Bridging the neck: eCLIPS for a previously ruptured middle cerebral artery aneurysm

CASE PRESENTATION

• Initial measurement 9mm x 5mm x 6mm, with murphy’s teat and a neck of 3mm
• Angio 8mm on maximal diameter
• 4mm to 7mm filling remnant on MRI July to October.      
• February post-treatment 3mm remnant   
• Also with pericallosal and acomm complex aneurysm

INITIAL NEUROIMAGING: 07-2019

ENDOVASCULAR REPAIR: 07-2019

• 2 coils placed
• 6mm by 26mm Cosmos Microplex
• 6mm by 6mm Hypersoft Helical

PRE AND POST REPAIR IMAGING

• MRI done a day after: 4mm remnant from previous 5mm

RECURRENCE: JULY TO OCTOBER 2019

• 4mm to 7mm remnant

ENDOVASCULAR REPAIR: 2-2020

• Red arrow on larger M2 branch measuring 2mm in width

eCLIPS DEVICE

eCLIPS + COILS: BILATERAL GROIN ACCESS

• Two Vascular Access PointsRight: 6F x 80 cm Shuttle + 0.072 x 105cm
• Navien Intermediate Catheter + Headway 27 Microcatheter + eCLIPS device
• Left: 5F x 11 cm Femoral sheath + 5F x 100cm Envoy catheter + Headway 17 microcatheter + Coils

ENDOVASCULAR REPAIR PLAN

• Secure the neck
  • Deploy the eCLIPS through the Headway 27 in the inferior M2 branch and across the neck of the aneurysm
• Coil the residual

  • Coil the residual portion of the aneurysm by crossing the eCLIPS leaf with the Headway 17

     

eCLIPS POSITIONING

COILING THROUGH eCLIPS

• 5mM x 15 helis
• 3mm x 4cm helix
• 3mm x 4cm helix
• 2.5mm x 3cm
• 2.5mm x 3cm
• 2.5mm x 6cm
• 2.5mm x 4cm
• ALL HELIX

PRE AND POST REPAIR IMAGING

• MRI one day after recoiling: 3mm remnant

   

PHYSIOLOGIC REMODELING

CLINICAL OUTCOMES

• Thirty-three patients were treated between June 2013 and September 2015. Twenty-five (76%) patients had successful placement of an eCLIPs device; 23 (92%) of these 25 patients had complete data. Eight cases of non-deployment occurred during the 1st year of use, consistent with a learning curve; no failures of deployment occurred thereafter. 
• Two periprocedural transient ischemic attacks and 2 asymptomatic thrombotic events occurred. Twenty-one (91%) of 23 patients underwent follow-up at an average of 8 months (range 3–18 months); 9 (42.9%) of these 21 patients demonstrated an improvement in Raymond grade at follow-up; no cases of worsening Raymond grade were recorded, and 17 (81.0%) patients sustained a modified Raymond-Roy Classification class of I or II angiographic result at follow-up.
• Two delayed ruptures were recorded, both in previously coiled, symptomatic giant aneurysms where the device was used as a part of a salvage strategy.

POINTS FOR DISCUSSION

• Clipping on initial presentation? 
• Would other devices have gotten better results?
• What are the properties of the eCLIPS device that make it unique?
• What aneurysm characteristics make it suitable for the eCLIPS device?

ENDOVASCULAR FIRST FOR RUPTURED MCAs

ONGOING TRIALS: EESIS