Together again! The First day at LINNC PARIS 2024

WITH A FIRST LIVE CASE FROM S.I.S CAN THO GENERAL HOSPITAL IN VIETNAM.

Our first case of LINNC Paris 2024 was a live transmission from Vietnam where a 72-year-old patient with an unruptured pericallosal artery aneurysm treated with Silk Vista baby 2.75x20 mm. This case was presented by Nhat Huy Nguyen Dao.

This was followed by a good discussion by Prof. Christophe Cognard about whether there was a need to treat this aneurysm since it was a distal aneurysm in a 72-year-old patient.

We also were able to further discuss in detail about the differences in treatment options such as stent assisted coiling, but the best option still seemed to be flow diversion (FD).

COURSE DIRECTOR’S CHOICE INNOVATION:

eCLIPS

eCLIPS are an endovascular clip system which was presented by Tom Marotta from Canada who, as one of the originators of this device, was able to speak about the development of eCLIPS which can be helpful in the treatment of bifurcation aneurysms.

Some cases were also presented using eCLIPS which demonstrated promising results of complete occlusion in angiographic controls. eCLIPS may prove to be a promising strategy for wide-neck aneurysms.

SECOND LIVE CASE – AND THE FIRST FROM PARIS – BICETRE WITH DR. CRISTIAN MIHALEA

This case involved a 48-year-old with a ruptured anterior communicating aneurysm that had been treated with WEB recanalization. The “live” case involved a re-treatment using a Fred Jr FD.

This led to a discussion about the systematic use of tirofiban in all FD use cases involving a bifurcation by the Bicetre team.

This was perhaps the most challenging case presented this morning with the most complex part being how to correctly choose the location to deliver the stent so that it ended in the right A1 segment.

A THIRD LIVE CASE, THIS TIME FROM VIETNAM

This was a case of intracranial stenosis of the left internal carotid artery in the communicating segment which led to an important discussion with Prof. Raul Nogueira speaking about the need to treat the stenosis, making it necessary to evaluate the MRI in order to check whether there is cortical ischemia or just the anterior choroidal artery symptom.

Another major discussion concerning this was about the possible techniques for performing angioplasty:

1) An exchange maneuver for angioplasty and then stenting

2) A balloon-mounted stent

3) New systems that do not require exchange maneuvers, such as the Credo Neurospeed system.

A FOURTH LIVE CASE FROM PARIS BICETRE WITH DR. VANESSA CHALUMEAU

This was the case of a 60-year-old patient with an incidental finding of an aneurysm of the right MCA which was prepared using a Sim & Cure simulation and an intrasaccular device (Artisse and WEB). It wasn’t possible to do the treatment with the intrasaccular device and so the decision was taken to use Trenza coils.

This opened the floor to a discussion about the possibility of treatment with an intrasaccular device or the Trenza. There were further discussions about the kick back that occurs when using the Trenza, which can be a problem for its use.

We also discussed the need for a trial comparing neurosurgery or endovascular surgery for MCA aneurysms.

An interesting point brought up by Prof. Laurent Spelle was the use of a radiological protection cabin that will make it possible in the future, after studies, to carry out treatment without the use of radiological protection aprons. The protective cabin is being used at Bicêtre but studies are still being carried out to approve its use without a lead apron.

FIFTH LIVE CASE FROM TORONO CANADA – PROF. VITOR MENDES PEREIRA

The following case was of a 58-year-old patient with previous subarachnoid hemorrhage (SAH) of an AcoA aneurysm with recanalization during follow-up. The treatment proposal involved the use of a WEB device and, if necessary, the use of a stent.

The first discussion was about whether there was any real need for treatment in the first place, though everyone agreed that it should be treated.  Then, an important point was brought up by Prof. Adnan Sidiqqui who discussed the need for bilateral puncture in some cases, which meant we need to be prepared for any complications that could arise, which is exactly what Prof. Vitor Mendes Pereira did in this case.

SIXTH CASE LIVE FROM PARIS – DR. LEON IKKA

A patient with multiple and previously treated aneurysms as well as recanalization of the pericallosal aneurysm was treated in this live case using an FD P64 MW that allows for manipulation of the guide during stent deployment.

This led to a very good discussion about which aneurysm should be treated and why the pericallosal. In addition, we spoke about the characteristics of the aneurysm wall that can influence the risk of bleeding. An important point that Prof. Jacques Moret raised was about the early embryological origin of the ACA and why it is the most common site of hemorrhage.

It was a great advantage using the P64 MW which offers the possibility of moving the micro guide during stent release. There was also an important discussion about the use of both hands to control the release of the stent and the movement of the micro catheter. Finally there was a vasospasm on the ACA that was very well managed by the infusion of nimodipine.

A MICROVENTION SYMPOSIUM

During this industry partner symposium, data was presented from the study on the use of LVIS EVO and hydro coils with very good results and, in addition, data was also presented on the use of SOFIA and SOFIA PLUS. The SESAME study by Prof. Markus Möhlenbruch demonstrated excellent results of the use of SOFIA as first line aspiration choice.

Prof. Raul Nogueira led a good discussion which offered the hypothesis of having good results influenced by the low NIH with LVO.

A SEVENTH LIVE CASE FROM PARIS WITH DR. CRISTIAN MIHALEA

A 61-year-old patient with two incidental aneurysms of the anterior communicating artery and M1 segment with a hypoplastic right A1 segment was treated.

Treatment was performed using a WEB intrasaccular device. With the help of Sim & Size, the 9x4 size was chosen and the treatment was carried out after having used a Sim & Train flow model the week before the actual live procedure.

Before the procedure Dr. Cristian Mihalea performed an occlusion test demonstrating that it was the right A1 segment that supplied the entire ACA bilaterally with occlusion of the left internal carotid artery. A major technical difference was the use of the Aristotle 24 microwire, which provides more support for the VIA 27 navigation for the WEB release.

During the treatment, only the CEREBASE long sheath was used as it was necessary to use a VIA 27 and a balloon and it was not possible to pass these two through a guiding catheter. As a result, there was no support for progressing the WEB beyond the carotid siphon, which was very angulated. A headway 17 was used inside the VIA 33 to provide more support, be able to pass more distally, and position the WEB through the VIA 33 and thus be able to perform the treatment.

During the treatment, Prof. Jacques Moret remembered that this is the beauty of live cases, where we can see the problems that can occur during treatments. But while it is necessary so that we can see the difficulties of a treatment, it is essential to keep the operator out of contact with the audience so that they can concentrate on the case.

AN EIGHTH LIVE CASE FROM CANADA WITH PROF. VITOR MENDES PEREIRA

This case involved a 73-year-old patient with an incidental aneurysm at the P1 and P2 junction of the right posterior cerebral artery.

In this case, Prof. Mendes Pereira demonstrated the use of a Fargomini to provide more support for a Silk Vista Baby used in this treatment. It was a beautiful navigation via the posterior communicating artery using a Headway 17 microcatheter. And the case was completed with a perfect release of the Silk vis baby stent which landed precisely in the posterior communicating artery.