Technical note
Reverse waffle cone technique in management of stent dislodgement into intracranial aneurysms

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Abstract

Stent-assisted coil embolization (SACE) is a common method to manage intracranial wide-neck aneurysm. Using this technique, a stent must be successfully deployed into the parent artery to cross the aneurysm neck. We describe the reverse waffle cone technique in management of intra-procedural stent dislodgement during SACE of internal carotid artery (ICA) wide-neck aneurysms. Two patients with unruptured wide-neck ICA aneurysms underwent SACE. Intra-procedural forward stent migration occurred during catheterization with proximal stent dislodgement and migration into the aneurysm sac. Navigation of a second stent to bridge the aneurysm neck failed in one patient because the second stent was impeded by the dislodged stent. Using the reverse waffle cone technique, a microcatheter was navigated into the aneurysm sacs. Coils were safely detached into each aneurysm sac without any device assistance. The two wide-neck aneurysms were successfully treated with preservation of flow to the internal carotid arteries. The complication of intra-procedural distal stent migration and dislodgement, with proximal stent prolapse into an aneurysm sac, may not result in a failure to coil the aneurysm. The reverse waffle cone technique provides an effective treatment in the management of this complication.

Introduction

The stent-assisted coil embolization (SACE) has expanded the applicability of endovascular treatment of wide-neck intracranial aneurysms with promising results.1, 2, 3, 4, 5 The major advantage of the SACE technique in the treatment of wide-neck aneurysms is the prevention of coil protrusion into the parent artery with preservation of flow to the parent artery. The technique may also allow safer and denser packing of the aneurysm sac, thus decreasing coil compaction and reducing aneurysm recurrence. However, the SACE technique may prove unsuccessful due to failure to navigate the stent to the ideal location within the parent artery in order to cross the aneurysm neck, particularly in those patients with difficult arterial anatomy and/or complex aneurysm morphology. Occasionally, intra-procedural stent migration, dislodgement, or misplacement can occur.6, 7

We utilized the reverse waffle cone technique to manage two patients with unruptured wide-neck aneurysms of the internal carotid arteries (ICAs) with intra-procedural distal stent migration. In both cases, the proximal end of the deployed stents had dislodged into the target aneurysm during the attempt to catheterize each of the aneurysm sacs.

Section snippets

Patient 1

A 36-year-old woman presented with left limb weakness. Magnetic resonance angiography and subsequent cerebral digital subtraction angiography demonstrated two wide-neck aneurysms in the left supraclinoid and para-ophthalmic ICA. The aneurysm sac/neck measured approximately 5 × 5 mm/4 mm and 6 × 5 mm/5 mm, respectively (Fig. 1a). The diameter of the supra- to para-clinoid ICA measured between 3.7 mm and 4.3 mm. Considering the location and morphology of the aneurysms, endovascular embolization with SACE

Discussion

SACE has become a standard endovascular technique in the treatment of wide-based intracranial aneurysms. To correctly perform the SACE, a stent has to be deployed, ideally into the parent artery, to bridge the aneurysm neck and to facilitate subsequent coil embolization. In general, a stent length should be chosen that provides at least a 5 mm landing zone beyond the aneurysm neck on the proximal and distal parent artery. The stent should be sized 0.3–0.5 mm greater than the diameter of the

Conclusion

Intra-procedural distal migration of a stent with proximal end dislodgement into the aneurysm sac may not result in failure to perform SACE. The reverse waffle cone technique following by coil embolization provides an alternative to manage this complication.

Acknowledgments

This work was supported in part by a grant from the Taipei Veterans General Hospital (V98C1-153, V99C1-012) and NSC (97-2314-B-075-062-my2, 99-2314-B-075-045-my2).

References (10)

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Cited by (3)

  • Small Tenuous Intracranial Arteries Can Well Tolerate the Deployment of 2 Stents in Y Configuration or an Overlapping Manner in Treating Intracranial Aneurysms

    2018, World Neurosurgery
    Citation Excerpt :

    A intracranial stent can be deployed alone for managing small or even large morphologically unfavorable intracranial aneurysms without subsequent coiling or for compressing protruded coil loops against the parent artery wall.3-5 If one stent is misplaced with one end located within the target aneurysm cavity, another stent can be deployed through the first stent interstices to correct the mistake, followed by aneurysm coiling.6 Furthermore, 2 stents have also been deployed in a Y configuration or an overlapping or kissing manner, followed by coiling, to treat morphologically unfavorable intracranial aneurysms such as fusiform and dissecting aneurysms, pseudoaneurysms, and aneurysms at arterial bifurcation.7-9

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