WEB deployment in off-center necks: The added value of balloon assistance

• A 45-year-old woman without any relevant previous medical history was first treated for a RUPTURED Aneurysm of the left MCA bifurcation with a simple coiling.
• The DSA follow-up revealed a small complex, wide-necked, UNRUPTURED Mirror Aneurysm at the Right MCA bifurcation measuring 6 mm width, 4 mm depth, 5 mm neck with a 1.5 mm bleb.

Strategy

After a multidisciplinary discussion, an endovascular approach with an intrasaccular device was selected: WEB SL 6 - 2 mm.

The challenge in this case was that the aneurysm was shallow and, more importantly, the neck was not perfectly aligned with the axis of the parent vessels.

In such situations, specific technical adjustments can further be considered, including the use of a balloon-assisted technique in order to change parent vessels’ anatomy and stabilize the new generation of low-profile VIA microcatheters.

Treatment

• The procedure was performed under general anesthesia via right femoral artery access, through an 80 cm 6F NeuronMax sheath.
• A FargoMax 105 cm (Figure 3 - in blue) intermediate catheter was placed in the right ICA
• A VIA 17 microcatheter (Figure 3 - in green) was advanced into the aneurysm sac over a Synchro Soft 0.014" microwire.

Figure 3

• As expected, once the catheterization of the sac was performed, the microcatheter was off-centered compared to the neck axis

• A Hyperglide 4x10 mm balloon was deployed across the inferior M2 branch to stabilize the microcatheter into the aneurysmal sac, and a 6 x 2 mm WEB™ SL device was then deployed within the aneurysm.

• 3D-rotational angiography with diluted contrast (20%) before detachment confirmed correct device placement and stability, with parent vessel patency

• Final angiograms confirmed optimal WEB positioning, contrast stasis within the device and parent vessel patency

Follow-up – 6-month MRI and IV VASO-CT

Conclusion

• This case highlights the value of a balloon-assisted WEB strategy in treating a wide-neck MCA bifurcation aneurysm with complex angulation. The use of balloon remodelling allowed optimal device positioning and neck coverage while maintaining a purely intrasaccular approach.
• This technique has become much simpler with the new generation of low-profile WEB-compatible microcatheters.
• In this case, simplicity met precision — but when facing a complex bifurcation aneurysm, would you have made the same choice?

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