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LINNC Americas 2025 started with a warm introduction from Vitor Mendes Pereira, Laurent Spelle and Jacques Moret, alongside Local Course Directors Michel Frudit, Elias Rabahi and Marco Tulio Rezende. This is an exciting year for LINNC Americas as it is the 10th edition , and for the first time taking place in Brazil.
The program began with two recorded aneurysm cases from Neuri Bicêtre presented by Prof Spelle. He introduced the first case, which was a ruptured wide-neck Acomm aneurysm treated using an intrasaccular WEB device with the small profile (017) delivery system. He demonstrated that despite the immediate post-op angio still showing filling of the aneurysm, the 6-month and 5.5-year follow-up demonstrated robust complete occlusion results. The second case was a complex bilobed Acomm aneurysm which was initially attempted to be treated using balloon-assisted coiling, however, the strategy was switched to treat using a small profile Pipeline Vantage device. Prof Spelle commented on the value of precisely placing the flow diverter so as not to cover side branches unnecessarily, like the frontal branch, which could be preserved in this case.
The next case of the program was dedicated to our first “best cases” series submitted by attendees. Igor Pagiola, a young interventional neuroradiologist from Sao Paulo, Brazil, presented a type 3 Dural AVF treated using a trans-osseous branch from occipital artery approach. He emphasized the value of using a smaller profile intermediate catheter that can be navigated more distally for support, like the Phenom Plus, which could be navigated into the occipital artery providing optimal support in this case.
Next, Prof Moret introduced an interesting case, initially misdiagnosed as a cardio-embolic ischemic stroke based on clinical symptoms alone. He highlighted the importance of performing imaging as part of the clinical work-up, as in fact, on a repeat visit with worsening symptoms, the MR revealed a mycotic dissecting aneurysm with hematoma extension, which was responsible for the patient’s hemiplegic symptoms.
Our next “best case” was presented by Alejandro Venegas, interventional neurosurgeon from Hospital Carlos Van Buren, Chile. He presented a ruptured craniocervical AV fistula with two fistulous points, which he embolized transarterially. He highlighted the ability to protect the parent artery using a stent retriever, which he showed was able to entrap and remove refluxed Squid. Prof Moret discussed that a balloon is also a good alternative to protect the parent artery and Adam Arthur also thought it could be a good case for open surgical approach, highlighting a range of approaches that could be used to treat the same case.
After the coffee break, Prof Mendes Pereira took the stage to present the first case from St. Michael’s Hospital in Toronto, performed together with our RADIS lab research team. This was a residual giant paraclinoid ICA Terminus aneurysm which was previously treated using flow diversion and coiling.
Neuro OCT imaging was used during the retreatment and provided invaluable information that informed the cause of the stenosis and helped plan effective landing zones for the second stent, which was difficult to visualize on DSA imaging due to the large coil mass. nOCT will undoubtedly change the way we understand neurovascular diseases and help inform treatment decisions in the future.
Prof Moret presented the next case of a 2-month-old baby with a Vein of Galen malformation which was successfully treated over two sessions, performed two months apart, using injection of Onyx through a Scepter Mini balloon. He highlighted the value of reusing the same DSA roadmap throughout the case by utilizing the SmartMask feature (Philips) to save contrast and radiation dose for treatment of young babies, like this one.
We then moved on to an industry-sponsored case discussion from Stryker Neurovascular. Course director, Prof Mendes Pereira spoke about his experience with the flow diverter, Surpass EVOLVE and detachable Target Tetra coils. He reviewed our publications from the RADIS lab highlighting the enhanced flow diversion properties of 64-wire designs over previous 48-wire devices in a controlled experimental set-up, as well as Surpass EVOLVE clinical trial results which showed excellent occlusion and follow-up results.
He also explained that the unique tetrahedral shape of the Target Tetra coil makes it easier to treat small aneurysms as they have a strong shape retention, as demonstrated in various case examples.
After lunch, we introduced Ricardo Hanel to the stage to give his personal perspective on the WEB to celebrate the 15th Anniversary of the device during the Terumo-sponsored symposium. Dr. Hanel is a pioneer in this field, having led numerous international trials. He presented the history of WEB trials and a series of cases, highlighting the importance of proper sizing of the WEB and the value of planning software such as Sim & Cure, which can improve treatment outcomes and prevent the need for aneurysm re-treatment.
Going back to our recorded cases from Bicêtre, Prof Spelle presented a fenestrated ruptured Acomm aneurysm that he treated using a Target Tetra coil with balloon remodelling. We always appreciate the self-deprecating humour of our French colleagues, who after losing access during his first coil deployment attempt, reminded us that if you have a balloon prepared, you should inflate it before you start coiling!
Next to take the stage was another one of our “best case” highlights from Justin Costello, neurointerventionalist from UT Southwestern Medical Centre, who reviewed endovascular techniques and current literature for embolization of spinal CSF venous fistulae. He showed that transvenous embolization is a promising technique for management of intracranial hypotension, secondary to CVF, by demonstrating great technical success rates and very low rates of major complication.
Prof Moret presented two cases from Bicêtre, the first using a new intrasaccular flow disruptor, the Artisse device. He commented that the delivery of this device is similar to the WEB, with a key difference being the ‘ball’-like shape of the base. The second case he presented was the treatment of a dural AVF using a transvenous approach to deploy HydroCoils and inject PHIL liquid embolic (25%). He reminded us that it is possible to cannulate an occluded inferior petrosal sinus, as demonstrated in this case.
Our next “best case” speaker was James Lord from the University Health Network in Toronto who presented a high-grade torcular DAVF which was treated using transvenous coiling of the distal straight sinus and proximal right transverse sinus with Onyx. He highlighted a few tricks used by their team, including placing a second MC in case their primary access got kicked out, and protection of the vein of Labbe using a balloon in the sinus.
After our afternoon coffee break, local Brazilian course organizer Elias Rabahi began our complications session, “the Dark Side of INR”. He presented a complicated treatment of a congenital dural sinus malformation that reinforced the importance of doing a full angiographic study at the beginning of the procedure to know what anatomy you are dealing with from the beginning. In this case, there was a dural anastomosis, believe it or not- they do exist! Prof Spelle presented the second case of the session, which showed us a technique of injecting glue to manage a wire perforation during stroke. An interesting discussion about the importance of general anesthesia vs. conscious sedation arose after this case.
The next case was presented by Marco Tulio, who showed the treatment of a dural AVF by arterial approach while protecting the venous sinus with a Copernic balloon. Despite perfect management of the case, bleeding occurred a few hours after the end of the procedure, raising the importance of understanding venous anatomy while treating these kinds of lesions.
Prof Moret presented the treatment of a ruptured tectal AVM using an arterial approach with Squid that refluxed. He taught us that care must be taken during withdrawal of the microcatheter in this situation to prevent a subarachnoid hemorrhage. Our final case was presented by Michel Frudit who discussed when and perhaps when not to dilate a FDS when malapposition is seen.
Complications can arise from various factors, but it is important to find teaching from these experiences and share them so we can all learn from one another.
At the end of the day, the course directors surprised Prof Moret with a slide show commemorating the incredible career and legacy that he has had in this field. Everyone shared memories and gratitude for the knowledge and training he has given all of his mentees. Prof Moret also expressed his gratitude for all of us, his pupils and peers, who to him, he said, are truly like family.
That concluded the first day of LINNC Americas 2025. We leave you today with this photo of the fun gift the Course Directors and Local Faculty gave to Prof Moret. Stay tuned for the report on Day 2.
Reported by Nicole Cancelliere
MRT(R), MSc(Research Program Manager and Co-lead of the RADIS lab at St. Michael’s Hospital, Toronto).
