Double Y-Stenting for stent assisted coil embolisation using 3 pEGASUS HPC

A 72-year-old female presented with daily headaches and vertigo. Meds: Candesartan, Amlodipin,  Xarelto (Afib). 

Imaging revealed large wide neck aneurysms of the distal MCA on both sides (both up to 12 mm in diameter).

We present this case of stent assisted coil embolisation using a triple-pEGASUS implant in a double-Y-configuration to manage this complex wide neck MCA aneurysm.

The MCA aneurysm on the right side revealed a complex shape: 4 branches (2 major M2 branches, 2 minor M2 branches) emerged distant from a wide neck (11 mm).

3D Rotational rendering shows 4 M2 branches (yellow, turquoise, pink, blue) arising from the aneurysm sack at the distal M1 segment (green)

Poll

The plan:

Coil + stent (triple pEGASUS implant)

1. Proximal M1 (green) to minor M2 (turquoise): 4.5x25 mm
2. Proximal M1 (green) to major M2 (pink): 4.5x30 mm. This stent also covers the origin of the minor M2 branch (blue)
3. Proximal M1 (green) to major M2 (yellow): 4.5x30 mm

Plan

4 branches of M1 aneurysm. Red area at neck of aneurysm must remain free of coils to ensure free flow

Treatment

Access:

• Transfemoral, Neuronmax
• Sofia 5F as intermediate
• SL10
• Synchro support 14

Coils:

• 17 in total (Target, Stryker)
• 225 cm total coil length implanted

1st stent: pEGASUS HPC 4.5x30

2nd stent: pEGASUS HPC 4.5x30

3rd stent: pEGASUS HPC 4.5x25

Crossing struts, placing SL10 into aneurysm

Coiling

Finish

Management, evolution, and follow-up

• Patient was released on 2nd day post intervention without symptoms, on prasugrel SAPT
• Follow Up at 6 months shows some compaction
• Currently wait and see, progression of compaction will be met with additional coil embolization

6 months

Comments/Conclusion

• Large (≥10 mm) wide-neck MCA bifurcation aneurysms carry 30–50% recurrence after stand-alone coiling; flow diversion remains controversial here due to perforator/M2 risk
• Triple overlapping Pegasus HPC stenting delivers dense neck scaffolding to approach complex wide neck aneurysm with more than two secondary branches
• The hydrophilic polymer coating reduces thrombogenicity and supports reduced/single antiplatelet regimens.

Take-home: Triple Pegasus HPC stent-assisted coiling is a feasible, branch-preserving option for large wide-neck MCA aneurysms, offering endocascular options with a lighter antiplatelet footprint.

References

• Aguilar-Pérez M, et al. The pCONUS HPC: 30-day and 6-month results of a hydrophilic-coated intrasaccular device for bifurcation aneurysms. Clin Neuroradiol, 2020.
• Henkes H, et al. Hydrophilic polymer coating (HPC) on neurovascular implants: mechanism and clinical application. Interv Neuroradiol, 2021.
• Brinjikji W, et al. Endovascular treatment of middle cerebral artery aneurysms: a systematic review and meta-analysis. AJNR Am J Neuroradiol, 2014

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