Anterior Communicating Artery Aneurysm: Incidental Wide-Necked Aneurysm and Stent-Anssisted Coil Occlusion Using a Barrel Stent with Transient In-Stent Stenosis
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An 83-year-old woman presented with an ischemic stroke in the supply territory of both anterior cerebral arteries (ACAs). During the diagnostic work-up, a midsized, wide-necked aneurysm of the anterior communicating artery (AcomA) was found. The right A1 segment was missing, and both ACAs were dependent on the left A1 segment. The aneurysm had to be treated while still preserving this solitary left-hand A1 supply channel to both A2 segments. It was decided to treat the patient with stent-assisted coil occlusion. The aneurysm was successfully treated using this method and a Barrel vascular reconstruction device (VRD; AKA “Barrel stent”) (Medtronic). There was a good clinical outcome with no neurological deficits. That the aneurysm had been completely occluded was confirmed by a follow-up DSA after 3 months. This also revealed moderate in-stent stenosis. This stenosis remained asymptomatic and resolved under continued dual platelet function inhibition. Using a Barrel stent as an assist device to treat wide-necked bifurcation aneurysms is the main topic of this chapter.
KeywordsAnterior communicating artery Wide-necked bifurcation aneurysm Barrel VRD 3D coil Emboli from aneurysm
An 83-year-old female patient who presented with ischemic stroke. Apart from well-controlled arterial hypertension, the medical history of the patient was unremarkable. Neither atrial fibrillation nor a patent foramen ovale had been found. The ischemic lesions were located in the ACA supply territory on both sides. Diagnostic work-up revealed an incidental midsized, wide-necked AcomA aneurysm.
The goal of the treatment was to prevent the AcomA aneurysm from growing further and rupturing, with the intention of completely occluding the aneurysm. The ischemic lesions were possibly related to the aneurysm and due to repeated emboli from the aneurysm sac into the dependent vasculature. Endovascular therapy was chosen in respect of the age of the patient, her existing medication including ASA, and the patient’s explicit personal preference. Due to the configuration of the aneurysm with its wide neck and aplasia of the right-hand A1 segment, stent-assisted coil occlusion using a bifurcation stent was considered an appropriate strategy.
Procedure, 06.02.2017: Barrel stent-assisted coil occlusion of an unruptured wide-necked AcomA aneurysm
Anesthesia: general anesthesia, 1 × 5000 IU unfractionated heparin (Heparin-Natrium, Rotexmedica) IV
Premedication: 1× 100 mg ASA PO daily; a loading dose of 1× 300 mg clopidogrel (Clopidogrel TAD, TAD Pharma GmbH) PO 5 days before the day of treatment, followed by 1× 75 mg clopidogrel PO daily thereafter. The response test 1 day before the procedure revealed a lack of response to clopidogrel. Therefore, the medication was switched to ticagrelor (Brilique, AstraZeneca) with a loading dose of 1× 180 mg PO followed by 2× 90 mg PO daily every 12 hours. The response test carried out the next day showed that ticagrelor was having a sufficient P2Y12 effect.
Access: left femoral artery, 8F sheath (Cordis); guide catheter: 6F Neuron MAX (Penumbra); microcatheters: Excelsior SL-10 (Stryker) for the coils and Headway 21 (MicroVention) for the Barrel stent; microguidewires: Synchro2 0.014“ 200 cm (Stryker) and Transend 0.014” (Stryker)
Implants: coils, Target 360° standard 6/300 mm, Target 360° soft 4/150 mm, and Target helical ultra 3/100 mm (all Stryker); Barrel stent (Medtronic) 3.5/5/20 mm
Duration: 1st–27th DSA run: 82 min; fluoroscopy time: 82 min
Postmedication: 1× 100 mg ASA PO daily for life and 2× 90 mg ticagrelor (1-0-1) PO daily for 3 months
The patient continued not to display any signs of neurological deficits (mRS 0) during the 9-month follow-up period after the endovascular treatment.
The ticagrelor medication was brought to an end, and a medication of 1× 100 mg ASA PO daily for life was prescribed. An MRI/MRA examination including TOF angiography as a baseline examination was carried out, and the next routine MRI/MRA examination is scheduled in 1 year’s time.
Treating an unruptured wide-necked AcomA aneurysm with a fundus diameter of 7 mm in an 83-year-old patient is certainly a matter of controversy. An abstract, statistic-oriented approach would be based on risk estimates. Only sparse data is available concerning the risk of recurrent distal emboli from such an aneurysm (Guest et al. 2017). The clinical course of this event is frequently benign (Cohen et al. 2010). The annual rupture risk of intracranial aneurysms was the subject of several research papers, with contradictory results. The risk rupture of AcomA aneurysms with a fundus diameter < 7 mm is higher than that of aneurysms in other locations of the anterior circulation (Bijlenga et al. 2013). In a large-scale study in elderly Japanese patients, being 80 years old plus and having an aneurysm with a fundus diameter of at least 7 mm were factors both associated with an increased rupture risk. The rupture rate was 1.6% for 1 year, 3.8% for 2 years, and 6.3% for 5 years of observation (Hishikawa et al. 2015). If an aneurysm rupture occurs, the risk of death in an octogenarian is >50% (Koffijberg et al. 2008). The likelihood of a poor outcome after a ruptured aneurysm increases with age (AlMatter et al. 2018). The average remaining life expectancy for a woman in 2013–2015 in the German federal state in question was 9.3 years for an 80-year-old and 6.3 years for an 85-year-old (Statistisches Bundesamt, Statistik der natürlichen Bevölkerungsbewegung). The risks associated with the microsurgical clipping or endovascular coiling of a midsized AcomA aneurysm depend on a variety of factors related to both the patient and the neurosurgeon. A rough guess would be a morbidity and mortality risk of about 4–8% for either treatment modality (O’Neill et al. 2017; Schmalz et al. 2018). Apart from these general considerations, which were explained to the patient, the individual risk assessment of the interventionist may deviate in either direction. Eventually, the well-informed patient has to decide if he or she prefers conservative, observational management or active treatment of the aneurysm. The patient whose case history can be found in this chapter clearly opted for an endovascular treatment after the numbers quoted above had been explained to her.
Straight coiling, maybe using a dual catheter technique or balloon remodeling
Stent-assisted coiling, possibly with “crossing” or “kissing” Y-stent technique
The use of a Barrel stent was chosen by the operator (CL).
Recommended vessel diameter (mm)
Proximal end diameter (mm)
Distal end diameter (mm)
Center herniation section diameter (mm)
Center herniation section span length (mm)
Usable length (mm)
The BV-3.5-5.0×20 and BV-3.5-6.0×20 are the most frequently used Barrel stent sizes.
The operator has to determine which of the efferent vessels allows more coverage of the aneurysm neck and better herniation of the central segment of the Barrel stent inside the aneurysm. Microcatheter access to this artery is usually more difficult. Choosing the appropriate size to use involves considering the diameters of the afferent and efferent arteries as well as the span at the aneurysm neck.
The usage of a Barrel stent requires dual platelet function inhibition, as it is currently the case with any other neurovascular stent. Under fluoroscopy, the center section can be identified by a distal and a proximal marker and six markers in the middle of the center section (Kabbasch et al. 2018). This center section has to be positioned over the aneurysm neck and herniates to the aneurysmal ostium upon deployment. The coil retention exerted by the Barrel stent is usually quite stable, and coil herniation into the parent artery is very uncommon (Gory et al. 2018; Mühl-Benninghaus et al. 2017). The usage of 3D coils together with the Barrel stent is recommended.
The advantage of the Barrel stent over any other self-expanding aneurysm stent is a matter of speculation. A potential alternative, among others, would have been a Neuroform Atlas stent (Stryker), which is accepted by a 0.017″ inner diameter (ID) microcatheter, while the Barrel stent requires a 0.021” ID (Ulfert et al. 2018). Y-stenting would have also been possible, but given the bifurcation geometry, it was assumed that a single stent would provide sufficient protection of the parent artery.
If the catheterization of one or both efferent arteries is an issue, pCONus (phenox) and PulseRider (Cerenovus) are potential alternative implants (Aguilar Pérez et al. 2014). The distal petals of the pCONus are deployed inside the aneurysm sac adjacent to the neck region. The two petals of the PulseRider are supposed to be deployed inside the efferent arteries, but deployment inside the aneurysm sac similar to a pCONus has been reported as well (Aguilar-Salinas et al. 2018). The in-stent stenosis of the Barrel stent, as described in this chapter, is an infrequent phenomenon (Gory et al. 2018). In the vast majority of patients, the in-stent stenosis has continued to be without hemodynamic relevance or clinical sequelae and usually resolves spontaneously under continued dual platelet function inhibition (Cohen et al. 2014).
The authors are most grateful to Sabine Wolff (Medtronic), who supported us with knowledge and material.
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