J Korean Neurosurg Soc.  2021 Jan;64(1):136-141. 10.3340/jkns.2019.0253.

Novel Noncrossing Y-Stent Technique Using Tapered Proximal End of a Solitaire AB Stent for Coil Embolization of Wide-Neck Bifurcation Aneurysms

Affiliations
  • 1Department of Neurosurgery, Daejeon-Chungnam Regional Cerebrovascular Center, Chungnam National University Hospital, Chungnam National University Medical School, Daejeon, Korea

Abstract

The crossing Y-stent method is one of the indispensable techniques to achieve sufficient neck coverage during coil embolization of bifurcation aneurysms with a wide neck and/or branch incorporation. However, the inevitable hourglass-like expansion of the second stent at the crossing point can result in insufficient vessel wall apposition, reduced aneurysm neck coverage, delayed endothelialization, and subsequent higher risks of acute or delayed thrombosis. It also interferes with engagement of the microcatheter into the aneurysm after stent installation. We expected to be able to reduce these disadvantages by installing a noncrossing type Y-stent using the Solitaire AB stent, which is fully retrievable with a tapered proximal end. Here we report the techniques and two successful cases.

Keyword

Intracranial aneurysm; Treatment; Stents

Figure

  • Fig. 1. Schematic diagram of the noncrossing Y-stent technique with the Solitaire AB stent. A : The Solitaire AB stent is deployed in one of the bifurcation branches. Note that the proximal part of the stent working zone is aligned with the aneurysm neck. B : The second stent is to be deployed in the other branch. No obstacle was found on the passage of the second microcatheter and stent. C : After full deployment of the second stent that accomplishes a noncrossing Y design, sufficient aneurysmal neck coverage for coil filling is achieved. A microcatheter for coil filling is inserted inside the aneurysmal dome after detachment of the Solitaire stent, and a frame coil was deployed. D : Variation of this technique. A microcatheter for coil filling can be jailed according to the operator’s discretion when the parent artery lumen is sufficient. E : A case in which the proximal tapered end of the Solitaire AB stent is directed at the origin of the opposite branch. By gently pushing of the delivery shaft, the proximal tapered end portion can be installed like the upper portion of the T-PulseRider, and better neck coverage can be achieved. Coil filling with single or multiple catheters may be attempted in this situation without second stent deployment.

  • Fig. 2. This patient has three aneurysms; two in the middle cerebral artery have been occluded with conventional stent-assisted coil embolizations. A : Initial angiogram shows a shallow aneurysm with bleb at the bifurcating type anterior communicating artery. B : A Solitaire AB (4×20 mm) stent is deployed first and a microcatheter for the second stent (Enterprise2 4×30 mm) is delivered to the contralateral distal anterior cerebral artery. C : Reconstructed flat panel detector computed tomography image after successful deployment of the two stents and microcatheter selection in the aneurysm dome showing adequate neck coverage without crossing of stents. D : Final native angiogram after complete coil packing in the aneurysm including the bleb. Proximal and distal markers of Solitaire AB (white arrows) and Enterprise2 (black arrows) stents are indicated.

  • Fig. 3. A patient with wide-neck aneurysm at the distal anterior cerebral artery trifurcation site. A : Initial angiogram. B : The Solitaire AB (4×15 mm) stent is deployed in one of the trifurcation branches as planned. The proximal marker of the stent is noted (arrow). C : Reconstructed flat panel detector computed tomography (CT) image after deployment of the Solitaire AB (4×15 mm) stent, showing that the proximal end of the stent working zone is aligned at the aneurysm neck. Measurement shows an approximately 15 mm- and 10 mm-long working zone (green line) and proximal tapered end portion (orange line) of the Solitaire stent, respectively. The proximal marker of the stent is noted (arrow). D : Native angiogram after successful deployment of a Neuroform Atlas (4.5×30 mm) stent from another distal branch to the proximal vessel via the aneurysm neck. The proximal marker of the Solitaire stent is noted (arrow). E : Another reconstructed flat panel detector CT image after deployment of both stents and microcatheter selection in the aneurysm dome showing adequate neck coverage without crossing of the stents. The proximal marker of the stent is noted (arrow). F : Final native angiogram after coil packing in the aneurysm showing minimal neck remnant and herniated coil loops without flow disturbance. Proximal and distal markers of Solitaire AB (white arrows) and Neuroform Atlas (black arrows) stents are indicated.


Cited by  1 articles

Long-Term Outcomes of Placement of a Single Transverse Stent through the Anterior Communicating Artery via the Nondominant A1 in Coil Embolization of Wide-Necked Anterior Communicating Artery Aneurysms
Seung Pil Ban, O-Ki Kwon, Young Deok Kim
J Korean Neurosurg Soc. 2022;65(1):40-48.    doi: 10.3340/jkns.2021.0191.


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