Wide-neck Bifurcation Aneurysms Research Articles

The outcomes of recurrent wide-necked intracranial aneurysms treated with the Woven EndoBridge (WEB): A retrospective bicenter study

BackgroundThe Woven EndoBridge (WEB) is a device for the treatment of intracranial wide-necked bifurcation aneurysms. The safety and effectiveness of WEB for intracranial aneurysms have both been evaluated in previous trials. Our aim was to study the outcomes of recurrent intracranial aneurysms (IAs) treated with WEB. MethodsClinical and radiological outcomes of patients with a wide-necked aneurysm recurrence, which was treated with WEB device, were assessed. Imaging follow-up was performed with digital subtraction angiography and/or magnetic resonance angiography. Aneurysm occlusion was determined using by the Raymond-Roy Occlusion Classification (RROC). RROC 1 and RROC 2 were considered as adequate radiological outcome. ResultsTwenty-two patients with 23 recurrent IAs were treated with WEB. Of which, 17 of recurrent IAs (74%) previously treated by coiling, three (13%) by clipping and three (13%) by WEB. The most common location of the recurrent IA was the middle cerebral artery (n = 10, 43%). Endovascular treatment with WEB alone was suitable for 20 recurrent IAs (87%). Ancillary devices were also used: coils in two (9%), and a stent in one (4%). Radiological follow-up results available for all patients (range: 3–60 months; median 24 months). Adequate occlusion (RROC I and II) was achieved in 20 recurrent IAs (87%). A hemorrhagic complication occurred 2 weeks post treatment in one patient (5%). ConclusionsWEB could be an effective treatment with low rates of complications for challenging cases of recurrent wide-necked IAs.

WEB device for treatment of posterior communicating artery aneurysms

BackgroundWoven EndoBridge (WEB) device treatment of wide-neck bifurcation aneurysms has proved to be safe and effective, but the use of these devices in sidewall aneurysms has been reported only in...

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

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

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

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

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

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

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

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. 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. 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. 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.

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

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 invitro model of the basilar artery using flat-panel computed tomography. 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). 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). In constant anatomy, cross-sectional geometry of the KDB stent configuration will vary depending on the design and structure of the stents employed.

Intrasaccular Flow Disruption with the Woven EndoBridge for Narrow-Necked Aneurysms: A Safety and Feasibility Study

The Woven EndoBridge (WEB) received U.S. Food and Drug Administration approval for endovascular treatment of wide-necked bifurcation aneurysms. We evaluated the feasibility, safety, and efficacy of the WEB for treatment of narrow-necked aneurysms. This multicenter study included 17 narrow-necked aneurysms, defined by a neck width <4 mm anda dome-to-neck ratio >2. Aneurysm characteristics, treatment strategies, technical success, complications, and angiographic outcomes were retrospectively assessed. Aneurysm locations included the internal carotid artery (7 cases), anterior communicating artery (4 cases), middle cerebral artery (4 cases), and basilar artery (2 cases). The median aneurysm size was 7.4 mm with a median neck width of 2.3 mm. The technical success rate was 100%. There were no neurological complications. Angiographic control revealed complete and adequate occlusion in 13 of 15 (86.7%) and 14 of 15 (93.3%) cases, respectively, after 6 months and in 6 of 7 (85.6%) and 7 of 7 (100%) cases, respectively, after a median of 13 months. Two aneurysms were retreated with flow diverters. WEB embolization of narrow-necked aneurysms was technically feasible and safe and might be considered as an alternative treatment option to conventional coiling in selected cases.

Intracranial aneurysm treatment with WEB and adjunctive stent: preliminary evaluation in a single-center series

BackgroundIntrasaccular flow disruption with WEB is a safe and efficacious technique that has significantly changed endovascular management of wide-neck bifurcation aneurysms (WNBAs). Use of stent in combination with WEB is...

Combination of temporary bridging device (Comaneci) and permanent stenting in the treatment of unruptured wide neck bifurcation aneurysms.

The double stent-assisted techniques for the treatment of wide neck bifurcation aneurysms (WNBAs) may be more complicating than single stent-assisted or balloon-assisted coiling. The Comaneci device (Rapid Medical, Yokneam, Israel) is a new temporary bridging device developed for covering the aneurysm neck during coiling. This new design enabled us to treat unruptured WNBAs with the use of single stent-assisted coiling instead of double stent in eight patients. At the 1-year angiographic follow-up, there was no filling in any aneurysm. There was no mortality or morbidity cases related to the procedure. In this study, we are reporting our experience of using single stent-assisted coiling combined with a Comaneci device in the treatment of unruptured WNBAs.

The Woven EndoBridge embolization device for the treatment of intracranial wide-necked bifurcation aneurysms.

Wide-necked bifurcation aneurysms are common when evaluating both ruptured and unruptured intracranial aneurysms and can pose unique challenges. The WovenEndoBridgedevice (recently approved in the US) is specifically designed for the treatment of these aneurysms. This article serves to introduce the device to a wider audience with a thorough review of the literature, device design, indications, pre-operative evaluation, procedural usage and potential pitfalls.

The Woven Endobridge as a treatment for acutely ruptured aneurysms: A review of the literature.

The Woven Endobridge (WEB; Microvention, Aliso Viejo, California, USA) is a relatively new device which has been shown to be safe and effective for the treatment of wide necked bifurcation aneurysms in multiple prospective Good Clinical Practice studies. However, the vast majority of aneurysms included in these studies have been unruptured. The aim of this review is to summarise the current evidence available on the treatment of ruptured aneurysms with the WEB.

Woven EndoBridge device for ruptured aneurysms: perioperative results of a US multicenter experience

BackgroundThe Woven EndoBridge (WEB) device is approved in the USA for treatment of unruptured wide-neck bifurcation aneurysms. However, the safety and effectiveness of the WEB device in the treatment of...

Volume-based sizing of the Woven EndoBridge (WEB) device: A preliminary assessment of a novel method for device size selection.

Accurate sizing of the Woven EndoBridge (WEB) device is of critical importance as it determines procedural safety and successful occlusion of wide neck bifurcation aneurysms. The aim of this study was to assess the ability of aneurysm volume to assist in accurate WEB size selection. All patients with an intracranial aneurysm treated with the WEB SL or WEB SLS device between March 2019 and October 2019 were identified for this retrospective study. Aneurysm volumes were calculated with auto-segmentation using a three-dimensional volume rendering program on an independent Syngo workstation (Siemens Healthineers AG). Pearson correlation coefficients were calculated for aneurysm auto-segmented volumes and WEB volumes, as well as for aneurysm height × width and WEB height × width. Follow-up angiographic outcomes were collected at 6-9 months post-procedure. Twenty-nine aneurysms were evaluated by 3D rotational angiography. The correlation coefficient with WEB size was larger for auto-segmented aneurysm volumes (r = 0.979) compared to height × width measurements (r = 0.867). Using Fisher r-to-z transformations, we found the difference between the two correlations to be statistically significant (p = 0.0007). Follow-up angiography available in 13 subjects demonstrated an 85% complete aneurysm occlusion rate. Aneurysm volumes are highly correlated with WEB volumes, with auto-segmentation volumes displaying statistically significant difference against conventional height by width measurements. These results suggest that volumetric measurements of aneurysm size provide a useful adjuvant measure to assist in appropriate size selection of the WEB device.

Endovascular Treatment of Small Wide-Neck Bifurcation Aneurysms with Single Solitaire AB Stent Technique.

We present our experience in using the single Solitaire AB stent for small wide-neck bifurcation aneurysms (WNBAs). During 18 months, 20 small (the largest width <10 mm) WNBAs were treated with the single Solitaire AB stent-assisted coiling. The patients were 12 women and 8 men, with a mean age of 52 years (range: 36-66 years). The mean aneurysm size was 4.2 mm (2-9 mm) and mean neck size was 3.9 mm (2-9 mm). Results at follow-up were graded as complete occlusion, neck remnant, or residual aneurysm. All 20 small WNBAs were adequately occluded after a single Solitaire AB stent placement. There were no procedural ruptures and no thromboembolic complications occurred. Two patients developed a transient neurological deficit. In 20 patients with angiographic follow-up at 6 months, 16 (80%) aneurysms remained adequately occluded. Clinical follow-up in the 20 patients revealed mRS 0-2 in all. Single Solitaire AB stent-assisted coil embolization for small WNBAs was safe and effective.

Strut remodeling with hypercompliant balloon: A new approach to Y stent-assisted coil embolization in the treatment of complex wide-neck bifurcation aneurysms.

The objective of this study was to present the long-term safety and effectiveness of strand remodelling with a hypercompliant balloon. Patients with complex wide-neck bifurcation aneurysms (WNBAs) who underwent strand remodelling with a hypercompliant balloon via Y-stent-assisted coil embolization (Y-SACE) between September 2016 and January 2020 were included in the study. The feasibility, safety, effectiveness, and complication rates of the strand remodelling technique were investigated. A total of 12 patients (6 females, 6 males) were included in this study. Significant expansion was obtained in the intersection zone after remodelling. No regression was observed in the expansion rates during follow-up. There was no additional morbidity or mortality. No delayed thromboembolic complications occurred in our patients during long-term follow-up. Performing strand remodelling to reduce thromboembolic complications triggered by structural faults caused by the Y-stent configuration is feasible, safe, and effective. This new approach can aid in the prevention of thromboembolic complications in Y-SACE.

Particle Image Velocimetry Measurements of the Flow-Diverting Effects of a New Generation of the eCLIPs Implant for the Treatment of Intracranial Bifurcation Aneurysms

Flow diverters (FDs) for the endovascular treatment of intracranial aneurysms are effective for sidewall aneurysms, but their use at a bifurcation is problematic because FDs only partially cover the aneurysm neck and impede flow into a daughter branch; they are thus not employed routinely in this anatomy. eCLIPs was developed as a non-tubular implant to completely cover the neck of an aneurysm and serve as a coil retention device necessary for the adequate treatment of wide-neck bifurcation aneurysms. eCLIPs has shown some flow diversion effects in bifurcation anatomy but not equal to those exhibited by clinically accepted flow diverters in sidewall anatomy. A new generation of eCLIPs implant, the eCLIPs bifurcation flow diverter (eBFD), with higher metal coverage, was developed to achieve a similar flow diversion as a Pipeline Embolization Device (PED), a prototypical FD. Particle image velocimetry was used to capture the fluid dynamics and velocity reduction within silicone aneurysm replicas. A circulatory mimicking loop was developed to circulate the flow through the silicone models. All generations of eCLIPs implants had some flow-diverting effect, with increasing metal coverage density of the implant proportionately increasing the flow diversion effect. The eBFD, with a metal density of 35%, showed greater flow diversion than PED, with 30% metal density, for bifurcation anatomy. The eBFD showed similar reduction of flow in a bifurcation anatomy to PED in a sidewall, both sufficient to permit early thrombosis of the aneurysm. Thus, the eBFD can potentially provide sufficient flow diversion for the treatment of bifurcation aneurysms to avoid adjunctive coiling.

Technical aspects of combined intrasaccular and endoluminal flow diversion.

The concurrent use of endoluminal flow diversion with coils is a viable option when treating complex or large aneurysms. Alternatives to coil embolization as an adjunctive treatment are currently limited. The Food and Drug Administration recently approved the Woven EndoBridge (WEB) device (Microvention, Aliso Viejo, California) as an intrasaccular flow diverter for wide-neck bifurcation aneurysms. We present the technical aspects of combined WEB device plus endoluminal flow diversion for the treatment of complex wide-necked intracranial aneurysms. A retrospective chart review of all patients treated via intrasaccular flow diversion at a single institution over the last 12 months was performed. In total, seven patients underwent treatment of eight aneurysms via combined intrasaccular and endoluminal flow diversion. Of the seven patients, six were treated in a single setting. The most common aneurysm location was the posterior communicating artery. The majority of the aneurysms required steam shaping of the Via deployment catheter to place the WEB device orthogonally to the aneurysm dome. There were no complications. We believe this is one of the first series reporting the combined use of the WEB device and endoluminal flow diversion for the treatment of intracranial aneurysms. This series demonstrates that the concurrent use of the WEB device with endoluminal flow diversion is safe for achieving immediate aneurysm treatment and may enhance the long-term durability in complex aneurysms.

Analysis of branch artery orifice angulation: Feasibility of the shelf technique for the treatment of wide-neck bifurcation aneurysms.

The aim of this study was to investigate the feasibility of the shelf technique by analyzing the angle between the two branch orifices and to present its safety and effectiveness compared with that of the double-stent technique. Patients with complex wide-neck bifurcation aneurysms (WNBAs) who underwent stent-assisted coiling (SAC) were reviewed. The study sample was divided into two groups: single SAC (shelf technique) and double SAC. The angle between the lines connecting the superior and inferior points of each branch orifice (α angle) was measured by two neurointerventional radiologists in both groups. The inter- and intraobserver repeatability and consistency of the α angle were assessed. The effect of the α angle on the feasibility of using the shelf technique to treat WNBA was analyzed. Technical and clinical success rates were investigated by comparing both groups. Forty-eight patients (32 shelf technique and 16 double-stent technique) were included. There was excellent agreement between the intra- and interobserver repeatability and consistency of α angle measurements. The α angle was smaller in the shelf technique group than in the double-SAC group (p < 0.001). The technical and clinical success rates of both groups were similar based on long-term follow-up (p > 0.05). WNBA treatment with the shelf technique is safe and effective. The α angle is a useful parameter to evaluate the performance of the shelf technique. The shelf technique is more suitable for WNBAs with a narrow α angle.

Transcirculation approach for stent-assisted coiling of intracranial aneurysms: a multicenter study

BackgroundThe transcirculation approach (TCA) for stent-assisted coiling (SAC) of intracranial aneurysms may be useful for certain wide-neck bifurcation aneurysms as well as those with acute-angle efferent branches.ObjectiveTo describe a multicenter...