Kissing-Y stenting for endovascular treatment of complex wide necked bifurcation aneurysms using Acandis Acclino stents: results and literature review

Comparative Analysis of the Low-Profile Acclino Stent and the Enterprise Stent for the Treatment of Unruptured Intracranial Aneurysms

OBJECTIVE

In preliminary studies, advanced intracranial stents appear to have a favorable safety profile for intracranial aneurysm treatment. This dual-center study is a head-to-head comparison of the low-profile Acandis Acclino stent (a third-generation stent) and the first- and second-generation Enterprise stent.

METHODS

Patients who underwent stent-assisted coiling with either the Enterprise or the Acclino stent for unruptured aneurysms during an 8-year period were enrolled and compared for complications, clinical outcomes, and angiographic results. Primary outcome measures were ischemic stroke rate and mid-term complete occlusion rate. Propensity score adjustment was performed to account for small differences between the groups.

RESULTS

Enterprise and Acclino stents were used in 48 cases each. The overall rate of thrombotic complications was higher in the Enterprise group than in the Acclino group (20.8% vs. 4.2%, HR: 6.6, 95%CI: 2.2-20.0, P = 0.01, adjusted P < 0.01), which translated into a higher rate of major ischemic stroke after Enterprise treatment (6.3% vs. 0%, HR: 2.1, 95%CI: 1.8-2.4, P = 0.08, adjusted P < 0.01). Mid-term and long-term angiographic follow-up showed complete occlusion rates of 83.3% and 75.0% for Enterprise and 89.2% and 75.9% for Acclino (both P > 0.05). Retreatment rates were 10.4% in the Enterprise group and 4.2% in the Acclino group (P = 0.42, adjusted P = 0.10).

CONCLUSIONS

The results indicate a favorable safety profile of the Acclino over the Enterprise, justifying the use of advanced stent systems in clinical practice. However, further comparative studies of the Acclino and other competing stent systems are needed to draw a definitive conclusion on the state of stent-assisted coiling.

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).

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.

Stent-Induced Vascular Remodeling in Two-Step Stent-Assisted Coiling Treatment of Brain Aneurysms: A Closer Look Into the Hemodynamic Changes During the Stent Healing Period

Stenting has become an important adjunctive tool for assisting coil embolization in complex-shaped intracranial aneurysms. However, as a secondary effect, stent deployment has been related to both immediate and delayed remodeling of the local vasculature. Recent studies have demonstrated that this phenomenon may assume different roles depending on the treatment stage. However, the extent of such event on the intra-aneurysmal hemodynamics is still unclear; especially when performing two-step stent-assisted coiling (SAC). Therefore, we performed computational fluid dynamics (CFD) analysis of the blood flow in four bifurcation aneurysms focusing on the stent healing period found in SAC as a two-step maneuver. Our results show that by changing the local vasculature, the intra-aneurysmal hemodynamics changes considerably. However, even though changes do occur, they were not consistent among the cases. Furthermore, by changing the local vasculature not only the shear levels change but also the shear distribution on the aneurysm surface. Additionally, a geometric analysis alone can mislead the estimation of the novel hemodynamic environment after vascular remodeling, especially in the presence of mixing streams. Therefore, although the novel local vasculature might induce an improved hemodynamic environment, it is also plausible to expect that adverse hemodynamic conditions might occur. This could pose a particularly delicate condition since the aneurysm surface remains completely exposed to the novel hemodynamic environment during the stent healing period. Finally, our study emphasizes that vascular remodeling should be considered when assessing the hemodynamics in aneurysms treated with stents, especially when evaluating the earlier stages of the treatment process.

Retrograde T-Stent Technique for Large, Wide-Necked Internal Carotid-Posterior Communicating Artery Aneurysm

Objective

We report a case of a wide-necked internal carotid-posterior communicating (IC-Pcom) artery aneurysm treated by the retrograde T-stent technique in which a stent was also placed in the Pcom artery via the posterior circulation.

Case Presentation

A 35-year-old woman was diagnosed with an unruptured right IC-Pcom artery aneurysm (maximum diameter: 11 mm, neck diameter: 8.5 mm) during a detailed examination for vertigo. The Pcom artery (2.1 mm) branched from the aneurysmal dome. A microcatheter was guided in retrograde via the Pcom artery from the posterior circulation. A low-profile visualized intraluminal support (LVIS) Jr. 2.5 mm × 17 mm was deployed from the internal carotid artery (ICA) to the Pcom artery, and then, an LVIS 4.5 mm × 23 mm was deployed while pressing the flare of the LVIS Jr. protruding into the ICA. T configuration stenting was completed, and the coil was inserted as tightly as possible.

Conclusion

The retrograde T-stent technique, which has the advantage of optimal stent positioning, is useful for preserving a Pcom artery branching from the aneurysmal dome.

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.

A Patient with a Large Basilar Artery Aneurysm in Whom Coil Embolization Was Performed by Protruding an LVIS into the Aneurysmal Neck in a Barrel-like Shape and Preserving a Branch Vessel

OBJECTIVE

We report a case of a low-profile visualized intraluminal support device (LVIS) being deployed and protruded into an aneurysmal neck in a barrel-like shape to perform dense coil embolization while preserving the branch vessel from the aneurysmal dome in order to prevent aneurysmal enlargement.

CASE PRESENTATION

A 74-year-old woman had a recurrent large cerebral aneurysm at the bifurcation of the basilar artery and the left superior cerebellar artery (SCA). Therefore, an LVIS was deployed from the left posterior cerebral artery to the basilar artery and protruded into the aneurysmal neck in a barrel-like shape to increase its metal coverage ratio. As the barrel-shaped protruding LVIS served as a scaffold to support the coils, dense coil embolization was performed while preserving the SCA branching from the aneurysmal dome. Images obtained at 6 months and 1 year after the embolization confirmed preservation of the SCA and prevention of aneurysmal enlargement.

CONCLUSION

Protruding the LVIS into an aneurysmal neck in a barrel-like shape is a technique that may help preserve the branch vessel and facilitate dense coil embolization.

Novel Noncrossing Y-Stent Technique Using Tapered Proximal End of a Solitaire AB Stent for Coil Embolization of Wide-Neck Bifurcation Aneurysms

The crossing Y-stent method is one of the indispensable techniques to achieve sufficient neck coverage during coil embolization of bifurcation aneurysms with a wide neck and/or branch incorporation. However, the inevitable hourglass-like expansion of the second stent at the crossing point can result in insufficient vessel wall apposition, reduced aneurysm neck coverage, delayed endothelialization, and subsequent higher risks of acute or delayed thrombosis. It also interferes with engagement of the microcatheter into the aneurysm after stent installation. We expected to be able to reduce these disadvantages by installing a noncrossing type Y-stent using the Solitaire AB stent, which is fully retrievable with a tapered proximal end. Here we report the techniques and two successful cases.

Low-Profile Laser-Cut Stents for Endovascular Treatment of Intracranial Aneurysms : Incidence, Clinical Presentation and Risk Factors of Thromboembolic Events

PURPOSE

Low-profile intracranial stents are characterized by a miniaturized design that enables deployment via a 0.0165″ or 0.017″ internal diameter microcatheter, which is typically intended for coil delivery. This study analyzed the incidence, clinical relevance and risk factors of thromboembolic events (TEE) occurring during low-profile stent-assisted coiling of intracranial aneurysms.

METHODS

This was a retrospective, multicenter analysis of consecutive patients who underwent stent-assisted aneurysm coiling (SAC) with the laser-cut Acandis Acclino and Neuroform Atlas stents. The study evaluated the incidence of symptomatic and asymptomatic TEEs and the impact on functional outcome. Risk factors for TEEs were determined by univariate and bivariate logistic regression analyses.

RESULTS

Among 131 procedures (mean patient age 56.5 ± 12.8 years, mean aneurysm size: 6.7 ± 3.9 mm) TEEs occurred in 14 cases (10.7%) of which 2 patients (1.5%) developed ischemic stroke, while the remaining TEEs remained asymptomatic. Multivariate analysis revealed Y‑stenting as potential risk factor for TEEs (odds ratio: 3.9, 95% confidence interval: 1.0-16.5; p = 0.08).

CONCLUSION

The use of SAC with low-profile intracranial stents is associated with a favorable safety profile; however, Y‑stenting may carry an increased risk of TEEs, which needs to be considered during treatment planning.

Clinical Importance of the Posterior Inferior Cerebellar Artery: A Review of the Literature

The posterior inferior cerebellar artery (PICA), with its unique anatomical complexity, is of great clinical importance and involved in many diseases including aneurysm, ischemic stroke, neurovascular compression syndrome (NVCS), arteriovenous malformation (AVM), and brain tumor. However, a comprehensive systematic review of the importance of the PICA is currently lacking. In this study, we perform a literature review of PICA by searching all the associated papers in the PUBMED database hoping to provide a better understanding of the artery. The PICA has tortuous and variable course and territory, divided into 5 segments. Various aneurysms involving PICA were not uncommon, of which the treatment is challenging. The PICA infarct typically manifests lateral medullary syndrome (LMS) and is more likely to cause mass effects. The PICA frequently compresses the medulla and the cranial nerves resulting in various neurovascular compression syndromes (NVCS). Arteriovenous malformation (AVM) fed by PICA are associated with aneurysm and dissection which have high risk of rupture and worse outcome. PICA injured by head trauma can cause fatal SAH. VA terminating in PICA probably cause Bow hunter's syndrome (BHS). The PICA supplies many brain tumors and can be used in intracerebellar chemotherapy. The PICA can be exposed and injured during surgeries especially in telovelar approach, and it also plays an important role in bypass surgeries, hinting the surgical importance of PICA. In conclusion, PICA is very important in clinical practice.

Stent-assisted coiling of cerebral aneurysms using the Y-stenting technique: a systematic review and meta-analysis

BACKGROUND

Bifurcation aneurysms can be treated with stent-assisted coiling using two stents in a Y-configuration. We aim to investigate the angiographic and clinical outcomes of Y-stent constructs for the treatment of intracranial aneurysms.

METHODS

A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE databases was conducted based on PRISMA guidelines. The study selection was performed using the 'Ryyan' application. Our analysis included 18 studies with 327 patients. Inclusion criteria were: articles published from January 2000 to November 2017, English language, including cerebral aneurysms treated via Y-stenting, and ≥5 cases with radiographic/clinical outcomes. Technical notes, editorials, reviews, and animal studies were excluded. A random-effect meta-analysis was performed on angiographic and clinical outcomes, including aneurysm occlusion, modified Rankin Scale, neurological outcome, and procedure-related mortality. 95% CIs and event rates were estimated. Statistical heterogeneity was assessed using I² statistics.

RESULTS

The procedure-related good outcome rate was 92% and complete occlusion rate was 91%. The permanent neurological deficit rate was 4% and procedure-related mortality was 2%. The procedure-related stroke rate was 12%. A total of 28/146 (19%) patients had ruptured aneurysms. At long-term follow-up, overall stroke rate was 9% in patients with unruptured aneurysm. The mortality rate was higher in cases with ruptured aneurysms than in those with unruptured aneurysms (18% vs 0.8%; p<0.001).

CONCLUSIONS

Y-stenting for bifurcation aneurysms yields a high rate of complete occlusion and low rates of mortality and stroke. Careful patient selection is needed.

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

BACKGROUND

Y-stent-assisted coiling for wide-neck intracranial aneurysms required further investigation.

PURPOSE

Our aim was to analyze outcomes after Y-stent placement in wide-neck aneurysms.

DATA SOURCES

We performed a systematic search of 3 data bases for studies published from 2000 to 2018.

STUDY SELECTION

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting Y-stent-assisted coiling of wide-neck aneurysms.

DATA ANALYSIS

Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and factors influencing the studied outcomes.

DATA SYNTHESIS

We included 27 studies and 750 aneurysms treated with Y-stent placement. The immediate complete/near-complete occlusion rate was 82.2% (352/468; 95% CI, 71.4%-93%; I² = 92%), whereas the long-term complete/near-complete occlusion rate was 95.4% (564/598; 95% CI, 93.7%-97%; I² = 0%) (mean radiologic follow-up of 14 months). The aneurysm recanalization rate was 3% (20/496; 95% CI, 1.5%-4.5%; I² = 0%), and half of the recanalized aneurysms required retreatment. The treatment-related complication rate was 8.9% (63/614; 95% CI, 5.8%-12.1%; I² = 44%). Morbidity and mortality after treatment were 2.4% (18/540; 95% CI, 1.2%-3.7%; I² = 0%) and 1.1% (5/668; 95% CI, 0.3%-1.9%; I² = 0%), respectively. Crossing Y-stent placement was associated with a slightly lower complication rate compared with the kissing configuration (56/572 = 8.4%; 95% CI, 5%-11%; I² = 46% versus 4/30 = 12.7%; 95% CI, 3%-24%; I² = 0%). Occlusion rates were quite comparable among Enterprise, Neuroform, and LVIS stents, whereas the Enterprise stent was associated with lower rates of complications (8/89 = 6.5%; 95% CI, 1.6%-11%; I² = 0%) compared with the others (20/131 = 14%; 95% CI, 5%-26%; I² = 69% and 9/64 = 11%; 95% CI, 3%-20%; I² = 18%).

LIMITATIONS

This was a small, retrospective series.

CONCLUSIONS

Y-stent-assisted coiling yields high rates of long-term angiographic occlusion, with a relatively low rate of treatment-related complications. Y-stent placement with a crossing configuration appears to be associated with better outcomes. Although Y-configuration can be obtained using many types of stents with comparable occlusion rates, the Enterprise stent is associated with lower complication rates.

Stent-assisted coil embolization of anterior communicating artery aneurysms: safety, effectiveness, and risk factors for procedural complications or recanalization

INTRODUCTION

Stent-assisted coil (SAC) embolization is an alternative treatment option for anterior communicating artery (AcoA) aneurysms. This study was undertaken to assess the safety and effectiveness of SAC embolization in treating AcoA aneurysms and to determine risk factors for related procedural complications or recanalization.

METHODS

Between August 2008 and December 2016, 184 patients with AcoA aneurysms were treated with SAC embolization. Cumulative medical record and radiologic data were analyzed using binary logistic regression to identify factors predisposing to procedural complications or recanalization.

RESULTS

Contralateral A1 segment hypoplasia was observed in 59 patients (32.1%). Three types of stents (LVIS, Enterprise, and Neuroform) were variably placed by one of two routes: (1) ipsilateral A1 to ipsilateral A2 (75.5%) or (2) ipsilateral A1 to contralateral A2 (24.5%). Procedural complications occurred in 17 patients (thromboembolism 12; procedural leakage 3; both 2), showing a significant relation to subarachnoid hemorrhage at presentation (OR 57.750; P<0.01). Occlusion was documented immediately after embolization in 130 aneurysms (70.6%) and, in 23 (13.1%) of 175 AcoA aneurysms followed by angiography (median 25.9±18.5 months), recanalization developed (minor, 15; major, 8). Stent configuration (ipsilateral A1 to contralateral A2, P=0.024), maximum aneurysm size (>7 mm, P<0.01), and A1 segment hypoplasia (P=0.039) were identified as risk factors for recanalization.

CONCLUSION

SAC embolization is a safe and effective method of treating unruptured AcoA aneurysms, regardless of anatomic or clinical features. However, in the event of rupture, procedural complications are likely. Stent configuration, aneurysm size, and A1 segment hypoplasia were identified as significant risk factors for recanalization.

Changing Paradigms in the Endovascular Management of Ruptured Anterior Communicating Artery Aneurysms

BACKGROUND

Approximately 17% of ruptured anterior communicating artery (ACoA) aneurysms were deemed unsuitable for coil embolization during the Barrow Ruptured Aneurysm Trial (BRAT), most commonly due to unfavorable dome-to-neck ratio or small size.

OBJECTIVE

To compare patients treated by coil embolization for ruptured ACoA aneurysms during the trial to those treated after the trial to determine whether advances in endovascular techniques have allowed for effective treatment of these lesions.

METHODS

All cases of ruptured ACoA aneurysms treated by endovascular modalities during BRAT (2003-2007) and post-BRAT (2007-2012) were reviewed for patient and aneurysm characteristics, treatment types, and clinical and angiographic outcomes at 3-yr or last follow-up.

RESULTS

The BRAT ACoA cohort included 39 patients treated with coiling (excluding those crossed over to clipping). The post-BRAT cohort included 93 patients who were significantly older (mean age, 59.5 vs 52.8 yr, P = .005) than the BRAT cohort; there were no significant cohort differences in sex, Hunt and Hess grade, or mean aneurysm size. The use of balloon remodeling was significantly higher in the post-BRAT cohort (31.2% [29/93] vs 5.1% [2/39], P = .001), as was the proportion of wide-necked aneurysms treated (66.7% [62/93] vs 30.8% [12/39], P < .001). There was no significant difference in clinical outcome or retreatment rate between the 2 cohorts (P = .90 and P = .48, respectively).

CONCLUSION

ACoA lesions thought unamenable to endovascular therapy in an earlier randomized trial are now successfully coiled with increased use of adjunctive techniques, without sacrificing patient outcome or treatment durability.

LVIS Jr Device for Y-Stent-Assisted Coil Embolization of Wide-Neck Intracranial Aneurysms: A Multicenter Experience

Background and Purpose

Complex wide-neck intracranial aneurysms are challenging to treat. We report a multicenter experience using the LVIS Jr stent for "Y-stent"-assisted coiling embolization of wide-neck bifurcation aneurysms.

Methods

Seven centers provided retrospective data on patients who underwent Y-stenting. Technical complications, immediate posttreatment angiographic results, clinical outcomes, and imaging follow-up were assessed.

Results

Thirty patients/aneurysms were treated: 15 basilar tip, 8 middle cerebral artery, 4 anterior communicating artery, 1 pericallosal, and 2 posterior inferior cerebellar artery aneurysms. The mean aneurysm size was 11 mm and the mean dome-to-neck ratio was 1.3 mm. Twenty-four aneurysms were unruptured and treated electively, and 6 were acutely ruptured. Fifty-eight LVIS Jr stents were successfully deployed without any technical issue. One pro-cedural and transient in-stent thrombosis resolved with the intravenous infusion of a glycoprotein IIb/IIIa inhibitor. Five periprocedural complications (within 30 days) occurred: 2 periprocedural neurological complications (1 small temporal stroke that presented with transient aphasia and 1 posterior cerebral artery infarct) and 3 nonneurological periprocedural complications (2 retroperitoneal hematomas, and 1 patient developed a disseminated intravascular coagulopathy). One permanent complication (3.3%) directly related to Y-stenting was reported in the patient who suffered the posterior cerebral artery infarct. Immediate complete obliteration (Raymond-Roy Occlusion Classification [RROC] I-II) was achieved in 26 cases (89.6%). Twenty-four patients had clinical and imaging follow-up (mean 5.2 months). Complete angiographic occlusion (RROC I-II) was observed in 23 patients (96%). A good functional outcome with a modified Rankin Scale score ≤2 was achieved in 26 cases.

Conclusions

In this multicenter case series, Y-stent-assisted coiling of wide-neck aneurysms with the LVIS Jr device was feasible and relatively safe. Follow-up imaging demonstrated very low recanalization rates.

Flanking the fenestration: circumferential limb-to-limb stent-assisted coiling of a basilar artery fenestration aneurysm

A man aged 61 years with a history of a ruptured basilar fenestration aneurysm underwent unassisted coiling in 1997 and repeat intervention for a recurrence at the aneurysm mouth in 2011. At repeat intervention, the decision was made to intentionally leave some filling at the base to preserve the parent vessels. Stent-assisted coil embolization, although technically feasible, was not pursued given the relative risks of the procedure. In 2017, the patient returned for repeat surveillance and further coil compaction was found at the aneurysm base. With the advent of more compliant woven stents deliverable through 0.017 microcatheters, stent-assisted coiling was possible. This case demonstrates hereto unseen agility afforded by novel low-profile stents allowing a circumferential approach to a basilar artery fenestration aneurysm and resultant limb-to-limb stent-assisted coiling. Techniques described here may be extended to more common anatomic variants that require stent-assisted coiling.

Flanking the fenestration: circumferential limb-to-limb stent-assisted coiling of a basilar artery fenestration aneurysm

A man aged 61 years with a history of a ruptured basilar fenestration aneurysm underwent unassisted coiling in 1997 and repeat intervention for a recurrence at the aneurysm mouth in 2011. At repeat intervention, the decision was made to intentionally leave some filling at the base to preserve the parent vessels. Stent-assisted coil embolization, although technically feasible, was not pursued given the relative risks of the procedure. In 2017, the patient returned for repeat surveillance and further coil compaction was found at the aneurysm base. With the advent of more compliant woven stents deliverable through 0.017 microcatheters, stent-assisted coiling was possible. This case demonstrates hereto unseen agility afforded by novel low-profile stents allowing a circumferential approach to a basilar artery fenestration aneurysm and resultant limb-to-limb stent-assisted coiling. Techniques described here may be extended to more common anatomic variants that require stent-assisted coiling.

Vascular angular remodeling by kissing-Y stenting in wide necked intracranial bifurcation aneurysms

Introduction

Single stent deployment leads to a change in vascular geometry in wide necked bifurcation aneurysms. In some complex cases, the use of the single stent technique might not be sufficient or may not be feasible. The kissing-Y stenting technique appears to be an alternative endovascular treatment option. The aim of this study was to evaluate the effects of the kissing-Y stenting technique on vascular angular remodeling.

Methods

21 patients with wide necked intracranial bifurcation aneurysms at different sites (10 anterior communicating artery, 6 middle cerebral artery, 3 basilar artery, 1 vertebral artery/posterior inferior cerebellar artery, 1 internal carotid artery/posterior communicating artery) were treated with 44 closed cell stents (follow-up 2012–2016) using the kissing-Y stenting technique. We analyzed vascular angle geometry between the mother and both affected daughter vessels by digital subtraction angiography, before and after stent deployment, using standard working projections.

Results

Endovascular treatment of wide necked intracranial aneurysms using the kissing-Y stenting technique significantly decreased the angle between the bifurcation branches from 130.4±9.5° to 91.5±9.1° (p<0.0001).

Conclusions

Kissing-Y stenting in wide necked bifurcation aneurysms leads to vascular angular remodeling of both affected branches. The resulting straightening of the bifurcation angle may prevent aneurysmal recurrence.

Endovascular treatment of complex intracranial aneurysms using Acandis Acclino stents

Objective

To determine the safety and effectiveness of a new low-profile, laser-cut, closed-cell stent system in the treatment of complex intracranial aneurysms.

Methods

A total number of 43 patients with complex intracranial aneurysms were treated using 60 Acandis Acclino stent systems (follow-up 2012–2016; mean 11 months). 36 patients presented with wide-necked intracranial aneurysms, dissecting aneurysms were seen in 7 patients. 39 patients received stent-assisted coiling. We analyzed demographic data and follow-up results.

Results

Sixty stents were successfully deployed. In one paraophthalmic internal carotid artery aneurysm the stent could not be placed. Thirty-three wide necked aneurysms were treated by single or multiple stent-assisted coiling. Complete occlusion was achieved in 31 of those cases (94% Raymond−Roy occlusion classification, RROC 1). Two patients showed stable residual aneurysmal filling (RROC 3). In three wide-necked aneurysms, sole stenting was the preferred treatment. For dual stent-assisted procedures the kissing-Y stenting technique was successfully performed in 11 aneurysms. In all dissecting aneurysms constructive therapy with stenting and preservation of the affected parent artery was achieved. Additional subsequent coil embolization was intentionally planned and successfully performed in 6 of the 7 dissecting aneurysms. The overall directly procedure-related complication rate was 7%, including one death.

Conclusions

Endovascular treatment of complex intracranial aneurysms using Acclino stents is a feasible and safe procedure with low complication rates. Even severe cases can be treated among others using the kissing-Y stenting technique, with good mid-term results.

Historical Landmarks in the Management of Aneurysms and Arteriovenous Malformations of the Central Nervous System

OBJECTIVE

To describe the history of vascular and endovascular neurosurgery.

METHODS

A literature research was conducted including historical events from 2000 bc to the twenty-first century ad, and a timetable was filled with information regarding the most representative historical landmarks regarding vascular and endovascular neurosurgery.

RESULTS

Starting from approaches limited to the cervical carotid artery, vascular neurosurgery gained its way through the intracranial and finally endovascular space thanks to the introduction of both innovative and progressively less invasive procedures. With the invention of cerebral angiography in 1927, Egas Moniz paved the way for modern endovascular neurosurgery.

CONCLUSIONS

Numerous pioneers have been described through this historical reconstruction. Their genius, effort, dedication, and passion brought a massive contribution to vascular and endovascular neurosurgery as we know it today.