Clinical Study
Y-Stent embolization technique for intracranial bifurcation aneurysms

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Abstract

Wide-necked bifurcation aneurysms often require the use of the technically complex Y-stent technique, which has recently been shown to narrow bifurcation angle in a hemodynamically favorable manner. We sought to evaluate the single center efficacy and safety of Y-stent supported aneurysm coil embolization. All patients undergoing Y-stent supported coiling between September 2006 and December 2012 were identified; records were analyzed for procedural results and complications, with follow-up evaluated for occlusion rate and neurological adverse events. Twenty consecutive patients underwent technically successful Y-stent supported coiling, with complete aneurysm occlusion achieved in 19/20 cases (95%). There were no peri-procedural clinically evident neurological complications following Y-stenting. Clinical follow-up was available for a mean of 20.0 months and radiographic follow-up was available for a mean of 18.5 months. During the follow-up period, three patients (15%) required re-treatment with through-stent coiling for recanalization. At latest follow-up, Raymond grade I occlusion was achieved in 16 patients (80%), Raymond grade II occlusion achieved in four patients (20%) and Raymond grade III occlusion in zero patients. Y-stenting for complex intracranial aneurysms appears effective in achieving durable aneurysm occlusion with an acceptable safety profile. Though the procedure is technically more complex than single-stent procedures, the Y-stent configuration should be considered when single-stent supported coiling is not feasible or sufficient.

Introduction

Stent assistance for coil embolization of wide-necked intracranial aneurysms has significantly expanded the spectrum of aneurysms amenable to endovascular therapy [1], [2], [3], [4]. Indeed, stent-assisted coil embolization may result in greater occlusion rates than coil embolization alone with comparable peri-procedural complications [5]. Despite this potential benefit, complex aneurysms can pose a significant challenge for achieving immediate and durable embolization.

Specifically, for wide-necked aneurysms located at shallow-angle arterial bifurcations, single stent-mediated coiling may provide insufficient support of the coil mass to prevent coil herniation through the aneurysm neck. Introduction of the Y-stent technique [6], [7], whereby dual stents are deployed sequentially proximal to the arterial bifurcation and then into each arterial branch, has enabled stent-mediated endovascular therapy for bifurcation lesions too complex for coiling alone. Several small series have reported on the use of this technique with minimal peri-procedural complications and good short and mid-term efficacy [8], [9], [10]. These reports have been limited in terms of size and follow-up. Recently, Y-stent mediated coiling has been shown to decrease the arterial bifurcation angle, a finding associated with beneficial hemodynamic alterations [11]. Given the significant potential benefit of this technique suggested by these studies, a larger case series, as well as a review of the literature, is warranted.

In the current series, we report on 20 patients who underwent dual stent deployment in the Y-fashion for treatment of an intracranial aneurysm at a single center. Our experience with this technique may aid in better defining the success rate of Y-stenting procedures and elucidate the complications associated with this technique.

Section snippets

Methods

From September 2006 through December 2012, 20 patients underwent Y-stent-mediated coil embolization of bifurcation aneurysms by the senior author (A.M.M.) at Tufts Medical Center, USA. Both the open-cell design Neuroform (Stryker Neurovascular, Fremont, CA, USA) and the closed-cell design Enterprise (Codman Neurovascular, Raynham, MA, USA) stents were used. Patient demographics, clinical information and radiographic data were maintained in a prospectively collected database.

Three men and 17

Results

Y-stent mediated embolization of an intracranial aneurysm was attempted in 22 patients and was successful in 20 (91%). Stent deployment without coiling was employed in two patients (10%). Dual Neuroform stents were used in 18 patients (Fig. 1), dual Enterprise stents were used in one patient with an MCA bifurcation aneurysm (Fig. 2), and hybrid stents (Enterprise and Neuroform) were used in one patient with a BA bifurcation aneurysm.

There were two cases where Y-stenting was attempted but could

Discussion

The current series reports patients undergoing Y-stenting for treatment of intracranial aneurysms at a single institution. A technique first introduced to the neurointerventional literature in 2004 [12], Y-stenting offers a valuable alternative for wide-necked aneurysms located at large intracranial arterial bifurcations.

By providing simultaneous scaffolding of the aneurysm neck and protection of the distal arterial branches, Y-stenting minimizes the risks of coiling alone and single

Conflicts of Interest/Disclosures

A.M.M. has received unrestricted research support from Microvention, Stryker Neurovascular, Codman Neurovascular, Siemens, Ansys, and CD-Adapco for unrelated work. The other authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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