Complex right middle cerebral media artery (MCA) aneurysm treatment with Pipeline™ Vantage with Shield Technology™ and RIST™ radial system

Authors: Rodríguez Paz Carlos Manuel, Rojas Jiménez Ana María

Check how proximal support influences the deployment of a flow-diverting stent

• Case presentation

  Patient situation

  Woman with incidental finding of an aneurysm on examination for meningitis. mRS 0. Inmunodepressed due to treatment for autoimmune hepatitis.

  • 68-year-old female patient 
  • Non-ruptured incidental 7 mm right MCA aneurysm. PHASES score 2; UIATS score 10/10. Elective treatment was decided as a committee based on the patient's desire and due to the irregularity of the aneurysmal sac.
  • Surgery was contraindicated due to comorbidity.

   

  Preparation for the intervention

  Seven days before, double antiplatelet therapy was prescribed and started with a loading dose of 300 mg of clopidogrel, followed by 75 mg and 100 mg of acetylsalicylic acid every 24 hours. Liver disease was not considered a contraindication. Platelet aggregation test was not performed.

   

  

  Volume rendering of the rotational angiography. Bifurcation wide neck and multilobular aneurysm in the middle cerebral artery.

  

  Volume rendering of rotational subtraction angiography. Optimal delivery of the distal end of the Pipeline Vantage device.

  

  MIP reconstruction of the MRI angiographic series. Before the treatment (right) and 6 months after the treatment (left).

  

  Simulation of the stent placement with the Sim & Cure software.

   

• Intervention

  Treatment chosen

  In this case the first treatment option was surgery. It was contraindicated due to comorbidity. For endovascular treatment, embolization with coils or intrasaccular devices does not seem suitable due to the lobulations and wide neck. We opted for the placement of a flow-diverting stent in the thickest M2 branch. Radial access was chosen to minimize puncture complications.

   

  Intervention

  • General anesthesia
  • Ultrasound-guided puncture of the distal radial artery (dTRA) in the right anatomical snuffbox.
  • Short 5F sheath was placed and 3,000 IU of heparin and 100 micrograms of nitroglycerin were administered.
  • This introducer was then exchanged for a 100 cm RIST catheter.
  • The internal carotid artery was selectively catheterized with a Simmons 130cm catheter and the distal part of the guide catheter was positioned in the distal extracranial internal carotid
  • A three-dimensional angiography was acquired for simulation and selection of the flow-diverting stent to be implanted. Pipeline™Vantage 3x20.
  • 0,021 microcatheter (Phenom™ 21 - compatible with selected device)
  • 0,014 micro guidewire (Traxcess™)
  • 5Fr 125cm selective catheter (Merit™)
  • An intracranial catheter was not necessary
  • Tip: The key to the success of the procedure was resolving the instability of the microcatheter in the M2 segment. This was achieved by advancing the RistTM guide catheter into the cavernous carotid.

   

  

  Volume rendering of rotational subtraction angiography. Optimal delivery of the proximal end of the Pipeline Vantage device.

  

  Standard non-subtraction angiography. Optimal delivery of the distal end of the Pipeline Vantage device.

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• Results

  Simple procedure that ends without complications. Good evolution during admission. Discharge 48 hours after the procedure. 8 months later, she remains asymptomatic, the aneurysm is closed in the control with magnetic resonance imaging.

  • The stent was deployed in the desired position with correct apposition to the walls.
  • No complications were demonstrated in the control series
  • The patient was discharged in 48 hours.
  • In the follow-up MRI at 8 months, the aneurysm is excluded, the branch covered by the stent is permeable, with a smaller caliber than in the pre-intervention study. She remains asymptomatic.

   

  This case is sponsored by Medtronic.

   

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