation aneurysms.

METHODS

A systematic review identified original research articles that used FD for treating intracranial bifurcation aneurysms. Articles with >4 patients that reported outcomes on the use of FDs for the management of bifurcation aneurysms along the anterior communicating artery (AComA), internal carotid artery terminus (ICAt), basilar apex (BA), or middle cerebral artery bifurcation (MCAb) were included. Meta-analysis was performed using a random effects model.

RESULTS

19 studies were included with 522 patients harboring 534 bifurcation aneurysms (mean size 9 mm, 78% unruptured). Complete aneurysmal occlusion rate was 68% (95% CI 58.7% to 76.1%, I2=67%) at mean angiographic follow-up of 16 months. Subgroup analysis of FD as a standalone treatment estimated a complete occlusion rate of 69% (95% CI 50% to 83%, I2=38%). The total complication rate was 22% (95% CI 16.7% to 28.6%, I2=51%), largely due to an ischemic complication rate of 16% (95% CI 10.8% to 21.9%, I2=55%). The etiologies of ischemic complications were largely due to jailed artery hypoperfusion (47%) and in-stent thrombosis (38%). 7% of patients suffered permanent symptomatic complications (95% CI 4.5% to 9.8%, I2=6%).

CONCLUSION

FD treatment of bifurcation aneurysms has a modest efficacy and relatively unfavorable safety profile. Proceduralists may consider reserving FD as a treatment option if no other surgical or endovascular therapy is deemed feasible.

Comparative effectiveness of stent-assisted coiling and Woven EndoBridge embolization for the treatment of unruptured wide-neck bifurcation intracranial aneurysms

OBJECTIVE

Woven EndoBridge (WEB) intrasaccular flow disruptors and stent-assisted coiling (SAC) are viable endovascular treatment options for wide-neck bifurcation intracranial aneurysms (WNBAs). Data directly comparing these two treatment options are limited. The authors aimed to compare radiographic occlusion rates and complication profiles between patients who received WEB and those who received SAC for WNBAs.

METHODS

Retrospective review of a prospectively maintained cerebrovascular procedural database was performed at a single academic medical center between 2017 and 2021. Patients were included if they underwent WEB embolization or SAC of an unruptured WNBA. SAC patients were propensity matched to WEB-embolized patients on the basis of aneurysm morphology. Complete and adequate (complete occlusion or residual neck remnant) occlusion rates at last angiographic follow-up, as well as periprocedural complications, were compared between the two groups. A cost comparison was performed for a typical 5-mm WNBA treated with WEB versus SAC by using manufacturer-suggested retail prices.

RESULTS

Thirty-five WEB and 70 SAC patients were included. Aneurysm width, neck size, and dome-to-neck ratio were comparable between groups. Follow-up duration was significantly longer in the SAC group (median [interquartile range] 545 [202-834] days vs 228 [177-494] days, p < 0.001, Mann-Whitney U-test). Complete (66% of WEB patients vs 69% of SAC patients) and adequate (94% WEB vs 91% SAC) occlusion rates were similar between groups at the last available angiographic follow-up (p = 0.744, chi-square test). Complete occlusion rates were comparable on Cox regression analysis after correction for follow-up duration (hazard ratio 1.5, 95% CI 0.8-3.1). Average time to residual aneurysm or neck formation was not statistically different between treatment groups (613 days for SAC patients vs 347 days for WEB patients, p = 0.225, log-rank test). Periprocedural complications trended higher in the SAC group (0% WEB vs 9% SAC, p = 0.175, Fisher exact test), although this finding was not significant. The equipment costs for a typical SAC case were estimated at $18,950, whereas the costs for a typical WEB device case were estimated at $18,630.

CONCLUSIONS

Midterm complete and adequate occlusion rates were similar between patients treated with WEB and those treated with SAC. Given these comparable outcomes, there may be equipoise in treatment options for WNBAs.

Need for Y-stenting in stent-assisted coiling of wide-neck bifurcation aneurysms

BACKGROUND AND PURPOSE

Stent-assisted coiling of wide neck bifurcation aneurysms in the anterior communicating segment and basilar tip region can be performed with varying stent configurations, including single stenting or Y-stenting. Y-stenting requires two stents and thus incurs greater cost and procedural complexity than single-stent constructs. The influence of first stent type on the need for Y-stenting remains unknown.

MATERIALS AND METHODS

Clinical and angiographic data were retrospectively obtained for patients that underwent stent-assisted coiling for basilar tip or anterior communicating aneurysms at a high-volume center. Patients were included in this study if stent-assisted coiling was performed using Neuroform Atlas or LVIS Jr stents. A multivariate binary logistic regression was performed to measure the influence of first stent type on the need for Y-stenting.

RESULTS

Stent-assisted coiling was used to treat 82 aneurysms in 81 patients during the study period, and Y-stenting was performed in 18.3% (15/82) of cases. In multivariate logistic regression analysis, use of LVIS Jr. as the first stent did not significantly influence the need for subsequent Y-stenting after controlling for aneurysm morphology (OR 0.65, 95% CI 0.18-2.43).

CONCLUSION

Controlling for aneurysm morphology and location, the use of Y-stenting for stent-assisted coiling was not independently influenced by the choice of LVIS Jr or Neuroform Atlas as the first stent. A larger cohort may reveal differences between these two stents, particularly for aneurysms with large neck sizes.

Evaluation of short- and long-term results of Y-stent-assisted coiling with Leo stents in endovascular treatment of wide-necked intracranial bifurcation aneurysms

PURPOSE

This study aimed to evaluate the feasibility, safety, and efficacy of Y-stent-assisted coiling (Y-SAC) using LEO Baby® stents in treating of bifurcation aneurysms.

METHODS

Patients who underwent Y-SAC using a braided stent (LEO Baby®, Montmorency, France) for wide-necked intracranial aneurysms between 2009 and 2019 and whose radiological and clinical follow-up data for at least 6 months could be obtained were evaluated. Data were obtained from patient records and analyzed retrospectively.

RESULTS

We evaluated 111 patients with a mean age of 56.0 ± 10.8 years (range, 25-88 years). Most of the aneurysms were detected incidentally. Three patients had ruptured aneurysms. LEO Baby deployment and coiling were successful in all patients. Immediate aneurysm occlusion rates were determined as modified Raymond-Roy classification (mRRC) I 95.5% (n = 106), mRRC II 3.6% (n = 4), mRRC IIIa 0.9% (n = 1). In the sixth month, aneurysm occlusion rates were found to be complete and nearly complete in all patients (mRRC I 94.6%, n = 105 and mRRC II 4.5%; n = 5, respectively). Follow-up data of 91 patients for > 2 years were obtained. Of these, 88 had MRRCI obstruction and 3 had MRRC II obstruction. The overall complication rate was 4.8%, and one patient died during the post-procedural follow-up.

CONCLUSION

The long-term follow-up results of Y-stenting with LEO Baby revealed that it provides stable closure of the aneurysm sac while preserving the main arterial structures. Therefore, it is a safe, durable, and effective method for treating wide-necked and complex bifurcation aneurysms.

Antiplatelet therapy discontinuation after stent-assisted coil embolization for intracranial aneurysms: a single-center, long-term, retrospective, observational study

OBJECTIVE

The protocol for antiplatelet therapy after stent-assisted coil embolization (SACE) for intracranial aneurysms is not well established. In particular, the indications for single antiplatelet therapy (SAPT) discontinuation remain controversial. The authors investigated the long-term outcomes of SAPT discontinuation after SACE among patients at a single institution.

METHODS

Patients who underwent SACE during the period from 2010 to 2020 and who were followed up for > 1 year were included in this study. The delayed ischemic and hemorrhagic complication rates were examined during follow-up. Moreover, the risk factors of antiplatelet therapy reduction or discontinuation and the outcomes of SAPT discontinuation were examined.

RESULTS

In total, 240 patients were included in the analysis. The average patient age was 60.3 years, and the average follow-up period was 46.7 months. Nine (3.8%) patients presented with symptomatic delayed ischemic complication, and 3 (1.3%) patients experienced a decline in modified Rankin Scale score. The stent configuration (T- or Y-stent) was the only risk factor associated with delayed ischemic complication (p < 0.001). SAPT was discontinued in 147 (71.7%) of 205 patients who were followed up for > 2 years, and no ischemic complications were observed.

CONCLUSIONS

It is safe to discontinue SAPT in patients without ischemic complications and with stable intraaneurysmal signals on MRA 2 years after SACE. The T- or Y-stent is a high-risk factor for delayed ischemic complications, and antiplatelet therapy reduction or discontinuation should be cautiously considered.

Treatment of intracranial bifurcation aneurysms with "X" stent-assisted coiling: A case series and literature review

PURPOSE

To clarify the safety and efficacy of "X" stent-assisted coiling (X-stenting) for the treatment of intracranial bifurcation aneurysms and to review the literature.

METHODS

We retrospectively reported five consecutive patients with six intracranial bifurcation aneurysms who underwent X-stenting between June 2014 and June 2020. The clinical and angiographic results were analyzed. We also performed an extensive PubMed review of medical literature up to June 2021.

RESULTS

Endovascular procedures were successfully applied to all six aneurysms. No procedure-related complications were noted. Follow-up angiograms were available for all patients and revealed occlusion in five aneurysms and improvement in one aneurysm. Clinical follow-up was performed for all patients, and the mRS score at follow-up was 0 in all patients. Thus, good outcomes were achieved in all patients, and no ischemic or hemorrhagic events were observed.

CONCLUSIONS

X-stenting appears to be safe for treating intracranial bifurcation aneurysms and effective in immediate and short-term outcome. Further research is required with well-designed, prospective studies with large sample sizes.

pCONUS 2 and pCONUS 2-HPC in the treatment of wide-necked intracranial aneurysms: Multicentre UK experience

BACKGROUND/PURPOSE

pCONUS 2 and pCONUS 2-HPC are neck-bridging devices that provide coiling support in the endovascular treatment of wide-necked intracranial aneurysms. To date, limited multicentre data has been published. This study provides the first pooled data from multiple UK centres regarding outcomes for these devices covering the periprocedural period to 6-month follow-up.

MATERIALS/METHODS

This retrospective, single-arm study assessed 65 patients treated over 3 years from the time of procedure to 6 months post-procedure across four UK centres. Data collected included patient demographics, aneurysm characteristics and antiplatelet regimens. Outcome measures were angiographic results and procedure-related complications from the immediate periprocedural period to 6-month follow-up.

RESULTS

Fifty-four unruptured (83.1%) and 11 ruptured (16.9%) aneurysms were treated. Fifty-five aneurysms were located in the anterior circulation (87.7%). There were four device-related intraprocedural complications: three cases of asymptomatic, temporary thrombus formation and one mortality associated with branch vessel occlusion and aneurysm re-bleeding in a ruptured case. There were no post-procedural device-related complications. Satisfactory occlusion was achieved in 58/65 procedures (89.2%) at time of treatment and in 44/60 (73.3%) at 6 months. Satisfactory occlusion correlated with aneurysm size and coiling packing density. Retreatment was required for five unruptured cases (7.7%) and was straightforward with the device in situ.

CONCLUSION

pCONUS 2 and pCONUS 2-HPC have good short-term safety profiles. The use of pCONUS 2-HPC in the acute treatment of ruptured aneurysms with postprocedural SAPT is feasible. The devices have an intraprocedural complication rate of 4/65 (6.2%) across multiple UK centres, including a single death (1.5%).

[pConus device for endovascular treatment of basilar bifurcation aneurysms]

Aneurysm occlusion with microcoils is an effective and safe procedure. However, bifurcation aneurysms usually have a wide neck, and their occlusion is still a difficult objective.

OBJECTIVE

To evaluate the efficacy and safety of bifurcation stents in the treatment of basilar bifurcation aneurysms.

MATERIAL AND METHODS

A retrospective analysis included 34 patients with basilar bifurcation aneurysms between 2016 and 2022. The pConus bifurcation stent was used as a stent-assistance for endovascular occlusion of aneurysms with microcoils. We analyzed technical features of stent implantation and clinical results of endovascular treatment. Mean aneurysm dimension was 8.4 mm, neck size - 4.6 mm. Preoperative MSR score 0-2 was observed in 94.7% of patients, 3-5 scores - in 5.3% of patients.

RESULTS

There were no significant changes in functional status early after surgery (MSR grading system). Total aneurysm occlusion was achieved in 67.6% of patients, subtotal - 17.6% of cases, partial - 14.8%. There were no technical or early postoperative clinical complications. Six months after surgery, total occlusion was observed in 77.8% of patients, subtotal occlusion - 14.8%, partial occlusion - 4%. MSR score 0-2 was observed between 3 and 12 months after surgery. One patient died from other cause rather aneurysm. Redo intervention due to aneurysm recanalization was performed in 1 patient.

CONCLUSION

The pConus bifurcation stent is effective and safe in endovascular treatment of basilar bifurcation aneurysms of the most complex configuration. There was a minimal risk of aneurysm recanalization in long-term postoperative period.

Opposite L-configuration double stenting for rupture of an extremely wide-necked anterior communicating artery aneurysm at the acute stage: illustrative case

BACKGROUND

Wide-necked aneurysms can be treated by double stenting in an X- or Y-configuration or by a double waffle-cone technique. However, some aneurysms remain untreatable.

OBSERVATIONS

The rupture of a complex wide-necked anterior communicating artery (AcomA) aneurysm that caused acute subarachnoid hemorrhage (SAH) was treated successfully using double stents with an opposite L-configuration as an alternative to the X-stent technique. The aneurysm involved both A1-A2 junctions in the aneurysm neck with acutely oriented A2 segments of the anterior cerebral artery bilaterally. It was densely packed and completely obliterated angiographically with preserved blood flow by implanting each stent in the ipsilateral A1-A2 bilaterally. Blood flow from the left A1 to the right A2 was confirmed through the AcomA on injection of the left internal carotid artery immediately after the procedure without critical infarction in the subthalamic area. Although the AcomA was not demonstrated by injection of the left internal carotid artery on angiography at 3 months or 1 year later, no cerebral infarction was seen on magnetic resonance images at the final hospital visit.

LESSONS

Opposite L-configuration double stenting was used successfully as rescue stent-assisted coiling for a rupture of a complex wide-necked AcomA aneurysm in a patient with acute SAH.

Results of Y-stent-assisted-coiling with a low-profile Neuroform Atlas stent in complex bifurcation aneurysms

Aim: Neuroform Atlas is a low-profile stent with an open-cell structure that can be deployed via a low-profile microcatheter. This study analyzed the safety, durability, and efficiency of Y-stent-assisted coiling (Y-SAC) with two Neuroform Atlas stents for treating unruptured wide-neck complex bifurcation aneurysms. Material and method: We retrospectively reviewed patients who were treated for intracranial bifurcation aneurysms using the Y-SAC technique with two Neuroform Atlas stents. A total of 94 consecutive patients were included in the study. Clinical and angiographic results and complications were evaluated before and after the procedure. Results: Y-SAC was successfully performed (100%) without any technical complications in any case. The mean angiographic follow-up period was 14.6±6.6 months. Follow-up DSA was performed on 93.6% of patients. The last follow-up angiograms demonstrated complete occlusion (RROC I) in 92%, and near-complete occlusion (RROC II) in 7% of the aneurysms. There was no mortality in this study. A procedure-related complication occurred in 4.2% of patients and caused permanent morbidity in 1% of patients. Conclusion: In the endovascular treatment of wide-neck complex bifurcation aneurysms, the Y-SAC method with two Neuroform Atlas stents is safe and effective with high aneurysm occlusion rates and a low risk of procedural complications.

Intracranial wide neck aneurysms: clinical and angiographic outcomes of endovascular management

Background

The treatment of intracranial wide neck aneurysms (WNAs) is usually difficult, hence several endovascular techniques were developed. This study aims to assess the clinical and angiographic imaging outcome of endovascular management of intracranial wide neck aneurysm. Forty patients were referred to the neuro-endovascular unit, at our hospital, each with a wide neck aneurysm. They were assessed regarding clinical presentation, aneurysm size, the character of the aneurysm, and the age and sex of the patient. Post-procedural, clinical, and angiographic outcomes of the patients who underwent endovascular intervention were reviewed.

Results

In this study, the mean aneurysmal neck was 5.4 ± 1.6 mm (mm). Endovascular intervention was carried out in all 40 patients in the form of simple coiling in 3 patients, double-catheter technique in 5 patients, balloon-assisted coiling (BAC) in 16 patients, stent-assisted coiling (SAC) in 13 patients, and flow diverter (FD) in 3 patients. Regarding clinical outcome, 4 patients had unfavorable outcome (the modified Rankin Scale, mRS > 2) at presentation and 3 patients at discharge. There was no unfavorable clinical outcome at 6- and 12-month follow-ups. Overall angiographic outcome at 1-year follow-up, 37/40 aneurysms (92.5%) had complete occlusion while two aneurysms had neck recurrence and one aneurysm had neck recanalization.

Conclusion

The current endovascular techniques in the treatment of WNAs are considered effective, feasible, and safe.

Usefulness and Problems of Y-Stent and T-Stent Assisted Coiling for Unruptured Cerebral Aneurysms

INTRODUCTION

We are going to discuss about usefulness and problems of Y-stent and T-stent assisted coiling for unruptured cerebral aneurysms.

METHODS

A retrospective review was performed to identify patients who were treated using Y-stent or T-stent assisted coiling (Y-SAC, T-SAC) for 25 unruptured cerebral aneurysms from April 2017 to September 2021. Fifteen cases were treated using Y-SAC, 10 were done using T-SAC. Only a case was treated with Low-profile Visualized Intraluminal Support (LVIS; MicroVention TRUMO, Aliso Viejo, California, USA) and Neuroform ATLAS (Striker, Kalamazoo, Michigan, USA), Others were done with two Neuroform ATLAS stents.

RESULTS

Y-SAC and T-SAC were succeeded in all cases. In two cases that were treated using Y-SAC, ischemic complications were observed. A patient received additional embolization because subarachnoid hemorrhage (SAH) was appeared after discharge. On follow-up imaging, CO (complete occlusion) was confirmed in all cases.

CONCLUSION

The position of deployment of stents was the most important issue. In particular, the second stent should be deployed as to contact the first stent, as possible. The case that the position of the second stent was shifted, and neck was not covered was observed. In the cases that are treated by using T-SAC, microcatheter must be navigated to distal position as possible. In that point, Y-SAC is more applicable. The familiarization of Y-SAC or T-SAC will expand the indication of endovascular treatment for unruptured cerebral aneurysms.

Micro-snare retrieval as bail-out technique for a distally migrated WEB-device: A case report

Intra-procedural intrasaccular device migration is an uncommon complication of endovascular treatment of wide-neck aneurysms. We report the case of a 52-years old Caucasian male who presented with a 3 × 3 mm posterior facing top of the basilar aneurysm in which treatment with WEB-SL (Woven EndoBridge-single layer) device was tempted. Inadvertent WEB migration in the right posterior cerebral artery occurred after detachment. Two retrieval attempts were performed using a combined technique with two different stent-retrievers and a 5-Fr distal access catheter. Upon WEBectomy attempt, the device rolled over the stents, and the passages were unsuccessful. The device was successfully removed using a microSnare, catching and retrieving it inside the 5-Fr distal access catheter. Micro-Snare is an effective bail-out technique to recover migrated intrasaccular WEB devices in cerebral arteries.

Intrasaccular flow disruption for brain aneurysms: a systematic review of long-term outcomes

OBJECTIVE

The long-term safety and efficacy of intrasaccular flow disruption (IFD) for the treatment of brain aneurysms remain unclear. With accumulating experience and increasing use of IFD devices, recent studies have provided additional data regarding their outcomes. This review summarizes the long-term outcomes of IFD-treated brain aneurysms.

METHODS

A systematic literature review was performed on May 23, 2021, in PubMed, Web of Science, and Ovid MEDLINE for aneurysm treatment outcomes with IFD devices. Procedural details, including use of adjunctive devices and complications, were collected. The quality of studies was assessed using the Downs and Black checklist. Angiographic outcomes were classified as complete occlusion, residual neck, and residual aneurysm. Other outcomes included need for retreatment, permanent neurological deficit, and mortality. Pooled analyses were performed.

RESULTS

The final analysis comprised 1217 patients with 1249 aneurysms from 22 studies. The mean aneurysm diameter and neck width were 6.9 and 4.5 mm, respectively, and 27.6% of aneurysms were ruptured. The complete occlusion rates at 12 months and final follow-up (pooled mean duration 15.7 months) were 50.1% and 58.2%, respectively. Adjunctive devices were used in 6.4% of cases. The rates of hemorrhage, symptomatic infarction, permanent neurological deficit, and mortality were 1.2%, 2.8%, 1.0%, and 2.6%, respectively.

CONCLUSIONS

IFD is a very safe treatment for appropriately selected brain aneurysms with low complication and neurological deterioration rates. However, complete occlusion is achieved in only half of IFD-treated aneurysms at 1 year with a modest increase beyond this time point. As the majority of the studies were single arm, the pooled data are subject to selection and reporting biases. Future device developments, increased operator experience, and direct comparisons with alternative endovascular strategies and surgical clipping may clarify the role of IFD in aneurysm management.

Intrasaccular neck-bridging: A technical note on Nautilus-assisted coiling of wide-necked cerebral aneurysms. Feasibility study, immediate and early angiographic results

PURPOSE

Various adjunctive devices have been reported to be helpful during the endovascular coiling of complex, wide-necked cerebral aneurysms. This study aimed to describe the utilization of a recently introduced intrasaccular neck-bridging implant specifically designed to facilitate coil embolization.

METHODS

We retrospectively reviewed eight consecutive patients who underwent treatment for intracranial aneurysms with the Nautilus intrasaccular bridging system between February 2022 to May 2022. We evaluated the angiographic appearances of treated aneurysms at the end of the procedure and early follow-up, the clinical status and complications.

RESULTS

Eight patients with eight cerebral aneurysms (3 men and 5 women, mean age 52.8 years (range 39-66) were analyzed. Five of the treated aneurysms were managed in an acute case scenario. There were no technical difficulties while executing the technique. No other procedural adverse events were documented. Immediate complete occlusion of the aneurysm was seen in 6 patients, neck remnant in 1 and stable aneurysm reperfusion in one case. Early radiological follow-up was available in five patients, and the observed occlusion rates were - RR class I in all radiologically screened aneurysms.

CONCLUSION

Nautilus-assisted coil embolization represents a rapid and safe solution for complex cerebral aneurysms. In our opinion this device symbolizes a significant step forward in treating intracranial aneurysms. We believe that the technique's actual value consists of the fact that the device is fully compatible with the modern low-profile microcatheter technology and does not involve the need for antiplatelet medications.

Treatment of wide-necked bifurcation aneurysms with the eCLIPs device: 5-year experience of a single center

BACKGROUND

The endovascular clip system (eCLIPs) is a novel device with both neck bridging and flow-diversion properties that make it suitable for the treatment of wide-necked bifurcation aneurysms.

OBJECTIVE

To describe the clinical and radiologic outcomes of the eCLIPs device, including the first-in-man use of the latest version of the device.

METHODS

This is a retrospective case series on all the wide-necked bifurcation aneurysms treated with the eCLIPs device in our center. The immediate and latest radiologic and clinical outcomes were assessed.

RESULTS

The device was successfully implanted in 12 of 13 patients. After a median follow-up period of 19 months (range 3-64 months), all patients with available data (11/12) had a good radiologic outcome (modified Raymond-Roy classification scores of 1 or 2). Two patients (18.2%) underwent re-treatment with simple coiling through the device. One of these had a subarachnoid hemorrhage prior to re-treatment. There were no major complications (death or permanent neurologic deficits) associated with use of the device.

CONCLUSION

Our series demonstrates occlusion rates that are similar to those of standard stent-assisted coiling and intrasaccular flow diversion for wide-necked bifurcation aneurysms. Larger registry-based studies are necessary to support our findings.

Long-term outcomes of Y-stent-assisted coil embolization using Low-profile Visualized Intraluminal Support Junior (LVIS Jr) for intracranial bifurcation aneurysms

OBJECTIVE

Y-stent-assisted coil embolization is indicated for the treatment of complex intracranial bifurcation aneurysms. However, the long-term outcomes associated with this technique remain unclear. The purpose of this study was to evaluate the long-term outcomes of Y-stent-assisted coil embolization using the Low-profile Visualized Intraluminal Support Junior (LVIS Jr) device.

METHODS

We retrospectively reviewed our databases to identify patients treated with Y-stent-assisted coiling using LVIS Jr. Digital subtraction angiography, silent magnetic resonance angiography (MRA), and time-of-flight MRA were performed at 1 year after the procedure. Patients also received an annual follow-up using MRA. Aneurysm occlusion status was classified into complete occlusion (CO), neck remnant (NR), and body filling (BF). Clinical outcomes were assessed using the modified Rankin Scale.

RESULTS

Twenty-one patients (22 aneurysms) were included in this study. All procedures were performed successfully. Immediate postprocedural angiograms showed CO in 13 aneurysms (59.1%), NR in two aneurysms (9.1%), and BF in seven aneurysms (31.8%). One-year follow-up angiograms revealed CO in 86.4% of patients. Only one patient had a major recurrence and required retreatment. The mean follow-up duration was 43.5 months. The last angiographic studies demonstrated CO in 18 aneurysms (81.8%), NR in three aneurysms (13.6%), and BF in one aneurysm (4.5%). Periprocedural and delayed complications occurred in two patients and one patient, respectively. There was no permanent morbidity or death. The modified Rankin Scale scores at last clinical follow-up were equal to those before the procedures in all patients.

CONCLUSION

Y-stent-assisted coil embolization using LVIS Jr for intracranial bifurcation aneurysms has favorable long-term angiographic and clinical outcomes.

Endovascular treatment for large (> 10 mm) basilar tip aneurysms: a retrospective case series

PURPOSE

To report the long-term clinical and angiographic outcomes of the endovascular treatment of large/giant basilar tip aneurysms (BTAs) in our institutions.

METHODS

We retrospectively reviewed cases of BTA larger than 10 mm that received endovascular treatment between January 2009 and December 2019. Data on the demographic and clinical characteristics and radiologic severity were obtained from the patients' medical records. The collected clinical follow-up data included neurological evaluation. Magnetic resonance angiography (MRA) was performed 6 to 12 months after the procedure, followed by once every 1 to 2 years as needed.

RESULTS

A total of 12 patients with BTA were included in this study. The median age was 60.08 years (27-80 years), and the mean clinical follow-up was 66.78 months (19.00-142.87 months). Almost half of the patients presented with unruptured BTAs (58.33%, n = 7). The median maximum aneurysm diameter was 13.00 mm (10.46-20.90 mm) and the mean neck size was 8.34 mm (4.82-13.04 mm). A Modified Raymond Roy Classification (MRRC1) of 1 or 2 was observed in 66.67% of the patients (n = 8) immediately after the first procedure. Procedural morbidity and mortality were 33.33% and 8.33%, respectively. Major recanalization occurred in two patients, one of whom underwent additional coiling with the other being merely observed due to older age.

CONCLUSION

It is very difficult to cure a large BTA completely at once and recanalization occurred often after endovascular treatment. Conducting long-term follow-up studies at short intervals is warranted, as well as improving existing treatment methods and developing new approaches.

Application of the Neuroform Atlas Stent in Intracranial Aneurysms: Current Status

The Neuroform Atlas stent (NAS) is the successor of the Neuroform EZ stent. The NAS is compatible with a low-profile 0.0165-inch microcatheter and is soft enough to pass through small and highly tortuous vessels. The NAS can be used in treating intracranial aneurysms at almost all locations, and its use is becoming increasingly common. However, there has not yet been a complete review of NAS applications. Therefore, we performed this review, which addresses several aspects of the NAS, mainly including its characteristics, clinical trials of its application in treating aneurysms, deployment techniques for the device, the prognosis and complications of its application in treating aneurysms, and antiplatelet requirements associated with its use. Based on the evidence reviewed here, as well as our experience, we found that the NAS is a promising device for treating intracranial aneurysms, especially complex and distal aneurysms. This stent can also be used as a powerful tool to assist in rescuing coil migration, completing dual-stent reconstruction, and coiling aneurysms via a transcirculation approach. The device may require antiplatelet therapy at a lower dose and over a shorter period than other stents. The deployment of the NAS to assist in aneurysm coiling can yield good clinical outcomes and an acceptable rate of complications. Thus, the NAS is a promising device.

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.

Stent-assisted WEB embolization: aneurysm characteristics, outcome and case report of a WEB delivered through a stent

PURPOSE

Woven Endobridge (WEB) embolization has become a well-established endovascular treatment option for wide-necked bifurcation aneurysms. The objective was to analyse cases that required additional stent-implantation.

METHODS

Images of 178 aneurysms ≤ 11 mm treated by WEB only or by WEB plus stent were retrospectively reviewed, evaluating aneurysm characteristics, procedural specifics, adverse events and angiographic results. Moreover, we report a case of a WEB delivered through a previously implanted stent.

RESULTS

Additional stent implantation was performed in 15 patients (8.4%). Baseline patient and aneurysm characteristics were comparable between both groups. A single stent was used in 12 cases and 2 stents in Y-configuration in 3. Thromboembolic complications occurred more often with stent assistance (33.3% vs. 8.0%, p = 0.002), while ischemic stroke rates were comparable between both groups (0% vs. 1.8%, p = 1.0). Six-month angiographic follow-up showed complete occlusion, neck remnants and aneurysm remnants in 73.4%, 19.4% and 7.3% after WEB only, respectively, and in 66.7%, 20.0% and 16.7% after WEB plus stent, respectively (p = 0.538). A case report shows that WEB deployment through the struts of a previously implanted standard microstent is feasible, even if a VIA 33 microcatheter is needed.

CONCLUSION

In the present study, stent-assisted WEB embolization had a comparable safety and efficacy profile compared to treatment by WEB only. However, stent-assisted WEB embolization requires long-term anti-platelet medication, which annihilates the advantages of the WEB as a purely intrasaccular device.

CLINICAL TRIAL REGISTRATION NUMBER

N/A.

Long-Term Outcomes of Placement of a Single Transverse Stent through the Anterior Communicating Artery via the Nondominant A1 in Coil Embolization of Wide-Necked Anterior Communicating Artery Aneurysms

Objective

Placement of a single transverse stent via the nondominant A1 across the anterior communicating artery (AComA) into the contralateral A2 can provide sufficient neck coverage for wide-necked bifurcation AComA aneurysms. The authors described the feasibility, safety and long-term outcomes of this technique.

Methods

Between January 2015 and February 2018, placement of a single transverse stent via the nondominant A1 was attempted in 17 wide-necked bifurcation AComA aneurysms. The authors reviewed the medical records and radiological studies.

Results

The technical success rate was 94.1% (16/17). Periprocedural thromboembolic complications occurred in one patient (6.3%) without permanent neurological deficits. The mean clinical follow-up duration was 39.9±9.8 months. No deaths or delayed thromboembolic complications occurred. The mean angiographic follow-up duration was 38.9±9.8 months. The immediate and final follow-up complete occlusion rates were 87.4 and 93.7%, respectively. There was no recanalization during the follow-up period.

Conclusion

Placement of a single transverse stent via the nondominant A1 across the AComA into the contralateral A2 is a feasible and relatively safe endovascular technique for the treatment of wide-necked bifurcation AComA aneurysms, with good long-term occlusion rates and a reasonable complication rate, if only the nondominant A1 is applicable.

Y-stent-assisted coiling with Neuroform Atlas stents for wide-necked intracranial bifurcation aneurysms: A preliminary report

Objective

To report our experience on Neuroform Atlas Y-stenting for coiling of unruptured wide-neck bifurcation aneurysms.

Methods

From March 2018 to January 2021, we treated 473 aneurysms in 436 patients with coil embolization, of which 15 cases with wide-necked bifurcation aneurysms were treated by Y-stent-assisted coiling with two Neuroform Atlas stents. We retrospectively reviewed the characteristics of patients and aneurysms, procedure-related complications, radiographic results, and clinical outcomes.

Results

All 15 cases using Neuroform Atlas Y-stenting were successful. Patients included 6 men and 9 women with a mean age ± standard deviation of 56.4±6.6 years. The mean dome and neck sizes were 6.4±3.1 mm and 4.7±1.8 mm, respectively. Immediate post-procedural angiograms showed complete occlusion in 46.7%, neck remnant in 13.3%, and incomplete occlusion in 40% of cases. No treatment-related morbidity or mortality occurred in any patients. All patients had good clinical outcomes (Glasgow Outcome Score 5) at both discharge and during a mean 12.3-month (range 1-28 months) follow-up. All aneurysms showed improved or stable occlusion on follow-up imaging. Further, the latest follow-up angiography showed complete occlusion in 73.3%, neck remnant in 6.7%, and incomplete occlusion in 20%.

Conclusions

Y-stent-assisted coiling with Neuroform Atlas stents might be a feasible and safe option for wide-necked bifurcation aneurysms.

A Case of Coil Embolization with Crossing Y-Configuration Stenting for a Recurrent IC-PC Aneurysm after Clipping

Objective

We report a case in which coil embolization using crossing Y-configuration stenting was effective for an internal carotid-posterior communicating artery (IC-PC) aneurysm with repeated recurrence after clipping.

Case Presentation

The patient was a 57-year-old woman. Nine months after undergoing clipping for a ruptured right IC-PC aneurysm at 55 years of age, she developed a second subarachnoid hemorrhage (SAH) due to recurrence of the aneurysm and underwent clipping at the same site. A third SAH due to rupture of the left IC-PC aneurysm developed 1.5 years after the second clipping. Simultaneously, recurrence of a right IC-PC aneurysm was noted and she was referred to our department. The recurrent right IC-PC aneurysm was considered to have originated from the distal to the initial neck. It was 7 mm in size and had an irregularly shaped wide neck. As it was assumed that there would be marked adhesion due to repeated surgery, we decided to treat the aneurysm by coil embolization instead of direct surgery. Although the aneurysm neck partially involved the posterior communicating artery (Pcom), tight packing with a minimal residual neck was required. Therefore, crossing Y-configuration stenting was deployed on the internal carotid artery and Pcom using two Neuroform Atlas stents, and coil embolization was performed by the jail technique. The recurrent aneurysm was obliterated. There were no deficits or thrombotic complications after surgery. On DSA follow-up, no compaction or recurrence was observed, and the Pcom was well visualized one year later.

Conclusion

Coil embolization by crossing Y-configuration stenting is a viable treatment option for a recurrent IC-PC wide neck aneurysm.

"Shelf" Technique Using a Novel Braided Self-Expandable Stent for the Treatment of Wide-Necked Bifurcation Aneurysms

Background

Different endovascular techniques exist for treatment of cerebral wide-necked bifurcation aneurysms (WNBA). We present the “shelf” technique with the novel woven LVIS EVO stent, which enables forming a buttress at the level of the aneurysm neck to prevent coil prolapse and additional stenting.

Methods

Single-center retrospective analysis of patients treated with the “shelf” technique by using LVIS EVO stent in incidental WNBAs between January 2020 and March 2021. Inclusion criteria were saccular aneurysms with neck width ≥4 mm or a dome/neck ratio ≤2. Primary endpoint was a favorable navigation to the target vessel and successful deployment of the LVIS EVO stent with forming a buttress that enables aneurysm occlusion by subsequent coiling. Secondary endpoints were aneurysm occlusion on follow-up, procedure-related complications and clinical outcome.

Results

A total of 15 patients were included. The primary end point was reached in 100% of cases. A complete aneurysm occlusion at the end of the procedure was achieved in 14/15 patients (93%). No intraprocedural complications occurred. All patients except one were discharged with an modified Rankin Scale (mRS) of 0. Procedure-related morbidity was 7%. Median follow-up imaging was 115 days (7–419 days) and available for 11/15 (73%) of the patients. Of those, 10 (91%) individuals had a complete aneurysm occlusion and 1 showed a residual neck. In all patients, the covered branch was patent and no ischemic complications occurred during follow-up.

Conclusion

This study demonstrates the “shelf” technique with LVIS EVO stents as a feasible and safe treatment option for WNBAs with very good short-term occlusion rates.

Dual Stenting with New-Generation Stents for Aneurysm Embolization in Acute Subarachnoid Hemorrhage

OBJECTIVE

Endosaccular treatment is the backbone of endovascular treatment for acutely ruptured aneurysms. Stent-assisted coiling is a niche technique in this context. Data on X-stenting or Y-stenting (dual crossing stenting, DCS) in the acute phase after subarachnoid hemorrhage (aSAH) are scarce, and the impact of stent properties on the outcome is unknown. We retrospectively evaluated the clinical and imaging results of DCS in patients treated for aSAH.

METHODS

Patients with aSAH treated with DCS were evaluated retrospectively. Patient and procedural characteristics were evaluated to determine clinical outcomes, associated complications, and follow-up imaging findings.

RESULTS

Sixteen procedures (16 patients; 10 women, mean age 55.8) were performed within 3.2 ± 2.6 days (range 1-10 days) of aSAH. Only the latest generation of intracranial stents (dual Neuroform Atlas-12 cases, dual Leo Baby-2 cases, Neuroform Atlas with Acclino Flex, or Leo Baby-2 cases) were used. Technical success rate was 100%; however, 25% of the procedures were complicated, leading to adverse events in 3 procedures (18.8%; 2 stent thrombosis, 1aneurysm rupture). Procedure-related morbidity and mortality and overall permanent morbidity and mortality were 6.3%, none, 6.3%, and 12.5%, respectively. No additional neurologic events were noted on a mean clinical follow-up of 160 ± 156 (range: 1-540) days.

CONCLUSIONS

Our findings and the patient-by-patient data we extracted from the literature suggest that DCS can be performed with new-generation, low-profile stents in aSAH if a definite procedural risk is acceptable for a specific patient. New-generation open-cell stent combinations appear as a viable choice for DCS in aSAH.

Safety, Efficacy, and Durability of Stent Plus Balloon-Assisted Coiling for the Treatment of Wide-Necked Intracranial Bifurcation Aneurysms

BACKGROUND

Wide-necked bifurcation aneurysms remain a challenge for endovascular surgeons. Dual-stent-assisted coiling techniques have been defined to treat bifurcation aneurysms with a complex neck morphology. However, there are still concerns about the safety of dual-stenting procedures. Stent plus balloon-assisted coiling is a recently described endovascular technique that enables the coiling of wide-necked complex bifurcation aneurysms by implanting only a single stent.

OBJECTIVE

To investigate the feasibility, efficacy, safety, and durability of this technique for the treatment of wide-necked bifurcation aneurysms.

METHODS

A retrospective review was performed of patients with wide-necked intracranial bifurcation aneurysms treated with stent plus balloon-assisted coiling. The initial and follow-up clinical and angiographic outcomes were assessed. Preprocedural and follow-up clinical statuses were assessed using modified Rankin scale.

RESULTS

A total of 61 patients (mean age: 54.6 ± 10.4 yr) were included in the study. The immediate postprocedural digital subtraction angiography revealed complete aneurysm occlusion in 86.9% of the cases. A periprocedural complication developed in 11.5% of the cases. We observed a delayed ischemic complication in 4.9%. There was no mortality in this study. The permanent morbidity rate was 3.3%. The follow-up angiography was performed in 55 of 61 patients (90.1%) (the mean follow-up period was 25.5 ± 27.3 mo). The rate of complete aneurysm occlusion at the final angiographic follow-up was 89.1%. The retreatment rate was 1.8%.

CONCLUSION

The results of this study showed that stent plus balloon-assisted coiling is a feasible, effective, and relatively safe endovascular technique for the treatment of wide-necked bifurcation aneurysms located in the posterior and anterior circulation.

Endoluminal flow diverters in the treatment of sidewall and bifurcation aneurysm: A systematic review and meta-analysis of complications and angiographic outcomes

BACKGROUND AND AIM

The use of endoluminal flow diversion in bifurcation aneurysms has been questioned due to the potential for complications and lower occlusion rates. In this study we assessed outcomes of endovascular treatment of intracranial sidewall and bifurcation aneurysms with flow diverters.

METHODS

In July 2020, a literature search for all studies utilizing endoluminal flow diverter treatment for sidewall or bifurcation aneurysms was performed. Data were collected from studies that met our inclusion/exclusion criteria by two independent reviewers and confirmed by a third reviewer. Using random-effects meta-analysis the target outcomes including overall complications (hematoma, ischemic events, minor ischemic stroke, aneurysm rupture, side vessel occlusion, stenosis, thrombosis, transient ischemic stroke, and other complications), perioperative complications, and follow-up (long-term) aneurysm occlusion were intestigated.

RESULTS

Overall, we included 35 studies with 1084 patients with 1208 aneurysms. Of these aneurysms, 654 (54.14%) and 554 (45.86%) were classified as sidewall and bifurcation aneurysm, respectively, based on aneurysm location. Sidewall aneurysms had a similar total complication rate (R) of 27.12% (95% CI, 16.56%-41.09%), compared with bifurcation aneurysms (R, 20.40%, 95% CI, 13.24%-30.08%) (p = 0.3527). Follow-up angiographic outcome showed comparable complete occlusion rates for sidewall aneurysms (R 69.49%; 95%CI, 62.41%-75.75%) and bifurcation aneurysms (R 73.99%; 95% CI, 65.05%-81.31%; p = 0.4328).

CONCLUSIONS

This meta-analysis of sidewall and bifurcation aneurysms treated with endoluminal flow diverters demonstrated no significant differences in complications or occlusion rates. These data provide new information that can be used as a benchmark for comparison with emerging devices for the treatment of bifurcation aneurysms.

The Application of "Stilted Building" Technique in the Embolization of Aneurysms with Secondary Branches

Objective

Many intracranial aneurysms often have branch arteries, and it is especially important to protect them during embolization. The purpose of the present study was to evaluate the curative effect and safety of the “stilted building” technique.

Methods

25 patients with intracranial aneurysms with branch arteries that have been treated by coil embolization with the “stilted building” technique were retrospectively reviewed. Clinical follow-up was performed after endovascular treatment.

Results

All 25 patients successfully underwent aneurysm embolization. During the operation, the ruptured sac and most of the body of the aneurysm were embolized using the “stilted building” technique. Immediate imaging showed that the blood flow to the branch arteries from the neck or sidewall of the aneurysm was unobstructed. The mRS scores of the 25 patients during the follow-up period were mRS 0 for twenty-one patients, mRS 1 for three patients, and mRS 6 for one patient. No aneurysms recurred among the patients who completed the follow-up.

Conclusions

In an aneurysm with a branch artery, when a balloon or stent cannot be effectively used to protect the branch artery, the use of “stilted building” embolization can achieve good therapeutic effects, and the short-term follow-up results are satisfactory; the technique can effectively protect branch arteries originating from aneurysms.

Flow-Diversion Treatment for Unruptured ICA Bifurcation Aneurysms with Unfavorable Morphology for Coiling

BACKGROUND AND PURPOSE

Few reports described flow diversion for ICA bifurcation aneurysms. Our aim was to provide further insight into flow diversion for ICA bifurcation aneurysms difficult to treat with other strategies.

MATERIALS AND METHODS

Consecutive patients receiving flow diverters for unruptured ICA bifurcation aneurysms were collected. Aneurysm occlusion (O'Kelly-Marotta grading scale) and clinical outcomes were evaluated.

RESULTS

Twenty saccular ICA bifurcation aneurysms were treated with the Pipeline Embolization Device deployed from the M1 to the ICA, covering the aneurysm and the A1 segment. All patients presented with an angiographic visualized contralateral flow from the anterior communicating artery. Mean aneurysm size was 6.5 (SD, 3.2) mm (range, 4.5-20 mm). All lesions had an unfavorable dome-to-neck ratio (mean/median, 1.6/1.6; range, 0.8-2.8; interquartile range = 0.5) or aspect ratio for coiling (mean/median = 1.5/1.55; range, 0.8-2.5; interquartile range = 0.6). One was a very large aneurysm (20 mm). Nineteen medium-sized lesions were completely occluded during the angiographic follow-up (13 months). No cases of aneurysm rupture or retreatment were reported. No adverse events were described. Aneurysm occlusion was associated with the asymptomatic flow modification of the covered A1 that was occluded and contralaterally filled among 10 patients (50%), narrowed among 9 patients (45%), and unchanged in 1 subject (5%). There was no difference in the mean initial diameter of the occluded (2.1 [SD 0.4] mm; range, 1.6-3 mm) and narrowed (2 [SD, 0.2] mm; range, 1.7-2.6 mm) A1 segments.

CONCLUSIONS

Medium-sized unruptured ICA bifurcation aneurysms with unfavorable morphology for coiling can be treated with M1 ICA flow diversion. Aneurysm occlusion is associated with flow modifications of the covered A1 that seems safe in the presence of a favorable collateral anatomy through the anterior communicating artery complex.

pCONUS 2 and pCONUS 2-HPC for the treatment of wide-necked intracranial aneurysms: Periprocedural, 6-month, and early 2-year follow-up outcomes

BACKGROUND/PURPOSE

pCONUS 2 and pCONUS 2-HPC are novel neck-bridging devices designed to support endovascular coil occlusion of wide-necked intracranial bifurcation aneurysms. This study summarises periprocedural outcomes, 6-month, and early 2-year follow-up results following its introduction in an interventional neuroradiology centre.

MATERIALS/METHODS

This prospective, single-arm study assessed 20 aneurysms treated over a 40 month time period from time of procedure to 2 years post-procedure. Data collected included patient demographics, aneurysm features, and intraprocedural, 6-month, and 2-year post-procedural complications and angiographic features.

RESULTS

The mean age of the cohort was 59+-SD 7.7 years. 16 unruptured aneurysms were treated (pCONUS 2 13/16, pCONUS 2-HPC 3/16) and 4 ruptured aneurysms were treated with pCONUS 2-HPC. Unruptured cases received dual antiplatelet therapy pre- and post-procedure while ruptured cases received single antiplatelet therapy. 9/20 aneurysms were located at the MCA bifurcation and 7/20 at the basilar tip. The remaining 4 aneurysms were at various bifurcations in the anterior circulation. 11/20 were small (<10mm) and 9/20 were large (10-25mm). There was one periprocedural complication: a retroperitoneal bleed. There were no post-procedural intracranial complications or at 6-months follow-up. At 6 months, satisfactory occlusion was achieved in 94% of cases (15/16). There was one delayed death at 2-year follow-up from an unrelated cause.

CONCLUSION

pCONUS 2 and pCONUS 2-HPC have excellent short and medium-term safety profiles and clinical outcomes with no procedure-related mortality or morbidity and good occlusion rates at 6-month follow-up. The use of pCONUS 2-HPC with single antiplatelet therapy is feasible and did not cause any complications.

Intentional Stent Herniation Technique Using Neuroform Atlas Stent System for Embolization of a Wide-Necked Basilar Tip Aneurysm

Objective

Endovascular treatment for complex wide-necked basilar tip aneurysms is challenging. Multiple stenting may be an option to deal with such aneurysms; however, the risk of ischemic complications is reported to be relatively high. Here, we report a case of unruptured basilar tip aneurysm treated using the intentional stent herniation technique to preserve the aneurysmal neck branches.

Case Presentation

A 65-year-old woman presented with a growing unruptured basilar tip aneurysm associated with bilateral posterior cerebral arteries (PCAs) arising from the aneurysmal dome. We intentionally selected a large-sized Neuroform Atlas stent (Stryker, Kalamazoo, MI, USA) compared to the parent artery and deployed it along the right PCA to the basilar artery. The stent was herniated into the aneurysmal dome near the origin of the left PCA, resulting in the preservation of the left PCA. Successful coil embolization was achieved with acceptable obliteration.

Conclusion

The intentional stent herniation technique may be an effective approach to treat complex wide-necked basilar tip aneurysms.

The Geometry of Y-Stent Configurations Used for Wide-Necked Aneurysm Treatment: Analyzing Double-Barrel Stents In Vitro Using Flat-Panel Computed Tomography

BACKGROUND

Stent-assisted coil embolization of wide-necked bifurcation aneurysms often employs a Y configuration stent. A similar stent configuration, termed kissing/double-barrel (KDB), is used often at the aortoiliac bifurcation. Studies of KDB stents in aortoiliac disease show that rates of thromboembolic complications vary with the cross-sectional geometry of the stent pair, a function of the radial crush resistive force of each stent. We assessed cross-sectional geometry of intracranial stent pairs in an in vitro model of the basilar artery using flat-panel computed tomography.

METHODS

In a silicone model of a wide-necked basilar tip aneurysm, 6 simulated KDB stent deployment trials were performed using combinations of 5 stents (Enterprise 1, Enterprise 2, Neuroform Atlas, LVIS, LVIS Jr.). Flat-panel computed tomography reconstructions were used to assess cross-sectional stent geometry. Relative conformability, defined by ovalization and D-ratio, radial crush resistive force (predicted vs. actual), and radial mismatch fraction were compared by stent type (braided vs. laser-cut).

RESULTS

Several distinct forms of cross-sectional stent geometry were observed. Braided stents had lower ovalization and D-ratio (P = 0.015) than laser-cut stents. The Neuroform Atlas/LVIS combination yielded the lowest radial mismatch fraction (19.7% vs. mean 44.3% ± 0.7%). Braided stents tended to have a deployed stent radius closer to the expected (nominal) diameter (i.e., higher relative crush resistive force) than laser-cut stents (measured vs. nominal diameter discrepancy +38.6% ± 21.1% vs. -10.7% ±16.1%, P = 0.14).

CONCLUSIONS

In constant anatomy, cross-sectional geometry of the KDB stent configuration will vary depending on the design and structure of the stents employed.

Y-stent assisted coiling of ruptured wide neck intracranial aneurysm in the acute phase

BACKGROUND

The objective of the present study is to analyze the outcomes of patients with subarachnoid hemorrhage (SAH) in the acute phase after treatment with Y-stent-assisted coiling (YSAC) embolization.

METHODS

This retrospective study assessed of 30 patients with acutely ruptured wide-neck aneurysms following YSAC treatment between April 2013 and October 2019. The demographic data, aneurysm occlusion grade, procedural and periprocedural complications, and clinical outcomes were assessed.

RESULTS

The procedure was completed in 30 cases (90.1%) and technical failure occurred in 3 cases (9.1%). Immediate control angiography revealed that total occlusion Raymond-Ray Class 1 (RR1) was achieved in 21 (70%), neck filling (RR2) in eight (26.6%) and sac filling (RR1) in one (3.3%) aneurysm. Upon angiographic follow-up, RR1 occlusion was observed in 15 (71.4%) patients, RR2 in three (14.3%) patients and RR3 in three (14.3%) patients. In-stent thrombus developed in five (16.6%) patients; procedural ischemic events were observed in four (13.3%) patients; and two (6.6%) patients were symptomatic. A periprocedural asymptomatic intracranial hemorrhage was detected in two patients. At discharge, 17 (56.6%) patients were in good clinical condition, six (20%) were in a severe disability condition, and seven (23.3%) patients had died. At the final follow-up visit (mean: 18.9 months), 16 (76,2%) of 21 patients were in a good clinical condition and five (23.8%) had severe disabilities.

CONCLUSIONS

Y-stent assisted coiling in might be a feasible and promising option for treatment in acute phase in selected wide-necked ruptured intracranial aneurysms.

Intrasaccular flow disruption (WEB) of a large wide-necked basilar apex aneurysm using PulseRider-assistance

Large, wide-necked basilar apex aneurysms are difficult to treat. Microsurgical clipping can result in neurologic morbidity and mortality. Endovascular treatment often leaves remnants that need retreatment and/or stent placement with dual antiplatelet therapy. The Woven EndoBridge (WEB) is an intrasaccular flow disruption device that can be used without dual antiplatelet therapy. However, the WEB cannot typically be used in large or giant aneurysms > 10 mm because the largest diameter device is the 11 × 9.6 mm single layer sphere (SLS). We present a case in which we use a PulseRider aneurysm neck reconstruction device in the basilar artery to assist in WEB deployment within a 22 mm basilar apex aneurysm with 14 mm neck, thereby permitting aspirin monotherapy postoperatively.

Safety and Efficacy of the Neuroform Atlas Stent for Treatment of Intracranial Aneurysms : A Systematic Review and Meta-Analysis

OBJECTIVE

The Neuroform Atlas (Stryker Neurovascular, Fremont, CA, USA) is a low-profile laser cut self-expanding nitinol stent designed to provide coil support and wall apposition during aneurysm embolisation. In this study, we performed a meta-analysis of outcomes after treatment with the Neuroform Atlas stent for the purpose of coil embolisation.

METHODS

The primary objectives of this meta-analysis were to define the safety (treatment-related complications, neurologic outcomes, mortality rate) and the efficacy (aneurysm occlusion rate) of the treatment of intracranial aneurysms with the Neuroform Atlas stent. A systematic review and meta-analysis was performed by searching PubMed, EMBASE, and the Cochrane CENTRAL Library for all published studies on the treatment of intracranial aneurysms with the Neuroform Atlas device up to 6 April 2020. The review was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 14 studies were analysed (577 patients with 593 intracranial aneurysms). The mean age was 58.2 years and 35.6% were male. Technical success of the procedure was 100%. RROC1/RROC2 (Raymond-Roy occlusion classification (RROC) 1/2) (total occlusion/neck remnant) at a mean follow-up of 8.9 months was achieved in 94.8%. RROC3 was 4.9%. All-cause mortality was 1.8% and permanent residual neurological deficit or disability was 2.7%. Overall complications at follow-up were 6.2%.

CONCLUSION

Our analysis demonstrated good rates of occlusion at follow-up for aneurysms treated with the Atlas device at follow-up. The safety profile appears similar to other low-profile intracranial stents.

Y-Configuration Stenting for Coil Embolization of Complex Intracranial Aneurysms: Distinguishing Between Use of Crossing-Y and Kissing-Y

OBJECTIVE

Coil embolization with Y stenting is recognized as a suitable treatment for complex wide-necked aneurysms. Y stenting comprises crossing-Y stenting, in which a stent is passed through the interstices of another stent, and kissing-Y stenting, in which 2 stents are arranged in parallel. The purpose of this study was to elucidate how to distinguish between use of the 2 Y-stenting techniques.

METHODS

Clinical and angiographic data of patients who underwent coil embolization with Y stenting at our department from 2015 to 2019 were retrospectively analyzed. Basic characteristics, endovascular procedure, complications, and outcomes were compared between kissing-Y and crossing-Y stenting groups.

RESULTS

Thirty-eight intracranial aneurysms in 38 consecutive patients were included in this study. Nineteen patients (50%) were treated with coil embolization with kissing-Y stenting and 19 (50%) with crossing-Y. Endovascular procedures were successfully performed in all but 1 patient, in the kissing-Y group, who had stent migration. One hemorrhage (2.6%) recurred 12 months after coiling with kissing-Y stenting. Angiographic follow-up (mean, 15.8 months) was available in 35 patients. Adequate occlusion was shown in 14 patients (77.8%) and 13 patients (76.5%) in the kissing-Y and crossing-Y groups, respectively. Larger, wider-necked, and more proximal aneurysms were treated with kissing-Y stenting than with crossing-Y stenting, although there were no significant differences between the groups in complication rates or clinical outcomes.

CONCLUSIONS

Kissing-Y and crossing-Y stenting of intracranial aneurysms were both feasible and yielded reasonable angiographic and clinical results. The choice between the kissing-Y or crossing-Y-stenting technique should be decided according to the angioarchitecture of targeted aneurysms.