Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street #178, Proger 7, Boston, MA 02111, USA.
Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street #178, Proger 7, Boston, MA 02111, USA.
J Clin Neurosci. 2014 Jun;21(6):1019-23. doi: 10.1016/j.jocn.2013.08.029. Epub 2013 Nov 12.
Several stent-supported coiling techniques have been devised for treating wide-necked bifurcation aneurysms including the Y-stent and waffle-cone constructs. The Y-stent technique is not technically possible with obtusely oriented daughter vessels, and the waffle-cone method is inadequate for aneurysms with necks exceeding the stent's maximal expansion diameter. We describe here the novel use of the Solitaire electrolytically detachable slotted stent (Solitaire, ev3, Irvine, CA, USA) featuring large-sized cells to fashion a concentric "double waffle-cone" construct. This method enabled the doubling of the neck coverage to treat an ultra-wide necked middle cerebral aneurysm with obtusely oriented daughter branches. The technique relies on the intra-cell crossing of the first stent using the second stent delivery microcatheter and fine tuning the relative position with the aid of cross-sectional cone-beam computed tomographic angiography to achieve optimal coverage of the neck prior to detachment of the stents in position. A retrievable stent with large cells such as the Solitaire device is optimal for this application given the need for relative adjustment of the deployment before final stent release to avoid under- or over-penetration of the distal stent struts into the aneurysm dome. An additional advantage of this approach over the kissing-stent technique is the absence of intraluminal stent struts, which was confirmed here by down-the-barrel cross-sectional imaging. The double waffle-cone construct enabled the successful coiling of the aneurysm with no post-procedural ischemic events detected on diffusion-weighted MRI and with stable complete embolization and no residual filling or in-stent stenosis at 6 month follow-up.
已经设计了几种支架辅助的线圈技术来治疗宽颈分叉动脉瘤，包括 Y 型支架和华夫饼锥形结构。对于钝角指向的子血管，Y 型支架技术在技术上是不可能的，而对于颈超过支架最大扩张直径的动脉瘤，华夫饼锥形方法是不够的。我们在这里描述了一种新颖的使用 Solitaire 电解可解脱的开槽支架（Solitaire，ev3，Irvine，CA，USA）的方法，该支架具有大尺寸的单元格，以形成同心的“双华夫饼锥形”结构。这种方法能够将颈部覆盖面积增加一倍，用于治疗钝角指向子分支的超宽颈大脑中动脉瘤。该技术依赖于第一个支架的细胞内交叉，使用第二个支架输送微导管，并借助横断面锥形束 CT 血管造影进行微调，以在支架在位置上分离之前实现最佳的颈部覆盖。对于这种应用，需要在最终释放支架之前进行相对调整，以避免支架的远端支架支柱过度或不足穿透动脉瘤顶部，因此具有大单元格的可回收支架（如 Solitaire 装置）是最佳选择。与吻架技术相比，这种方法的一个额外优势是不存在腔内支架支柱，这在本研究中通过桶内横断面成像得到了证实。双华夫饼锥形结构能够成功地对动脉瘤进行线圈填塞，在弥散加权 MRI 上没有发现术后缺血事件，并且在 6 个月的随访中完全栓塞稳定，没有残留填充或支架内狭窄。
