Stent-assisted WEB repair of an MCA bifurcation aneurysm

CASE PRESENTATION

NEUROIMAGING

• Previously 11mm in greatest dimension in the first 2 DSAs.

DIAGNOSTIC ANGIO

• Final: neck 9mm, width 10mm
• Perpendicular width is 9mm
• Height: 9mm
• Top lobule 8mm by 5mm
• Largest diameter is 15mm

TREATMENT OPTIONS

DEFINITION OF ‘WIDE-NECKED’ ANEURYSM

• Hendricks et al. Wide-neck aneurysms: systematic review of the neurosurgical literature with a focus on definition and clinical implications.

WIDE NECK?

• Hendricks et al. Wide-neck aneurysms: systematic review of the neurosurgical literature with a focus on definition and clinical implications.

ENDOVASCULAR REPAIR

• Double puncture set-up: Shuttle, navien VS Envoy on left.

WEB DEPLOYMENT

• WEB 11x8 over VIA 33 catheter.

PARTIAL WEB DEPLOYMENT

• Insufficient expansion of the WEB to the superomedial portion of the aneurysm. Superior lobule is now adequately covered.

INITIAL DIVERSION EFFECT

STENT PLACEMENT

FINAL DYNA CT

POST REPAIR IMAGING

WEBCAST 1+2 AND FRENCH OBSERVATORY

• Aneurysm size was between 2.8 and 17.0 mm (mean 7.6±2.5 mm). Aneurysm neck size was between 2.4 and 13.8 mm (mean 5.2±1.6 mm).
• The neck was wide (≥4 mm) in 144/169 aneurysms (85.2%). 
• Antiplatelet treatment before and during the procedure is reported in (table 2).
• Antiplatelet activity testing was not performed in all participating centers and was not analyzed.

• Treatment was successfully performed in 163/169 aneurysms (96.4%). Causes of failure were protrusion and subsequent retrieval of the device in two aneurysms, lack of appropriate device sizing in three aneurysms, and inability to deploy the WEB in one aneurysm.

USE OF ADJUNCTIVE DEVICES? (PIEROT)

• 7.4% (12/163) aneurysms treated with WEB
• Coils alone: 4.3% (7)
• Stents or flow diverters: 3.1% (5)

WIDE-NECK ANEURYSMS

• In the American study only the retreated patients used adjunctive devices(?)

POINTS FOR DISCUSSION

• Was the stent really needed?
• Does the aneurysm have features that will lead to retreatment later on?
• Did we use the appropriate size of WEB?
• Difficulties with putting WEB inside aneurysms with large top lobules.