The second day at LINNC Asia 2018 began with the presentation of best cases submitted by the attendees themselves. An interesting treatment of a giant basilar top aneurysm in a 16-year-old boy was presented by Dr. J.H. Shin from Korea. Prof. Moret pointed out that recanalization is the problem in such case when treated only by coils. Using a flow diverter could be a therapeutic option.
We also discussed how to manage dual antiplatelet therapy in young children.
From Pakistan, Dr. M. Noor H.U. Huda presented a nice case report of a 36-year-old patient with post-traumatic arteriovenous fistula.
A distal stroke case was shown by Dr. T.M. Pham from Vietnam, with the discussion focusing on ways to differentiate between thrombus from intracranial stenosis in distal artery occlusions. Dr. Pham also presented the organization of the thrombectomy network in Vietnam.
The first recorded case of the day was a small non-ruptured anterior choroïdal arterial aneurysm treated with the Pipeline flow diverter stent. The Sim&Cure platform was presented by K. Mahadea during the case to show how this software can help in device sizing.
The question of how to deal with neointimal hyperplasia following flow diverter stent deployment was discussed. This discussion, led by Dr. J. Caroff and others from the Bicêtre team, was based on an interesting, recently published paper in the Journal of Neurointerventional Surgery.
We then turned to the second recorded case of the day, a giant unruptured intracavernous ICA aneurysm with very challenging navigation. This required an exchange maneuver in the middle cerebral artery in order to navigate the micro-catheter and deliver a Leo Stent and then two Silk flow diverter stents. Unfortunately, due to the bad compliance in following their dual antiplatelet therapy, the patient developed a thromboembolic complication in the middle cerebral arterial territory on the eighth day post-embolization.
The take-home message to manage these patients was very direct and offered to us by Prof. Moret, "If you don’t follow the therapy, you die!”
After the coffee break, the Balt symposium, presented by Jason Wenderoth, offered the preliminary Australian experience with the low-profile Silk Vista Baby – which is an inspiring innovation in the flow diversion field. An important group of aneurysms, located distally or on smaller branches, is now accessible to endovascular treatment using flow diversion with this new low-profile stent.
The 12th recorded case of LINNC Asia was presented by Prof. Spelle.
An MCA aneurysm was embolized using a WEB device balloon remodeling-assisted technique. This was proposed as a feasible and elegant endovascular solution when compared with other techniques. The optimization of the WEB placement was perfectly demonstrated, despite the wide-neck bifurcation and obtuse angle of the bifurcation branches.
The next recorded case presented an M1 occlusion thrombectomy using a combined technique for aspiration and stent retrieval. An overview of reperfusion therapy highlighted the fact that endovascular treatment is highly beneficial. Skepticism surrounding the use of mechanical thrombectomy in acute stroke appears unnecessary, whatever the time from onset, the severity of the lesion, or the age of the patient.
We then saw an excellent demonstration of the fast, safe and effective treatment of a partially thrombosed MCA aneurysm using a flow diverter. The 6-month follow-up confirmed the complete occlusion of the aneurysm. Coiling this partially thrombosed aneurysm is almost impossible. Hopefully with this device, complex aneurysms, more challenging to treat, will be more easily approached.
Before the lunch break, the Phenox symposium presented the technical features of a new p48 stent in the setting of distal aneurysms.
The last afternoon of the seminar began with a very interesting case of a PICA aneurysm treated with an FD. Anatomical criteria have to be taken into consideration, especially when there is a low origin of the PICA, because the territory involved is more important. Knowledge of anatomy plays a key role in anticipating and preventing complications related to both the treatment and pathology.
We then saw a very surprising recorded case of a marginal clot miming an intracranial stenosis. We still don’t know how to properly identify intracranial stenosis. Further research should focus on identification and treatment of this high-risk subgroup of ICAS patients.
The next recorded case was memorable.
A successful AVM embolization was assured with the occlusion of the draining vein directly by the transvenous approach, permitting a final retrograde reflux into the nidus. This approach requires significant experience in the endovascular treatment of AVMs. Furthermore, advanced anatomical knowledge and careful analysis of the venous and nidal anatomy is required in order to determine security limits for reflux.
To end this last part of the course, a case of AVM associated with dAVF was presented by Dr. Terada from Japan. A very rare lepto-meningeal AVM was well-illustrated from the point of view of the neurointerventionist and neurosurgeon.
This was followed by Dr. Wing Kit Ng from Hong Kong who presented a second case of a foramen magnum dural AV fistula, a rare disease with difficult managements issues.
Prof. Ishihara presented a case of bilateral cervical carotid stenosis post-radiation. While patient selection for carotid stenting vs. endarterectomy is always a difficult choice, in this case, the primary concern was kidney dysfunction. A brilliant combination of both modalities – ultrasound and angiography – allowed Prof. Ishihara to avoid using too much contrast media. Surprisingly, good visibility of the stent apposition during deployment was made possible by ultrasound.
Finally, we ended with a beautiful case of Surpass efficacy in the setting of an PComA aneurysm with a fetal PCA. Flow diversion in this case is a promising, safe and durable endovascular procedure.
We spent two truly great days at this wonderful event in Singapore and we wish you all a good return to your homes and hospitals.
We hope to see you in Miami, FL, USA for the very first Edition of the LINNC AMERICAS 2019 Seminar from March 22nd to 23rd... mark your calendars and be there!
And remember, you can always follow LINNC at LINNC online!
Vanessa Chalumeau & Marta Iacobucci