J Cerebrovasc Endovasc Neurosurg.  2018 Sep;20(3):181-186. 10.7461/jcen.2018.20.3.181.

Endovascular Coiling for a Wide-neck Bifurcated Aneurysm with Anterograde Horizontal Stenting via Microcatheter Looping: A Technical Case Report

Affiliations
  • 1Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea. ace988161@gmail.com
  • 2Department of Neurosurgery, Gangwon National University College of Medicine, Chuncheon, Korea.

Abstract

Technical advances with devices such as catheters, balloons, and stents have widened the indications for endovascular coiling for unfavorable aneurysms. The authors report two cases of coil embolization for a wide-neck bifurcated aneurysm with anterograde horizontal stenting via microcatheter looping. Two women, aged 56 and 38 years, respectively, had an undertall- and overwide-neck aneurysm with bifurcated branches at the basilar bifurcation and middle cerebral bifurcation, respectively. The delivery microcatheter was steamed so that it could be looped deliberately to the opposite vessel. The enterprise stent was first anchored to the vessel of the posterior cerebral artery on one side. The remaining portion was spanned into a looped microcatheter to the opposite branch while pushing the stent. The Neuroform Atlas stent was passed directly through the looped segment of the microcatheter at the M2 branch and spanned horizontally by unsheathing. Under horizontal stenting, complete coil embolization was achieved without immediate or delayed complications in both cases. This novel technique presents a viable option for stent-assisted coiling within an optimal anatomy.

Keyword

Intervention; Intracranial aneurysm; Stent; Catheter

MeSH Terms

Aneurysm*
Catheters
Embolization, Therapeutic
Female
Humans
Intracranial Aneurysm
Posterior Cerebral Artery
Steam
Stents*
Steam

Figure

  • Fig. 1 (A) For a BABIF aneurysm, a microcatheter was selected and a delivery microcatheter was navigated into the right PCA. Note the shape of the undertall- and overwide-neck aneurysm in the anteroposterior plane. (B) Anchoring the proximal portion of the Enterprise stent to the right PCA by microcatheter unsheathing and stent pushing. (C) As the stent is pushed, the steamed curved portion of the delivery microcatheter is moved toward the contralateral PCA, with final deployment by unsheathing. (D) The Vaso-CT image that confirmed the horizontal stenting. (E) Framing achieved with the stent. (F) Complete stent-assisted coil embolization. BABIF = basilar bifurcation; PCA = posterior cerebellar artery; CT = computed tomography.

  • Fig. 2 (A) Initial ruptured MCBIF aneurysm completely treated with a double microcatheter. (B) Neck growth seen as an undertall- and overwide-neck aneurysm with vessel branches 2 years after the initial treatment. (C) The delivery microcatheter is looped from the inferior to the superior trunk of the MCA. (D) A Neuroform Atlas stent placed directly over the looping segment with control of tension. (E) Complete stent-assisted coil embolization. (F) The Vaso-CT image that confirmed the stenting. MCBIF = middle cerebral bifurcation; MCA = middle cerebral artery; CT = computed tomography.

  • Fig. 3 (A) Initially, the distal segment of Enterprise stent (short size) is expanded to secure the vessel wall via pushing the microcatheter (0.021 inch). (B) As pushed the microcatheter, steamed looped part (asterisk) moves into the contralateral trunk of basilar artery bifurcation. The proximal marker of the stent needs to be positioned below the neck. (C) The horizontal stenting is achieved by unsheathing of microcatheter. (D) The microcatheter (0.0165 inch) is positioned from the superior to the inferior trunk of the middle cerebral artery via steamed looping part (asterisk). (E) As the Neuroform Atlas was pushed, the stent directly passes the looping segment and deploys. (F) The horizontal stenting is achieved by holding the stent delivery wire and unsheathing of microcatheter.


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