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A, 3D view of a complex left MCA aneurysm with both superior and inferior trunks of MCA originating from the aneurysm sac. B, Preoperative DSA revealing both trunks of left MCA stented in Y-configuration, creating a neck. C, Six-month control DSA showing stable aneurysm occlusion. D and E, Two-year control angiography with subtracted (D) and nonsubtracted (E) views confirming long-term aneurysm occlusion and MCA bifurcation reconstruction.
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Background and purpose:
The goal of endovascular treatment of cerebral bifurcation aneurysms is to achieve safe coiling of the sac along with preserving patency of the diverging branches. Our purpose was evaluate procedural safety and efficacy as well as the long-term durability of endovascular treatment of bifurcation aneurysms with double stent-...
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Citations
... Altogether, the balloon-and stent-assisted techniques allowed neurointerventionalists to treat aneurysms that otherwise would not have been endovascular targets in the early period of coiling adoption. 69,70 The use of liquid polymer (i.e., Onyx HD 500) in the treatment of aneurysms was a step in the direction toward parent artery reconstruction in the treatment of cerebral aneurysms, 71,72 though the technique faded due to its complexity. The use of covered stents in the cerebral aneurysm treatment provided a transition from the endosaccular to endoluminal treatment with parent artery reconstruction which preceded flow diverters. ...
In this review article, we aim to provide a summary of the discoveries and developments that were instrumental in the evolution of the Neurointerventional field. We begin with developments in the advent of diagnostic cerebral angiography and progress to cerebral aneurysm treatment, embolization in AVMs and ischemic stroke treatment. In the process we discuss many persons who were key in the development and maturation of the field. A pivotal aspect to rapid growth in the field has been the multidisciplinary involvement of the different neuroscience specialties and therefore we close out our discussion with excitement about ongoing and future developments in the field with a focus on treatments in the non- cerebrovascular disease realm.
... In addition, "stent-assisted coiling technique" includes the use of one (or two) stent(s) that is (are) opened between the parent vessel and one (or two) branch(es) of the bifurcation to cover the neck. In particular, when the aneurysm is centered on the bifurcation, it is useful to position two stents in the branches of the bifurcation ("Y-shape") in order to prevent coil protrusion and protect the branches [4,[14][15][16][17] . ...
... In the literature, the adverse events rates range from 2% to 25% in patients treated with Y-stenting with NA [29] . Bartolini et al., in their experience of 105 aneurysms treated with Y and X SAC, report permanent neurological deficit in 10% [15] , while Ciccio et al., on the other hand, assess a 12.7% of symptomatic complications (7/55 patients), including 2 cases (3.6%) of permanent neurological handicaps [25] . Aydin et al. treated 30 aneurysms with NA Y stenting and reported complications in 6.7% of cases, resulting in permanent morbidity in 3.3% of patients [34] . ...
Aim: Endovascular treatment of cerebral bifurcation wide-neck aneurysms remains a therapeutic challenge in terms of safety profile and timely treatment efficacy. The aim of this study is to investigate the very long-term efficacy and safety of Y stenting-assisted coiling with Neuroform Atlas in the treatment of wide-neck bifurcation aneurysms.
Methods: Clinical, procedural and follow-up data were analyzed to evaluate the safety and effectiveness of the treatment with Y-stenting assisted coil strategy (with Neuroform Atlas) in wide-neck bifurcation aneurysms. Endovascular technical aspects were also investigated. Morbidity and mortality were recorded. Digital subtraction angiography (DSA) for mid-term follow-up (12-15 months) and MR-angiography (MRA) for long-term follow-up (24-36 months) and very long-term follow-up (48-60 months) were evaluated in order to assess the efficacy.
Results: The study included 21 Patients (12 Females, 9 Males) aged between 41 and 78 years, with a median age of 60 years. Of the aneurysms treated, 6 belonged to the middle cerebral artery bifurcation (MCA) (28.6%), 10 to the anterior communicating artery (AComA) (47.6%) and 5 to the basilar artery tip (BA) (23.8%). The median aneurysm size and dome/neck ratio were 5 and 1.2 mm, respectively. Technical success was achieved in all 21 cases (100%). No complication related to stent placement was observed. The morbidity rate was 9.5% (2/21) procedure-related; 1 case of intra-procedural SAH and 1 post-procedural stroke were observed. No death was observed. Mid-term DSA, according to the modified Raymond-Roy Occlusion Classification (RROC), showed 16 Class I (76.2%), 4 II (19%), and 1 IIIa (4.8%). Long-term MRA follow-up (24-36 months) showed aneurysm complete occlusion (CO) in 17 cases (80.9%) and residual neck (NR) in 4 cases (19.1%). Very long-term MRA follow-up (48-60 months) confirmed the same rate of occlusion (CO 80.9%; NR 19.1%). Long-term and very long-term MRA follow-up showed vessels’ patency in all cases (100%).
Conclusion: Y-stenting-assisted coil embolization represents a safe and effective technique demonstrating an adequate rate of aneurysm occlusion at long-term follow-up and very long-term follow-up.
... Ancak stentlerin yan yana durduğu proksimal kesimde damar çapı uygun genişlikte olmalıdır. Y stent tekniği %90 "crossing" Y stent tekniğiyle yapılmaktadır [42][43][44]. ...
... Conventionally, for the treatment of wide-neck aneurysms, multiple stents, including X and Y configurations, are required and the periprocedural ischemic complication rate has been shown to increase in such complex cases. 1,2) With the introduction of PR, wide-neck aneurysms are treated with lesser metal coverage of the parental artery, and improvement of the ischemic complication is expected, with early experiences by multiple center registries having widely demonstrated the safety and efficacy of PR. 3,4) However, as the time period from the approval of the PR has been short, inconsequential or rare complications are yet to be reported. Here, we report a rare complication in which the PR could not be detached completely. ...
Objective: Owing to the limited time since the introduction of the PulseRider (PR), inconsequential or rare complications that clinicians should be aware of remain unreported yet. Here, we report a rare complication of incomplete detachment.
Case Presentation: A 50-year-old male underwent PR-assisted coil embolization for a basilar tip aneurysm. Coiling was completed, and the detachment procedure was performed using a detachment machine; the success signal was observed. The delivery microcatheter was subsequently advanced back up to the proximal markers, and no reapproximation of the proximal markers, which indicates successful detachment, was observed. However, only one of the proximal markers returned to the microcatheter, and incomplete detachment of only one leg was detected. Ultimately, electrical detachment was not possible, and physical separation by tension was achieved.
Conclusion: Our case report presents a rare case of a detachment problem in the PR. The PR could not be detached, although the signal revealed successful detachment. Therefore, careful withdrawal of the delivery wire by checking not only the proximal markers but also the behavior of the entire PR and coil complex is important.
... In particular, cases such as the present one, with a complex shape and multiple vessels branching off from the dome (PCA, superior cerebellar artery), are often difficult to treat with the usual balloonassisted technique or the stent-assisted technique using a single stent. Y-configured stenting and other forms of complex stenting have been reported to be useful in such cases, 4) as it is possible to create a scaffold for coil embolization while preserving the branch vessels. This not only ensures placement of the coil inside the aneurysm, but it has been reported that the stent itself has a flow diversion effect and that changing the geometry of the blood vessel modifies blood flow into the 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 strategy of utilizing 2 stents in ABBREVIATIONS: AO, adequate occlusion; AComA, anterior communicating artery; BA, basilar apex; MCA, middle cerebral artery; mRS, modified Rankin Scale; PR, PulseRider; RR, Raymond-Roy; WNBA, wide-necked bifurcation aneurysms a Y-configuration is effective and reliable. [5][6][7][8][9][10] However, Y-stenting remains challenging and requires many steps to be successful. Indeed, there are many potential challenges in case of small branch lumen, very wide neck, steep angulation of bifurcation branches or origin of the branches from the sac. ...
... Moreover, Y-stenting assisted coiling has been accepted as a valid alternative for complex WNBA with good results. [6][7][8][9][10] In the Cagnazzo et al 4 meta-analysis, the immediate AO rate was 82.2%, rising to 95.4% at follow-up with 3% recanalization rate. The complication rate was 8.9%, permanent morbidity and mortality were 2.4% and 1.1%. ...
Background:
Y-stenting is an effective but challenging approach for wide-neck aneurysms. PulseRider (PR) (Pulsar/Cerenovus) is a new device designed to provide scaffolding during coiling but has never been compared with other techniques.
Objective:
To compare the immediate and 6-mo results of Y-stenting vs PR assisted coiling.
Methods:
A total of 105 consecutive patients were retrospectively divided into 2 groups (73 Y-stenting and 32 PR). All underwent angiographic 6-mo follow-up. We evaluated if some anatomical features could influence treatment results.
Results:
The groups were homogeneous. Immediate adequate occlusions as well as complication rates were similar in Y-stenting and PR group (94.5% vs 96.9% and 8.2% vs 6.2%, respectively). At 6 mo, adequate occlusion was 93.1% after Y-stenting and 84.3% after PR (P = .28), complete occlusion was significantly higher after Y-stenting: 90.3% vs 62.5% (P = .0017). Occlusion grade worsening occurred in 6.9% of Y-stenting and 18.7% of PR patients (P = .09).Neck size was associated with occlusion grade in both groups. Maximal aneurysm size was associated with occlusion grade in the PR group (P = .023) but not in the Y-stenting group (P = .06). After PR, 6-mo occlusion rate was higher in small (< 10 mm) than in large aneurysms (P = .0094); this was not observed after Y-stenting (P = .54).Location did not significantly affect the mid-term occlusion rate in both the groups. After PR, occlusion was more stable in basilar than anterior or middle cerebral artery aneurysms.
Conclusion:
Y-stenting and PR are both effective with similar immediate and mid-term results. However, treatment stability seems higher after Y-stenting. Aneurysm size seems to negatively affect PR results.
... They have been developed specifically for bifurcation aneurysms, and most of the cases do not require the use of dual anti-platelet therapy as the endoluminal devices. Therefore, they constitute a promising approach for complex bifurcation aneurysms 7 , and an alternative to other techniques such as Y-stenting and coiling 8,9 . However, not all aneurysms are immediately occluded after implantation of intrasaccular flow diverters. ...
Background and purpose:
Intrasaccular flow diversion offers a promising treatment option for complex bifurcation aneurysms. The purpose of this study was to compare the flow conditions between successfully occluded and incompletely occluded aneurysms treated with intrasaccular devices.
Materials and methods:
The hemodynamics in 18 completely occluded aneurysms after treatment with intrasaccular devices was compared against 18 that were incompletely occluded at follow-up. Hemodynamic and geometric parameters were obtained from computational fluid dynamics models constructed from 3D angiographies. Models of the intrasaccular devices were created and interactively deployed within the vascular models using posttreatment angiography images for guidance. Hemodynamic and geometric variables were compared using the Mann-Whitney test and univariate logistic regression analysis.
Results:
Incomplete occlusion was associated with large posttreatment mean aneurysm inflows (P = .02) and small reductions in the mean inflow rate (P = .01) and inflow concentration index (P = .03). Incompletely occluded aneurysms were larger (P = .002) and had wider necks (P = .004) than completely occluded aneurysms and tended to have more complex flow patterns, though this trend was not significant after adjusting for multiple testing.
Conclusions:
The outcome of cerebral aneurysm treatment with intrasaccular flow diverters is associated with flow conditions created immediately after device implantation. Flow conditions unfavorable for immediate and complete occlusion seem to be created by improper positioning or orientation of the device. Complete occlusion is more difficult to achieve in larger aneurysms, aneurysms with wider necks, and aneurysms with stronger and more complex flows.
... However, single stent-assisted coiling in particular situations does not provide sufficient support when the neck of the aneurysm is centered on the bifurcation branches. In these cases, the use of two stents or Y-stenting has been proposed [9][10][11][12]. From technical point of view this technique remain challenging but it has high immediate and long-term occlusion rates [11].The waffle-cone technique is a feasible alternative to Ystenting and consists of deploying the distal end of a dedicated stent, such as pCONus (Phenox GmbH, Bochum, Germany) and PulseRider (Pulsar Vascular, San Jose, California, USA), inside the aneurysm sac and the proximal end in the parent artery. ...
... This represented an efficient endovascular solution for bifurcation lesions that are too complex for coiling alone, remodeling technique, or single-stent assisted coiling. Several authors have evaluated this technique in retrospective single-center studies, mostly including unruptured aneurysms [9][10][11]. The safety was relatively limited: Bartolini et al. reported 10.0% procedure-related permanent neurologic deficits and 1.0% death [10]. ...
... The safety was relatively limited: Bartolini et al. reported 10.0% procedure-related permanent neurologic deficits and 1.0% death [10]. However, in other studies, the rate of intra-procedural complications was lower, with 4.2% in the study by Limbucci et al. and 2.7% in the study by Yavuz et al. with mortality rates of 2.1% and 0.5%, respectively [9,11]. At longterm follow-up, the rate of complete aneurysm occlusion was high with 85.8% in the Bartolini study, 95.7% in the Yavuz study, and 93.6% in the Limbucci study. ...
Introduction. Despite the use of new techniques, such as Y-stenting, the waffle-cone technique and intrasaccular flow disrupters the treatment of wide-neck bifurcation aneurysms is still challenging, especially for those where adjacent branches are arising at the neck level. Moreover, the use of flow diverter stents in bifurcation aneurysms has been proposed by several teams, although the results remain controversial.
This study is reflecting initial experience in our department with a relatively new device available on the market: Barrel VRD stent. The unique design feature of the device is the “belly-like” central part of the stent which protects the adjacent branches.
Methods. We retrospectively reviewed all patients in whom stenting with braided or laser-cut stents had been performed in our center. Three patients were identified and analyzed. Technical success, complications, immediate angiographic outcomes, procedural data, are reported here.
Results. One MCA bifurcation and two basilar tip large neck aneurysms with one branch arising from the neck level have been identified. Technical success was achieved in all procedures. Overall procedure-related morbidity and mortality was 0%. In the immediate post-treatment angiography, adequate occlusion (neck remnant or total occlusion) was observed in all patients. Short- and mild-term follow-up angiography showed adequate occlusion of the aneurysms.
Conclusions. In this small case series, retrospective single-center analysis we showed that Barrel VRD - stent assisted coiling is a safe and feasible technique. Moreover, it offers an elegant and effective endovascular solution for large neck basilar tip aneurysms on which the neurosurgical clipping remains challenging.
... Several studies of the dual-stent technique for intracranial complex and wide-necked bifurcation aneurysm have been reported, with a greater rate of complete aneurysm occlusion and lower rates of procedure-related complications and aneurysm recanalization. [9][10][11] However, all these studies were single-center case series or case reports with a limited number of patients. Also, to the best of our knowledge, no systematic assessment has been performed of the currently available evidence regarding the safety and efficacy of dual stent-assisted coiling in the treatment of intracranial complex and wide-necked bifurcation aneurysms. ...
... Use of a single stent can only prevent the coil from herniating into 1 daughter branch (stented branch) but cannot prevent the coil from prolapsing into another branch with no stent implanted. 11,43 However, dual stent-assisted coiling can protect both bifurcation branches. Therefore, multistent configurations were developed, including the X-stent, Y-stent, T-stent, and H-stent techniques 9,11,28 (Table 4). ...
... 11,43 However, dual stent-assisted coiling can protect both bifurcation branches. Therefore, multistent configurations were developed, including the X-stent, Y-stent, T-stent, and H-stent techniques 9,11,28 (Table 4). ...
Objective:
To evaluate the safety and efficacy of dual stent-assisted coiling in treatment of intracranial complex and wide-necked bifurcation aneurysms, we have reported our own center experience and performed a systematic review and meta-analysis of the reported data.
Methods:
The experience in our center was reviewed and a comprehensive search of the reported data on dual stent-assisted treatment of intracranial complex and wide-necked bifurcation aneurysms was performed using the databases PubMed, Ovid EMBASE, and Ovid MEDLINE before October 1, 2018. Information was extracted regarding patient demographic data, clinical characteristics, radiographic data, treatment outcomes, complications, and clinical and angiographic follow-up data. The data were analyzed using random effects and fixed effects meta-analyses.
Results:
Including our series of 26 patients, the data from 21 studies with 721 patients were analyzed. The procedure was technically successful in 97.6% (95% confidence interval [CI], 96.5%-98.7%). The complete occlusion rate was 61.6% (95% CI, 47.3%-75.8%) immediately after the procedure compared with 88.4% (95% CI, 84.6%-92.2%) at the last follow-up examination. The rate of periprocedural complications, total complications, procedure-related mortality was 8.8% (95% CI, 5.8%-11.9%), 9.5% (95% CI, 6.2%-12.9%), and 1.1% (95% CI, 0.3%-1.8%), respectively. The recurrence rate, retreatment rate, and good neurologic outcome rate was 3.3% (95% CI, 2.0%-4.7%), 2.7% (95% CI, 1.5%-4.0%), and 96.6% (95% CI, 95.0%-98.1%), respectively.
Conclusions:
The dual stent-assisted coiling technique is a feasible and effective option for the treatment of intracranial complex and wide-necked bifurcation aneurysms. It results in a relatively low rate of procedure-related complications and mortality and recurrence and a high rate of mid-term complete occlusion and good neurologic outcomes.
... While 82.2% of aneurysms were occluded immediately after treatment, nearly 95% of the lesions had complete/near-complete occlusion during the 14 months of radiologic follow-up. The immediate occlusion rate reported in the literature is quite variable, ranging from 50% to 100%, 8,12,13 whereas long-term occlusion rates appear homogeneous. Assessing the heterogeneity of the data, we found a low rate of I 2 for the long-term occlusion rate and a very high rate of I 2 for the immediate occlusion rate. ...
Background: Y-SAC for wide-neck intracranial aneurysms required further investigation.
Purpose: To analyze outcomes after Y-stenting of wide-neck aneurysms.
Data Sources: A systematic search of three databases was performed for studies published from 2000 to 2018.
Study Selection: According to PRISMA guidelines, we included studies reporting Y-SAC 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-stenting. Immediate complete/near complete occlusion rate was 82.2% (352/468,95%CI=71.4-93%,I2=92%), whereas long-term complete/near complete occlusion rate was 95.4% (564/598,95%CI=93.7-97%,I2=0%) (mean radiological follow-up of 14 months). Aneurysm recanalization rate was 3% (20/496,95%CI=1.5-4.5%,I2=0%) and half of the recanalized aneurysms required retratement. 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-stenting was associated with a slightly lower complications rate compared to kissing configuration (56/572=8.4%,95%CI=5-11%,I2=46% vs 4/30=12.7%,95%CI=3-24%,I2=0%). Occlusion rates were quite comparable among Enterprise, Neuroform, and LVIS stents, whereas Enterprise was associated with lower rates of complications (8/89=6.5%,95%CI=1.6-11%,I2=0%) compared to the others (20/131=14%,95%CI=5-26%,I2=69% and 9/64=11%95%CI=3-20%,I2=18%).
Limitations: Small and retrospective series
Conclusions: Y-SAC gives high rate of long-term angiographic occlusion, with a relatively low rate of treatment-related complications. Y-stenting with crossing configuration appears to be associated with better outcomes. Although Y-configuration can be obtained using many types of stent with comparable occlusion rates, Enterprise is associated with lower rates of complications.
Abbreviations: Y-SAC= Y-stent-assisted coiling
