I use stents regularly (when necessary) in the embolization of acutely ruptured aneurysms, applying a special anticoagulation - antiplatelet protocol.
Would you like to comment on your views and your practice?
I minimize the use of additional materials like stents in acutely ruptured aneurysm. In my view most of so called wide neck aneursyms can be coiled with double catheter technique or by means of careful manipulations of the basket coils(often GDC-360). However in a situation where you definately need it, one should. Now a days I prefer to deploy stent at the end of coiling or just before final finish. I use regular anticoagulation and anti-platelet protocol, that means ASA+Clopigrel in loading dose.
I dont find recent SAH a contraindication to using a stent when one is actually needed.
I dont load with ASA+Clopidogrel before placng a stent.
I give 5,000 IU heparin 10 minutes before placing the stent and an additional 2,500 IU at 45 minutes if the operation has not finished by that time. Then, I remove the sheath and start immediately the patient on 0.6 mg nadroparine sc every 12 hours for 4 days. This is double the therapeutic dose of nadroparine for deep venous thrombosis The same evening, or the next morning if the operation was performed in the evening, I start the patient on ASA 100 mg and Cloidogrel 75 mg per day. After administering all three medicines for 4 days I discontinue the nadroparine and leave the patient on ASA for 3 months and Clopidogrel for 6. I had zero postoperative thrombotic complications with this protocol except when I used the Leo stent. It works fine with Neuroform, Wingspan and Solitaire. I dont know about the Enterprise since I have not used it yet.
The advantage of working only with heparine until the aneurysm is safely occluded is that if needed, a craniotomy can bee performed safely. I had to remove surgically a hematoma that happened intraprocedurally during stent assisted coiling and there was no intraoperative bleeding by keeping the ACT to 250 with heparine alone. In another case of an acutely ruptured aneurysm I placed a stent but could not enter the aneurysm to embolize it. So I clipped it, again keeping the ACT to 250 with heparin without hemorrhagic complications. This would not have been possible if I had loaded the patients with ASA+Clopidogrel. This protocol is described in the following article:
Embolization of acutely ruptured and unruptured wide-necked cerebral aneurysms using the neuroform2 stent without pretreatment with antiplatelets: a single center experience.
Katsaridis V, Papagiannaki C, Violaris C.
AJNR Am J Neuroradiol. 2006 May;27(5):1123-8
I have only tried the Pipeline. I treated some cases with it and it was excellent. It performed perfectly and the results were excellent. From what I hear, the Silk has longer lengths than the Pipeline but longer Pipelines are coming. Also the Silk has the tendency to overexpand inside the aneurysm at the level of the neck. But no personal experience
Professor Moret is one of the most experienced and respected neuroradiologists in the world. If he says it works, it works. I have not tried it yet but this is what I have been told by my proctor in Pipelines, Professor Boccardi.
You can see a case I did with 5 Pipelines in a giant carotid aneurysm. I have posted it in the Neurointerventional group
Why do think stenting is necessary in addition to coil embolization particularly in narrow neck aneurysms? As Professor Shakir HUSAIN has mentioned, we too do practice of double catheter technique to wave compact basket or double basket technique if aneurysm is a longer in length and neck is moderately wide. But for classic wide neck aneurysms, stent assisted coil embolization is a rule.