Snare Wars - The catheter strikes back

Samer AL ALI

A woman in her 40s with an incidental 5 mm PCom aneurysm and a strong family history of rupture was offered endovascular treatment. During deployment of the intrasaccular device, a complication occurred, leading to a creative rescue using a 2 mm gooseneck snare.
Don’t miss this case of precise troubleshooting and smart decision-making presented by Samer Al-Ali, winner of the LINNC online 2025 Clinical Case Contest .

Case presentation

Normally fit and well female in her 40s
Incidental finding of a 5mm left PCom aneurysm after investigations for a seizure
Smoker
Family history of ruptured cerebral aneurysms in a first-degree relative
Offered endovascular embolisation

Snare Wars - May the fix be with you - Figure 1

DSA

Snare Wars - May the fix be with you - Figure 2

Snare Wars - May the fix be with you - Figure 3

Following the initial DSA and 3D, decision was made to treat with a WEB device.

Snare Wars - May the fix be with you - Figure 4

Snare Wars - May the fix be with you - Figure 5

Average height = 3.3 mm
Average width = 4 mm

Procedure

GA. 6-French radial access. Co-axial system.
Benchmark/MPA/Terumo used to access the left ICA for angiography and 3D.
90-degree Via 17 with Synchro wire to cannulate aneurysm. WEB 4.5 x 2mm device deployed.
Good result on deployment with complete aneurysm coverage, early stasis and maintained patency of the small PCom vessel.

Snare Wars - May the fix be with you - Figure 6

Detachment

During detachment, the VIA 17 catheter jumped forward, compressing the WEB device within the aneurysm sac, causing a significant neck residual.

Solution

Snare Wars - May the fix be with you - Figure 7

A 2mm Amplatz gooseneck snare device was used to “capture” the proximal marker
At this point, the WEB device could have been retrieved and the procedure started again

Instead, the WEB device was repositioned with gentle traction on the captured marker. Once a satisfactory appearance was achieved, the marker was released.

Final Run

The end of procedure angiogram showed an excellent result with signs of early aneurysm occlusion.

Result

Snare Wars - May the fix be with you - Figure 8

Snare Wars - May the fix be with you - Figure 9

Discussion

WEB devices are a useful solution for the treatment of wide-necked intracranial aneurysms, but can otherwise also provide a straightforward “one and done” solution for the treatment of many intracranial aneurysms.
An excess of retained tension within the deployment catheter can result in forward “jumping” of the catheter on WEB deployment.
The use of snare devices has been shown to be useful in the retrieval of intracranial devices such as the WEB device.
This case describes the successful use of a 2mm gooseneck snare to “capture” the proximal marker of a mal-positioned WEB device and re-adjust the position without the need for retrieval and re-deployment of the WEB device.

References

Chew, H. S., Altibi, M., Al-Ali, S., Butler, B., Butt, W., Chavda, S., & Lamin, S. (2024). Microsnare retrieval as a bail-out technique of Detached Woven EndoBridge device: Illustrative series. Interventional Neuroradiology.

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