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Table of Contents    
ORIGINAL ARTICLE
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 879-882

Endovascular Treatment of Small Wide-Neck Bifurcation Aneurysms with Single Solitaire AB Stent Technique


Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China

Date of Submission11-Oct-2017
Date of Decision01-Apr-2018
Date of Acceptance09-May-2020
Date of Web Publication14-Aug-2021

Correspondence Address:
Prof. James Wang
Changping, Litang Road 168, Beijing, 102218
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.323897

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 » Abstract 


Background and Purpose: We present our experience in using the single Solitaire AB stent for small wide-neck bifurcation aneurysms (WNBAs).
Materials and Methods: During 18 months, 20 small (the largest width <10 mm) WNBAs were treated with the single Solitaire AB stent-assisted coiling. The patients were 12 women and 8 men, with a mean age of 52 years (range: 36–66 years). The mean aneurysm size was 4.2 mm (2–9 mm) and mean neck size was 3.9 mm (2–9 mm). Results at follow-up were graded as complete occlusion, neck remnant, or residual aneurysm.
Results: All 20 small WNBAs were adequately occluded after a single Solitaire AB stent placement. There were no procedural ruptures and no thromboembolic complications occurred. Two patients developed a transient neurological deficit. In 20 patients with angiographic follow-up at 6 months, 16 (80%) aneurysms remained adequately occluded. Clinical follow-up in the 20 patients revealed mRS 0–2 in all.
Conclusions: Single Solitaire AB stent-assisted coil embolization for small WNBAs was safe and effective.


Keywords: Aneurysm, bifurcation, coiling, Solitaire AB stent
Key Message: Although new devices of WEB and mini-stents are available on market, Solitaire AB stent is also a good option for small wide-neck bifurcation aneurysms. The thrombotic complication rate is low for its easy to open and soft property. The Rebar18 catheter is soft and there is no tip wire in Solitaire stent system. The drawbacks Solitaire AB stent are of low obliteration rate for large aneruysms and electric detachable devi


How to cite this article:
Lv X, Zhang W, Zhao X, Zhang H, Wang J. Endovascular Treatment of Small Wide-Neck Bifurcation Aneurysms with Single Solitaire AB Stent Technique. Neurol India 2021;69:879-82

How to cite this URL:
Lv X, Zhang W, Zhao X, Zhang H, Wang J. Endovascular Treatment of Small Wide-Neck Bifurcation Aneurysms with Single Solitaire AB Stent Technique. Neurol India [serial online] 2021 [cited 2021 Oct 22];69:879-82. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/879/323897




Endovascular treatment with coils of wide-neck bifurcation aneurysms remains a technical challenge.[1] To prevent extrusion of coils from the aneurysmal sac, a stent can be used. Recently, an intravascular flow disruptor, Woven EndoBridge (WEB; Sequent Medical, Aliso Viejo, California), has been developed.[2] Experience with the device is preliminary, and ongoing clinical investigation is examining the safety and efficacy. In this article, we present our results of the use of the Solitaire AB stent in treatment of the wide-neck bifurcation aneurysms.


 » Materials and Methods Top


This study was retrospective. Twenty patients and 20 small WNBAs were consecutively treated in our center using a single Solitaire AB stent between October 2015 and April 2017. There were 12 women and 8 men with a mean age of 52 years (range: 36–66 years). Clinical condition at the time of treatment was unruptured in 15 and Hunt and Hess 1–3 in 5 ruptured patients. The timing of treatment after SAH was 2–4 days. Aneurysm location was the middle cerebral artery bifurcation in 6; the basilar artery tip bifurcation in 5, the anterior communicating artery in 4; pericallosal artery bifurcation in 3; basilar-superior cerebella artery bifurcation in 1 and internal carotid bifurcation in 1. The mean aneurysm size was 4.2 mm (range: 2–9 mm) and mean neck size was 3.9 mm (range: 2–9 mm). Of 20 aneurysms, 7 (35%) had a wide neck defined as >4 mm and 13 (65%) had a dome/neck ratio of <1.5.

Medical premedication was initiated in unruptured aneurysms 3 days prior to the procedure with 100 mg of aspirin and 75 mg of clopidogrel per day. In patients who presented with SAH, a loading dose of 300 mg of clopidogrel and 300 mg of aspirin was administered 2 h before treatment. With the patient under general anesthesia, we advanced a microcatheter (Rebar 18, Medtronic) distal to aneurysm and a microcatheter (Echelon10, Medtronic) into the aneurysm via a coaxial or triaxial approach. Distal-access guiding catheters, such as 6 F Navien (Medtronic), are preferably used to enhance the support and stability of the microcatheter in tortuous internal carotid artery. Apart from heparin in the pressure bags for flushing (3000 IU/500 ml), no anticoagulation was used. Solitaire AB stent 4.0 mm × 15 mm was chosen. Coils were placed in the aneurysm dome through the jailed microcatheter [Figure 1], [Figure 2], [Figure 3]. Angiographic follow-up was scheduled at 6 months.
Figure 1: (a) 3D angiogram reveals a 3-mm pericallosal artery aneurysm. (b) After placement of coils in the dome and a Solitaire AB stent 4.0 mm × 15 mm in the neck. (c) Control angiogram with complete occlusion

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Figure 2: (a) Contrast injection through a Navien catheter shows a small anterior communicating artery aneurysm. Note the tortuous ICA. (b) After placement of coils in the dome and a Solitaire AB stent 4.0 mm × 15 mm in the neck. (c) Angiogram demonstrates complete occlusion of the aneurysm

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Figure 3: (a) 3D angiogram reveals an ICA bifurcation aneurysm. (b) Angiogram after placement of a Solitaire AB stent 4.0 mm × 15 mm in the neck, the aneurysm was coiling. (c) Six-month follow-up angiogram with complete occlusion

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 » Results Top


Initial results and complications

All Solitaire AB stent placement can seal of the aneurysm neck; the position of the stent was judged as good. Aneurysms were incompletely occluded in 1 patient with an anterior communicating artery aneurysm and 3 patients with basilar tip aneurysm. There were no procedural ruptures and no complications related to Solitaire AB stent. No thromboembolic complications occurred.

Clinical and imaging follow-up

Of 20 patients, 6-month angiographic follow-up, 16 aneurysms (80%) remained completely occluded. Four aneurysms remained opacification of the central recess. Clinical follow-up in the 20 patients revealed mRS 0–2 in all patients. There were no rebleeds from the ruptured aneurysms during follow-up.


 » Discussion Top


WNBAs present a unique challenge to neurointerventionalists due to a mismatch between mainstream neuroendovascular devices and bifurcation anatomy.[1] Despite significant technological advancements over the past decade, WNBAs remain a significant impediment to the progression of endovascular aneurysm treatment.[1] Our experience with endovascular treatment of small WNBAs by using the Solitaire AB stent seems improved patient outcome.

During the study, once the microcatheter was inside the aneurysm, deployment of the Solitaire AB stent was technically straight forward and quick in most cases. The detachment system proved reliable. The Solitaire AB stent system is slightly soft than Enterprise (Codman)[3] and Neuroform EZ systems (Stryker), and negotiating slack in the microcatheter during advancement may result in unwanted forward or backward movement of the catheter tip. There were no opening difficulties during stent releasing, which may be encountered in LVIS junior stent (Microvention). Solitaire AB stent was a safe and efficient tool in assisting coiling of microaneurysms with wide neck, but may not be suitable for a blaster-like one.[4],[5] Angiographic mid-term follow-up revealed a complete occlusion in 60% aneurysms of the ophthalmic ICA aneurysms.[6] Guo et al. reported that 6 patients with complex, wide-neck, bifurcation cerebral aneurysms were treated using the “waffle-cone” technique.[7] No complications occurred perioperative. There were no lesion-related strokes or deaths during the 6-month follow-up period. In our experience, we feel that the “waffle-cone” technique may not give enough support for coiling. In previous reports, for ICA and VA aneurysms, the follow-up angiography showed that the rate of complete occlusion was 60% to 80%.[8],[9],[10]

In the case of bifurcation aneurysms, thromboembolic complications are especially deleterious, as the respective perforator vessels of each bifurcation frequently supply eloquent brain areas, such as the thalamus by basilar bifurcation perforators. Medium- and large-sized WNBAs often incorporate one or both branch vessels, which are also at significant risk for stent-induced stenosis, occlusion, or distal emboli in Y-stent constructs.[4] The incidence of procedural thromboembolic complications in Y-stent technique was 12% and the mortality rate was 8%.[11] The relatively high metal-to-artery ratio at the intersection of the two stents promotes the conversion of laminar blood flow to turbulent flow, thereby increasing the predisposition to thromboembolic phenomena.[6],[7],[12] However, a recent study reported a 98% good patient outcome was achieved in Y-stent technique using double Neuroform stent for the endovascular treatment of difficult wide-neck bifurcation aneurysms.[13] With specific consideration given to these limitations, we chose single stent for small bifurcation aneurysms.

Flow disruption is a new endovascular approach, which involves the placement of a Woven EndoBridge Device (WEB; Sequent Medical, Aliso Viejo, California), which modifies the blood flow at the level of the neck and induces intraaneurysmal thrombosis.[1],[2] Preliminary clinical evidence with the WEB is promising, although it has been limited to a few small case series with relatively brief follow-up.[14] The WEB did not obviate the need for post-procedural antiplatelet therapy completely. We currently await further evidence to support or refute the utility of these novel devices for WNBA treatment. The burden of proof will be on the WEBs to not only show long-term safety and efficacy for WNBAs but also to demonstrate superiority over existing endovascular and microsurgical approaches.


 » Conclusions Top


Although new devices of WEB and mini-stents are available on market, Solitaire AB stent is also a good option for small wide-neck bifurcation aneurysms. The thrombotic complication rate is low for its easy to open and soft property. The Rebar18 catheter is soft and there is no tip wire in Solitaire stent system. The drawbacks Solitaire AB stent are of low obliteration rate for large aneruysms and electric detachable device.

Financial support and sponsorship

This work was supported by Beijing Municiple Administration of Hospitals Incubating Program(PX2020039), Beijing, China & Tsinghua Precision Medicine Foundation(20219990008), Tsinghua University, Beijing, China.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Ding D. Expanding the boundaries of endovascular aneurysm treatment: Emerging technologies for wide-necked bifurcation aneurysms. Acta Neurochir 2015;157:1049-50.  Back to cited text no. 1
    
2.
Asnafi S, Rouchaud A, Pierot L, Brinjikji W, Murad MH, Kallmes DF. efficacy and safety of the woven endobridge (web) device for the treatment of intracranial aneurysms: A systematic review and meta-analysis. Am J Neuroradiol 2016;37:2287-92.  Back to cited text no. 2
    
3.
Ge H, Jin H, Li Y, Lv X. Extraction of a migrated coil from the Enterprise stent strut using a Solitaire AB stent. Neuroradiol J 2016;29:470-2.  Back to cited text no. 3
    
4.
Li XD, Qin J, Xiao ZY, Feng Y, Chen JK. Solitaire AB stent-assisted coiling of wide-neck micro aneurysms. J Korean Neurosurg Soc 2016;59:341-5.  Back to cited text no. 4
    
5.
Zhang J, Wang D, Li X. Solitaire AB stent-assisted coiling embolization for the treatment of ruptured very small intracranial aneurysms. Exp Ther Med 2015;10:2239-44.  Back to cited text no. 5
    
6.
Gory B, Klisch J, Bonafé A, Mounayer C, Beaujeux R, Moret J, et al. Solitaire AB stent-assisted coiling of wide-necked intracranial aneurysms: Mid-term results from the SOLARE study. Neurosurgery 2014;75:215-9.  Back to cited text no. 6
    
7.
Guo XB, Yan BJ, Guan S. Waffle-cone technique using Solitaire AB stent for endovascular treatment of complex and wide-necked bifurcation cerebral aneurysms. J Neuroimaging 2014;24:599-602.  Back to cited text no. 7
    
8.
Kim SW, Sung SO, Chae KS, Park HS, Lee SH. Clinical and angiographic outcomes of aneurysms treated with two self-expanding stent-assisted coiling systems: A comparison of Solitaire AB and enterprise VRD stents. J Cerebrovasc Endovasc Neurosurg 2015;17:149-56.  Back to cited text no. 8
    
9.
Lee SY, Chae KS, Rho SJ, Choi HK, Park HS, Ghang CG. Clinical and angiographic outcomes of wide-necked aneurysms treated with the Solitaire AB stent. J Cerebrovasc Endovasc Neurosurg 2013;15:158-63.  Back to cited text no. 9
    
10.
Zhang J, Lv X, Yang J, Wu Z. Stent-assisted coil embolization of intracranial aneurysms using Solitaire stent. Neurol India 2012;60:278-82.  Back to cited text no. 10
  [Full text]  
11.
Rahal JP, Dandamudi VS, Safain MG, Malek AM. Double waffle-cone technique using twin Solitaire detachable stents for treatment of an ultra-wide necked aneurysm. J Clin Neurosci 2014;21:1019-23.  Back to cited text no. 11
    
12.
Martínez-Galdámez M, Saura P, Saura J, Martínez A, De Campos JM, Pérez A. Y-stent-assisted coil embolization of anterior circulation aneurysms using two Solitaire AB devices: A single center experience. Interv Neuroradiol 2012;18:158-63.  Back to cited text no. 12
    
13.
Castaño C, Terceño M, Remollo S, García-Sort MR, Domínguez C. Endovascular treatment of wide-neck intracranial bifurcation aneurysms with 'Y'-configuration, double Neuroform stents-assisted coiling technique: Experience in a single center. Interv Neuroradiol 2017;23:362-70.  Back to cited text no. 13
    
14.
Lv X, Zhang Y, Jiang W. Systematic review of Woven EndoBridge for wide-necked bifurcation aneurysms: Complications, adequate occlusion rate, morbidity, and mortality. World Neurosurg. 2018 Feb; 110:20-25.  Back to cited text no. 14
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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