Masterclass #4: I am a bifurcation aneurysm: do I prefer being in a cage or do I prefer being the cage: Y-stenting vs WEB

Christophe COGNARD, Ricardo HANEL, Vitor MENDES PEREIRA, Jacques MORET, Laurent SPELLE

Inside or out? Or nothing at all?

That’s another way of reformulating this Masterclass’s question as Professors Jacques Moret, Laurent Spelle and their expert international panel discuss – and debate - the treatment of bifurcation aneurysms.

• Should all bifurcation aneurysms be treated?
• What is the evidence for endovascular treatment of unruptured aneurysms?
• Since the TEAM trial, have there been any other randomized studies addressing this question?
• Do we know what percentage of unruptured aneurysms change, and if we choose not to treat, how should we follow these patients and the evolution of their aneurysms?

When we do treat a bifurcation aneurysm, should we be using an external caging technique, such as Y-stenting, or is it better to let the aneurysm itself form the cage, as when an intrasaccular device, the Woven EndoBridge (WEB), is employed?

• How do we choose which approach to use?
• WEB alone or coils/balloon? Stenting or Y-stenting and coils? Flow diverters?
• Do we look for simplicity first over complexity? Safety? Efficacy?

Would the choice of strategy differ between a ruptured MCA aneurysm with recurrence – even one that has been clipped or treated with coils, and an unruptured one?

• How important is properly sizing the WEB?
• How does imaging help us to better understand the relationship of the WEB and the side branches or determining the relationship of the neck of the aneurysm and the WEB device when it is deployed?
• Would you be comfortable using a balloon and WEB at the same time?
• What are the primary complications of WEB deployment – thromboembolic complications or a rupture during the deployment of the device?
• Do we have long-term results of WEB in terms of aneurysm recurrence?
• Are coils simpler and with better results in the long term?
• Could intracranial vessel wall imaging play a future role in managing bifurcation aneurysms?

Is this, as Prof Spelle says, a Corneillian dilemma?

To begin looking for an answer, follow these specially chosen cases and enter the debate….