LVIS-within-enterprise double-stent procedure without coiling beneficial as treatment of unruptured vertebral artery dissecting aneurysms

Stenting of vertebral artery dissecting aneurysms (VADAs) may promote mural apposition of intimal flaps, preserving the patency of injured vessels. Moreover, stent deployment may serve to alter intra-aneurysm flow, inducing saccular thrombus formation, neointimal development, and remodeling of injured vessels. Although an overlapping multistent strategy with coiling has proven successful in this setting, yielding good anatomic and clinical outcomes, coiling may be technically infeasible in some VADAs with unfavorably configured circumferential elevations. Herein, we describe three patients with VADAs for whom coiling was deemed technically problematic. Each underwent double stenting (LVIS within Enterprise), without coil insertion, using local anesthesia. Conventional angiographic follow-up regularly disclosed excellent saccular occlusion and subsequent remodeling of stented arteries. LVIS-within-Enterprise double stenting may be of particular benefit in patients with VADAs, the Enterprise providing outer support to minimize stent bulging (as a fusiform aneurysm) as the inner LVIS reinforces flow diversion.

Stenting of left main bifurcation lesion using modified double-kissing culotte technique

Left main coronary artery bifurcation represents one of the most challenging settings for the interventional cardiologists. The conventional stents are designed and shaped to restore tubular geometry, while the left main coronary artery bifurcation is far more complex with different diameters and non-tubular cross-sections. In relevant patients, two stent strategy is preferred over provisional T-stenting. The double-kissing crush has been the preferred double stent technique. We present a case in which the double-kissing approach was used in left main coronary artery bifurcation stenting with the culotte technique, which resulted in good angiographic outcome and no malapposition. Patient was stable even at 4 months follow-up.

Safety and Efficacy of Endovascular Therapy for Blood Blister-Like Aneurysms: Willis Covered Stents and Double Stents Assistant Coils—A Single Center Cohort Study

Objective: To summarize and discuss the application of Willis covered stents (WCSs) and double stent-assisted coils in the treatment of blood blister-like aneurysms (BBAs).Materials and Methods: Thirty-two patients with BBAs treated from January 2015 to October 2020 were included in the study. Among them, 18 were treated using WCSs and 14 using double stents-assisted coils. The indications for treatment, perioperative findings, and postoperative follow-up results were collected and analyzed.Results: All 32 patients had successful stent deployments. Complete aneurysm occlusion was achieved in all 18 patients treated with WCSs immediately. WCS-related adverse events included 2 cases of mild vasospasm and 4 aggressive procedure-related vasospasms during WCS deployment, a case of dissection after WCS deployment, and 1 death due to ipsilateral temporal lobe rebleeding at the sixth day after WCS deployment. In patients treated with double stent-assisted coils, there were 3 cases of neck remnants, 1 acute occlusion of the ipsilateral MCA branch, and 4 mild procedure-related intraoperative vasospasms. The mean follow-up period was 4.2±1.6 months (range 3–6 months). Follow-up imaging data were available for 25 patients (78.1%). In the first postoperative angiographic follow-up, all BBAs were completely occluded. Mild asymptomatic stent stenosis was observed in 3 patients treated with WCSs. Follow-up examination at 6 months after the employment of WCSs showed that the modified Rankin score (mRs) was 0 in 6 patients, 1 in 5 patients, 2 in 3 patients, 3 in 1 patient, 4 in 2 patients, and 6 in 1 patient. After treatment with double stents-assisted coils, the mRs was 0 in 4 patients, 1 in 5 patients, 2 in 3 patients, and 4 in 2 patients.Conclusions: WCSs and double stent-assisted coils for the treatment of BBAs are both safe and efficient. WCSs provide a higher rate of immediate occlusion; however, there was no significant difference in the long term.

Haemodynamic Analysis of Single And Double Bare-metal Stents For Coronary Artery Aneurysm

Background The aim of this study was to investigate a novel method to treat coronary artery aneurysms(CAAs).Methods Three CAAs patients who underwent single or double bare-metal stent implantation were recruited. The CAAs and parent artery diameters were measured for model construction. Single- and double-stent implantation were simulated, and the changes in the CAAs haemodynamics after stenting were analysed. Results In Case 1, the flow velocity in the single-stent model was significantly lower than that in the double-stent model (0.0046±0.013 vs 0.0050±0.011, p<0.001), while the pressure (127.33±18.03 vs 121.19±26.92, p<0.001) and wall shear stress (WSS, 0.28±1.19 vs 0.22±1.13, p<0.001) were significantly higher. In Case 2, the flow velocity (0.005±0.011 vs 0.007±0.01, p<0.001) and WSS (0.17±0.82 vs 0.23±0.88, p<0.001) in the double-stent model were significantly lower than those in the single-stent model, while the pressure was significantly higher(117.70±10.07 vs 110.64±6.34, p<0.001). The same tendency was also observed in Case 3. All CAAs occluded during the follow-up period without obvious in-stent restenosis.Conclusion Application of the single or double bare-metal stent technique, according to the neck diameter of the coronary artery aneurysms, can effectively change the flow in vessels and aneurysm haemodynamics to achieve occlusion.Trail registration: Clinicaltrails, NCT04265989. Registered 12 February 2020, https://clinicaltrials.gov/ct2/show/NCT04265989?term=NCT04265989&draw=2&rank=1

Long-term outcomes of wide-necked intracranial bifurcation aneurysms treated with T-stent–assisted coiling

OBJECTIVEThe endovascular treatment of complex bifurcation aneurysms possessing a neck that incorporates multiple side branches remains a surgical challenge. Double-stent–assisted coiling techniques, such as those with stents in an X and Y configuration, enable the endovascular treatment of wide-necked complex intracranial bifurcation aneurysms. However, the intraluminal struts at the intersection point in X- and Y-stents are not amenable to endothelialization, which may lead to thromboembolic complications. Stenting in the T configuration is a relatively new double-stent coiling technique. T-stenting differs from X- or Y-stenting in that there are no overlapping or intersecting stent segments. Promising short-term results of T-stent–assisted coiling were recently reported. However, the long-term results have not yet been demonstrated. This retrospective study investigated the long-term angiographic and clinical results in patients with wide-necked complex intracranial bifurcation aneurysms treated with T-stent–assisted coiling.METHODSA retrospective review was performed to identify patients with wide-necked complex intracranial bifurcation aneurysms treated with T-stent–assisted coiling at 4 institutions. The technical success and the initial and follow-up clinical and angiographic outcomes were assessed. Aneurysm filling status was assessed according to the Raymond classification. Periprocedural and delayed complications were reviewed. The neurological status of the patients was evaluated using the modified Rankin Scale (mRS).RESULTSOne hundred two aneurysms in 102 patients (54 females), whose mean age was 57.9 ± 13.0 years, were included in the study. T-stenting was performed successfully in all patients. Immediate postprocedural angiography revealed complete occlusion in 83.3% of patients. Periprocedural complications developed in 13.7%, resulting in permanent morbidity in 1.9% and death in 1%. Eighty patients (78.4%) had at least one follow-up DSA examination performed at 6 months or later following the endovascular procedure. The mean duration of angiographic follow-up was 30.0 ± 16.3 months. The last follow-up examinations showed complete occlusion in 90.0% of patients. During the follow-up period, only 1 patient (1.3%) required retreatment. Delayed thromboembolic complications were observed in 4 patients (3.9%) without permanent morbidity. The mRS scores of all patients at the last clinical follow-up were between 0 and 2.CONCLUSIONSThe short-term angiographic findings showed that T-stent–assisted coiling is a feasible and effective endovascular method to treat wide-necked complex bifurcation aneurysms. The long-term angiographic follow-up results suggest that T-stent–assisted coiling provides a durable treatment for wide-necked complex bifurcation aneurysms with favorable clinical outcomes, demonstrating the long-term safety of T-stent–assisted coiling.

Analysis of branch artery orifice angulation: Feasibility of the shelf technique for the treatment of wide-neck bifurcation aneurysms

Background and purpose The aim of this study was to investigate the feasibility of the shelf technique by analyzing the angle between the two branch orifices and to present its safety and effectiveness compared with that of the double-stent technique. Materials and methods Patients with complex wide-neck bifurcation aneurysms (WNBAs) who underwent stent-assisted coiling (SAC) were reviewed. The study sample was divided into two groups: single SAC (shelf technique) and double SAC. The angle between the lines connecting the superior and inferior points of each branch orifice (α angle) was measured by two neurointerventional radiologists in both groups. The inter- and intraobserver repeatability and consistency of the α angle were assessed. The effect of the α angle on the feasibility of using the shelf technique to treat WNBA was analyzed. Technical and clinical success rates were investigated by comparing both groups. Results Forty-eight patients (32 shelf technique and 16 double-stent technique) were included. There was excellent agreement between the intra- and interobserver repeatability and consistency of α angle measurements. The α angle was smaller in the shelf technique group than in the double-SAC group (p < 0.001). The technical and clinical success rates of both groups were similar based on long-term follow-up (p > 0.05). Conclusion WNBA treatment with the shelf technique is safe and effective. The α angle is a useful parameter to evaluate the performance of the shelf technique. The shelf technique is more suitable for WNBAs with a narrow α angle.

Coronary artery double stenting techniques and their results in complex left main bifurcation disease

Aim: Complex left main (LM) bifurcation disease seems to be better approached by a planned double stent technique. Materials & methods: Medline search for articles including randomized trials, prospective series, large registries and retrospective studies >50 patients has been performed. Results: Double kissing crush demonstrated its superiority over culotte stenting and cross over, while other techniques such as the T-stenting and T-stent and Protrusion have not been extensively reported in LM setting. The nano inverted-T-stenting has provided evidences that the use of ultrathin strut stents and very minimal crush is beneficial for both the physiological and rheological properties. Conclusion: The double stenting techniques used in LM should be evaluated in terms of procedural differences and technical simplicity.

Dual SAVE technique for mechanical thrombectomy rescue on MCA bifurcation clots

The Stent retriever Assisted Vacuum-locked Extraction (SAVE) technique in mechanical thrombectomy consists of the simultaneous use of a stent retriever and a distal aspiration catheter, with the removal of both as a unit when performing the thrombectomy pass. This is a safe procedure that provides a high rate of first-pass reperfusion.1 In the distal M1 segment of the middle cerebral artery (MCA) occlusions, with the distal portion of the clot extending to the upper and lower MCA branches, mechanical thrombectomy can be challenging since the thrombus is not fully trapped, with risk of distal clot migration to the branch in which the retriever is not placed. In these cases the double stent-retriever technique has been described as a rescue strategy.2–4 We describe a case of the combined use of SAVE and double stent-retriever techniques as a rescue strategy in a patient with tandem occlusion of the proximal internal carotid artery and distal MCA—the D-SAVE technique. (video 1)