Technical note
X-microstenting and transmesh coiling in the management of wide-necked tent-like anterior communicating artery aneurysms

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Abstract

Anterior communicating artery (AcomA) aneurysms frequently have wide necks and an irregular shape, incorporate parent vessels, and are associated with significant variations in vascular anatomy. Safe and complete endovascular occlusion of these aneurysms usually requires the assistance of combined approaches using balloons and stents in an individually tailored strategy. We describe a technique for X-configured stent-assisted coiling in the management of a small tricuspid tent-like wide-necked AcomA aneurysm by means of two crossed nitinol self-expandable Leo+ Baby stents (Balt Therapeutics, Montmorency, France) followed by “in stent” transmesh coiling. The addition of a low-profile stent into the neurointerventional armamentarium will substantially enhance our capability to treat previously uncoilable tent-like AcomA aneurysms.

Introduction

Anterior communicating artery (AcomA) aneurysms are among the most challenging aneurysms for both microsurgical clipping and endovascular techniques [1], [2]. AcomA aneurysms frequently have wide necks and an irregular shape, incorporate parent vessels, and are associated with significant variations in vascular anatomy. Safe and complete endovascular occlusion of these aneurysms usually requires the assistance of combined approaches using balloons and stents in an individually tailored strategy.

X-configured stent-assisted coiling for the treatment of wide-neck and complex AcomA aneurysms has recently been described [3]. This technique requires double crossing from A1 to the contralateral A2, through the AcomA, with relatively large (0.021) microcatheters in order to navigate stents that are usually indicated for vessels over 2 mm in diameter; it was thus originally described as appropriate only for specific AcomA complex anatomy and diameter.

A recently introduced low-profile nitinol self-expandable stent (Leo+ Baby, Balt Therapeutics, Montmorency, France) that can be navigated through a regular coiling microcatheter is promising to expand the use of stents for neurovascular indications. We report the use of this microstent in X-stenting for the treatment of a symptomatic AcomA aneurysm in a patient with small anterior cerebral arteries.

Section snippets

Case report

A 54-year-old woman presented to our Neurosurgery Department with a history of sudden onset severe headaches that began 3 days before admission. The patient had an unremarkable medical history and her neurological examination was normal.

Noncontrast head CT scan was negative for subarachnoid hemorrhage; however, CT angiogram showed a small wide-necked AcomA aneurysm and subarachnoid hemorrhage was then confirmed by lumbar puncture. Cerebral angiogram followed by bilateral internal carotid artery

Discussion

Endovascular coil embolization for the treatment of wide-necked cerebral aneurysms has progressed substantially after the introduction of specially designed self-expanding stents for neurointerventional use. Stents are used not only as a scaffold for safe coiling (stent-assisted coiling), but have proven to allow better initial occlusion rates while sparing the parent artery lumen. Moreover, stents have been shown to stabilize aneurysm occlusion and decrease recanalization due to their effects

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

Acknowledgements

The authors wish to thank Shifra Fraifeld, a research associate and senior medical writer in the Hadassah-Hebrew University Medical Center, for her editorial contribution to the preparation of this manuscript.

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