The day began with the very same topic with which we ended the first day: giant fusiform and partially thrombosed basilar artery aneurysms. U. Limaye presented his series of 26 patients whose treatment involved, for most of these cases, flow diverters. He presented the problems he encountered in some of these patients, highlighting the difficulty of treating this kind of pathology.
Then K. Chen showed us a case of a fusiform BA aneurysm which had been successfully treated by partial coiling and reconstruction of the parent artery with braided stents. This case had a good clinical and anatomic outcome, highlighting the problem of the biological activity inherent in the aneurysm wall.
Other case presentations, taking place during the morning and afternoon sessions, looked at thromboaspiration of a per-coronarography emboli of basilar tip (H.A. Khazatsin), balloon remodeling of a ruptured complex MCA aneurysm (S.S. Islam) and two brain AVM treatments (Dr. Shadad and A. Nurhasyim).
Using the first two recorded cases, Professor L. Spelle illustrated the problem of blood flow in branches covered by a flow diverter.
The first case was an illustration of the danger of covering big branches. We saw that these might need active blood pressure support until a new pressure balance is established, while the recovering of small perforators proved to be less problematic. This was a recurring basilar tip aneurysm treated by a flow diverter placed from the right P1 to the basilar artery. Whereas, the left PCA and superior cerebellar artery were supplied by a sufficient cross flow, the patient experienced a hemodynamic stroke of the covered right superior cerebellar artery in the early postoperative period.
The second case was a lateral irregular wide neck aneurysm of the basilar artery. The patient had a perforator stroke two weeks after positioning of the flow diverter due to its imperfect apposition in the proximal section.
In conclusion, Professor L. Spelle advocated routine complementary balloon-plasty of the flow-diverter whenever necessary.
The following topic concerned the “Y-stenting” technique.
Professor J. Moret demonstrated some very useful “tips and tricks” essential to treatment success; illustrating these with two recorded cases of MCA bifurcation aneurysms treatments with braided stents. The first stent should be deployed in the branch which is the most difficult to catheterize, it is important to size the stent adequately in order to anchor it well in order to avoid displacing it in subsequent maneuvers. Then, you should give some push on the braided stent while deploying it at the level of the neck in order to enlarge the struts.
This “Y stenting” technique is a “competing” strategy with the WEB device and flow diverter stents for bifurcation aneurysms. The afternoon session saw Professor L. Spelle presenting a recorded case for each of these latter two techniques, both of which are technically easier.
First, a recurrent giant left MCA aneurysm was treated with a flow diverter between M1 and the temporal branch showing good angiographic long-term follow-up.
Second, an incidental basilar tip aneurysm was treated with a WEB device with a very short pr
ocedure time. In this case, the WEB protruded into the vessel lumen, closing the origin of the left PCA, but no rescue stenting was required because of a good cross flow from the PComm.
Later, using another recorded case of an MCA bifurcation aneurysm, Professor L. Spelle presented the management of intraprocedural aneurysmal perforation in a patient receiving dual antiplatelet therapy. First, the systemic heparinization had to be reversed and then the bleeding was tempered by coiling. In this situation, a micro-balloon was very useful since it offered the possibility of controlling bleeding and could be employed, at the same time, as a remodeling technique.
A difficult temporal AVM case with deep venous drainage was then presented to the participants. Professor J. Moret explained the necessity of adapting a clear strategy during the treatment of AVMs, from targeted embolization to a complete occlusion. Nonetheless, the question at which point to stop Onyx injection comes up regularly and he advised us not to stop before the draining vein ceases to opacify on the angiographic control.
Professor J. Moret also presented the case of a tricky spinal dural fistula which he treated with diluted glue, demonstrating that it behaves almost like Onyx…and encouraging us to inject the glue as slowly as possible.
Further, during the second day, two cases of acute stroke were presented with proximal MCA occlusions. These could be completely recanalized: one, by thrombectomy using an Embotrap retriever, plus distal aspiration with an intermediate catheter; the other, by thrombectomy with a Trevo retriever and flow inversion with a balloon guiding catheter.
It was of great interest that during the two days of the seminar we saw different ways of performing thrombectomies, and yet current understanding makes it less than clear how to choose the best method since, at this point in time, there are no comparative studies.
The day’s program also included two sponsored symposiums in which the speakers shared their experiences of the braided Leo Baby stent (T. Struffert), the Silk flow diverter (T.C. Cuong), and a partially permeable membrane covered stent, the XCalibur (S. Joseph).
We would like to thank everyone who attended for participating and making the discussions so interesting, and to all speakers for sharing their experience during these two very intense days in Singapore. We look forward to seeing you all again in March 2018 for the next LINNC seminar in New York and, of course, at LINNC Paris in June!
Dr. Leon Ikka
> Back to Day 1: The LINNC Seminar is back and Singapore is the host!