The procedure performed in GA status, right femoral approach initially for diagnostic angiography, 5F H1 catheter applied and had been introduced to left and right ICA, left and right VA for diagnostic contrast flushes. Standard frontal and lateral views acquired, 3D acquisition from left vertebral artery performed for complete evaluation of the vertebral-basilar anomalies. The left vertebral artery is actually initiated from the aortic arch but not left subclavian artery that may count into normal variation.

There is a rather large fusiform shape aneurysm noted in the confluence of left and right vertebral arteries involving both left and right vertebral arteries as well as basilar artery, the aneurysmal sac is predominantly bulging to the left.

Size of the aneurysm of the aneurysm has been measured, 13.5mm in width and 14.2mm in length. The caliber of the vertebral arteries and basilar artery has been measured, 4mm to 3.7mm. The length from proximal basilar artery to distal left vertebral artery across the aneurysmal sac has been measured, 3cm roughly.

According to hemo-dynamic flow pattern and tortuous shape of the fusiform aneurysm, I decided to introduce a open cell metallic stent (neuroform 4mmx3cm BS) from left vertebral artery to basilar artery and I need to create another arterial pathway and took place from left femoral artery. Guiding catheter for the stent in left vertebral artery is 6F Mach 1 (40 deg, 90cm, BS). The metallic stent is considered as a bridging lumen serving both left and right vertebral arteries during metallic coils impacting into the aneurysmal sac.

 

Before deliver the metallic stent from left vertebral artery, right femoral to right vertebral catheterization perform with coaxis technique, 6F neuron (penumbra Inc) and 1018 micro-catheter (Excelsior 1018 pre-shape 45 deg, BS), navigated into the aneurysmal sac.

Thereafter, optimal metallic stent deployment noted in between basilar artery and left vertebral artery and jailed the 1018 in the aneurysmal sac. The guide wire (Transsend Floppy 300 BS) for delivering the metallic stent has been left in the lumen of the stent for increasing radical force of the stent as well as marking clearly the lateral margin of the stent during impacting metallic coils from the 1018.

Initial coil was 12mmx30cm. The metallic coils have been delivered smoothly during the procedure and monitoring by contrast running test until complete and dense embolization of the aneurysmal sac. Total 16 metallic coils impacted into the aneurysmal sac, the final coil is 4mmx8cm. The parent arteries namely left and right vertebral arteries as well as basilar artery and all major branches of the vertebral-basilar arteries including PICA, AICA, SAC and PCAs are all patently noted in the final run.

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Replies to This Discussion

I like very much the case, especially the fact that with one stent you managed to protect both vertebral arteries! I think you have to publish that. I send as a pdf file a similar case that i have performed in Germany but your case includes both vertebral artery protection.

How many days after the rupture did you embolized the aneurysm? and did you administrate plavix & salospir? were you afraid of a re-hemorrhage?

best regards

Vasilis
Attachments:
I performed the case on the day the patient admitted to ER after diagnostic angiography, I gave plaxis 75mgx3 and aspirin 100mgx3 after the procedure and followed by plaxis 75mg and aspirin 100mg daily for follow up. No post procedural hemorrhage found. The most concern in this case was prolapse coil into the stent that may compromise the bridging stent for both left and right vertebral arteries. In fact, that's why I maintain the guide wire inside the stent during coiling in case prolapse do happen. I also prepare a wingspan (BS) stent to deal with this situation. Fortuately, it didn't.
Your case is also excellent, I like it very much. Thanks for sharing! Next week, I will have another challenging case in MCA, I'll post the case later for sharing.

best regards

Kuok
Hi Kuok,

i hope this is my last question concerning this case. did you administrate IV Heparin intraoperatively?

Vasilis
Yes Vasilis,

Certainly I did, when I delivered the first coil into the aneurysm, I gave 3000u Heparin IV base on the patient weight about 60kg.

Kuok

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