LIVE CASE 01: Extradural giant aneurysms - SLICE Next Frontiers 2022

LIVE CASE

1 / 13 episodes

Vincent COSTALAT , Paolo Machi , Vitor Mendes Pereira , Federico Cagnazzo , michel piotin , Francisco José Mont' Alverne , anne christine JANUEL , Dhaval Thakkar

LIVE CASE 01: Extradural giant aneurysms - SLICE Next Frontiers 2022

02
Vitor Mendes Pereira , Tufail Patankar , michel piotin , anne christine JANUEL , Adnan Siddiqui , Jean-Christophe GENTRIC

LIVE CASE 02: Giant cavernous aneurysm treatment - SLICE Next Frontiers 2022

03
Vitor Mendes Pereira , Tufail Patankar , michel piotin , Adnan Siddiqui , Jean-Christophe GENTRIC

LIVE CASE: Yves Moulin & Paulina Hachette - SLICE Next Frontiers 2022

04
Paolo Machi , Vitor Mendes Pereira , Federico Cagnazzo , Tufail Patankar , michel piotin , Francisco José Mont' Alverne , Waleed Brinjikji , Adnan Siddiqui , Arianna Rustici , Flavio Andresciani

LIVE CASE 04: Axel Bilbon & Axel Bilbon - SLICE Next Frontiers 2022

05
Vincent COSTALAT , Paolo Machi , Federico Cagnazzo , Tufail Patankar , Francisco José Mont' Alverne , anne christine JANUEL , Waleed Brinjikji , RAPHAEL BLANC , Jean-Christophe GENTRIC , Helena Guerreiro

LIVE CASE 05: Recanalization of top-of-the basilar aneurysms after simple coiling - SLICE Next Frontiers 2022

06
3.5
Vincent COSTALAT , Paolo Machi , Federico Cagnazzo , anne christine JANUEL , Adnan Siddiqui , RAPHAEL BLANC , Jean-Christophe GENTRIC , Flavio Andresciani

LIVE CASE 06: 10mm size MCA aneurysm - SLICE Next Frontiers 2022

07
Vincent COSTALAT , Vitor Mendes Pereira , Francisco José Mont' Alverne , Waleed Brinjikji , Adnan Siddiqui , RAPHAEL BLANC

LIVE CASE 07: Endovascular treatment of MCA- SLICE Next Frontiers 2022

08
4.5
Vincent COSTALAT , Paolo Machi , Vitor Mendes Pereira , anne christine JANUEL , Waleed Brinjikji , BOURCIER romain , Adnan Siddiqui , Arianna Rustici , Manisha Joshi

LIVE CASE 08: Wide neck-bifurcation aneurysms - SLICE Next Frontiers

09
Vincent COSTALAT , Vitor Mendes Pereira , michel piotin , Tufail Patankar , Francisco José Mont' Alverne , BOURCIER romain , Adnan Siddiqui , Dhaval Thakkar , Arianna Rustici , Helena Guerreiro

LIVE CASE 09: David Plateau - SLICE Next Frontiers 2022

10
Vincent COSTALAT , Vitor Mendes Pereira , Federico Cagnazzo , Tufail Patankar , michel piotin , Francisco José Mont' Alverne , BOURCIER romain , Adnan Siddiqui , Dhaval Thakkar , Arianna Rustici , Helena Guerreiro

LIVE CASE 10: Alexandro Pretro - SLICE Next Frontiers 2022

11
Vincent COSTALAT , Vitor Mendes Pereira , Tufail Patankar , Francisco José Mont' Alverne , Adnan Siddiqui , RAPHAEL BLANC , Jean-Christophe GENTRIC

Complication 01 - SLICE Next Frontiers 2022

12
4.5
Vincent COSTALAT , Paolo Machi , Federico Cagnazzo , Tufail Patankar , Adnan Siddiqui , Jean-Christophe GENTRIC , Manisha Joshi

Complication 02 - Slice Next Frontiers 2022

13
Vincent COSTALAT , Vitor Mendes Pereira , Francisco José Mont' Alverne , Waleed Brinjikji , Adnan Siddiqui , RAPHAEL BLANC , Jean-Christophe Gentric

Complication 03 - SLICE Next Frontiers 2022

Live Case

ANTEROGRADE VS RETROGRADE

Extradural giant aneurysms:

Main issue: 

  • Compressive symptoms and cranial nerve lesions
  • No important hemorrhagic risk
  • Risk of growth up to 20% per year in giant cavernous aneurysms (>= 12mm)


Before treatment decision:

  • Define clinically the relationship between symptoms and aneurysm
    • Blurred vision is due to diplopia or due to optic neuropathy?
    • Mass Effect – with compression on optic chiasm?
    • Mass Effect – with pituitary compression?
  • Control risk factors
  • Complete ophthalmic evaluation
  • Inform the patient that even with treatment it is possible that the symptoms won’t disappear 
  • Consider steroids in selected cases

Doctor Montalverne's quotation : " " We have a period of recovery after the installation of the symptoms. So we should balance between the recovery and the risk of the treatment."

Diagnostic work-up:

  • MRI – evaluate mass effect
  • DSA with balloon test occlusion

Informed treatment decision:

  • Very low chance of self-occlusion, probably will lead to worsening of compressive symptoms
  • Two types of therapies if favourable balloon test occlusion

 

Reconstructive therapy

Deconstructive therapy

Complete occlusion

71%

93%

Need of retreatment

32%

4%

Complication rate

30%

16%

Morbidity

16%

9%

Mass effect improvement

48%

77%


  • If nice cross-flow and both therapies available: 
    • Expert-opinion suggests reconstruction in younger patients and focal disease;
    • In the case of deconstructive therapy in young patients with connective tissue disease, it has to be taken into account the subsequent high-flow in the contralateral ICA may lead to de novo aneurysms in this territory which might pose future treatment problems
    • Recent literature data suggest much higher rates of occlusion with flow-diverter and symptoms improvement in 80% of the patients.

Doctor Siddiqui's quotation : "Unless i had no good solution for reconstruction. I would not deconstruct in a young patient."

Reconstructive Treatment Technique:

  • Consider number of stents needed 
  • One stent approach: may pose problems with opening very long flow-diverter stents in curbed anatomy
  • Anterograde or retrograde reconstruction depends on anatomy if you have concerns about losing access to the flow-diverter anterograde reconstruction may be the superior technique (large saccular). If the aneurysm is large fusiform probably the techniques are equally reasonable.
  • Using coils – if large fusiform and partially thrombosed coils may disrupt thrombus and lead to distal embolization during the procedure.
  • Telescopic anterograde technique:
    • Simulation of the devices may really help with choosing the stent size
    • Endoleak prevention at the proximal sight – most important vessel diameter to ensure good apposition
    • Use the smallest devices that give you safe landing zones and optimal overlapping 
    • Terminate in straight segments
    • Simulate the positions of your stents to know exactly where to start and where to finish
    • During catheterization if partially thrombosed aneurysm avoid touching the walls of the aneurysm in order not to avoid thrombus mobilisation
    • Advance as distal as possible in the MCA with the microcatheter and advance intermediate catheter as much as possible in order to have very good support
    • When the device gets out of the intermediate catheter relax the system and take the tension out of the microcatheter
    • Use fluoroscopic views during deployment, ensure that guidewire of the flowdiverter is in a safe point

Doctor Siddiqui's quotation : “I think both procedures are equally reasonable [...] because it's a relatively straight fusiform aneurysm”

  • Telescopic retrograde technique:
    • Simulation of the devices may really help with choosing the stent size
    • Diameter of the devices in retrograde reconstruction must be increased progressively you have to take a smaller one distally and a larger one proximally in order for the proximal one not to float in the first one
    • Choose nice straight segments in order to start and finish
    • Once completely delivered pull a little bit on the pusher and advance the microcatheter inside try not to lose the lumen and to push the braid of the first stent
    • If it is not a straight segment you may try to push forward the pusher of the first stent in the intracranial part in order to have more support to push your microcatheter inside the first stent
    • Deploying the second stent in a safe straight point, push and pull during deployment to ensure good apposition
    • End of the delivery: you just unsheath the implant
    • Remember the smaller the diameter of the stent the better it opens, oversized stents are more difficult to open in curves
    • Length of overlapping should be no less the 5-10mm

Devices in use

BLOC A

Surpass Evolve™ STRYKER

Synchro 2 STRYKER

BLOC B

Pipeline™ Vantage MEDTRONIC

Navien™ MEDTRONIC

Sources :

Cavernous sinus aneurysms: risk of growth over time and risk factors

Endovascular Treatment of Very Large and Giant Intracranial Aneurysms: Comparison between Reconstructive and Deconstructive Techniques-A Meta-Analysis

Treatment of cavernous sinus aneurysms with flow diversion: results in 44 patients

Cavernous carotid aneurysms in the era of flow diversion: a need to revisit treatment paradigms


Doctor Razvan Radu our Expert Analysis who wrote this article


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LIVE CASE

1 / 13 episodes

Vincent COSTALAT , Paolo Machi , Vitor Mendes Pereira , Federico Cagnazzo , michel piotin , Francisco José Mont' Alverne , anne christine JANUEL , Dhaval Thakkar

LIVE CASE 01: Extradural giant aneurysms - SLICE Next Frontiers 2022

02
Vitor Mendes Pereira , Tufail Patankar , michel piotin , anne christine JANUEL , Adnan Siddiqui , Jean-Christophe GENTRIC

LIVE CASE 02: Giant cavernous aneurysm treatment - SLICE Next Frontiers 2022

03
Vitor Mendes Pereira , Tufail Patankar , michel piotin , Adnan Siddiqui , Jean-Christophe GENTRIC

LIVE CASE: Yves Moulin & Paulina Hachette - SLICE Next Frontiers 2022

04
Paolo Machi , Vitor Mendes Pereira , Federico Cagnazzo , Tufail Patankar , michel piotin , Francisco José Mont' Alverne , Waleed Brinjikji , Adnan Siddiqui , Arianna Rustici , Flavio Andresciani

LIVE CASE 04: Axel Bilbon & Axel Bilbon - SLICE Next Frontiers 2022

05
Vincent COSTALAT , Paolo Machi , Federico Cagnazzo , Tufail Patankar , Francisco José Mont' Alverne , anne christine JANUEL , Waleed Brinjikji , RAPHAEL BLANC , Jean-Christophe GENTRIC , Helena Guerreiro

LIVE CASE 05: Recanalization of top-of-the basilar aneurysms after simple coiling - SLICE Next Frontiers 2022

06
3.5
Vincent COSTALAT , Paolo Machi , Federico Cagnazzo , anne christine JANUEL , Adnan Siddiqui , RAPHAEL BLANC , Jean-Christophe GENTRIC , Flavio Andresciani

LIVE CASE 06: 10mm size MCA aneurysm - SLICE Next Frontiers 2022

07
Vincent COSTALAT , Vitor Mendes Pereira , Francisco José Mont' Alverne , Waleed Brinjikji , Adnan Siddiqui , RAPHAEL BLANC

LIVE CASE 07: Endovascular treatment of MCA- SLICE Next Frontiers 2022

08
4.5
Vincent COSTALAT , Paolo Machi , Vitor Mendes Pereira , anne christine JANUEL , Waleed Brinjikji , BOURCIER romain , Adnan Siddiqui , Arianna Rustici , Manisha Joshi

LIVE CASE 08: Wide neck-bifurcation aneurysms - SLICE Next Frontiers

09
Vincent COSTALAT , Vitor Mendes Pereira , michel piotin , Tufail Patankar , Francisco José Mont' Alverne , BOURCIER romain , Adnan Siddiqui , Dhaval Thakkar , Arianna Rustici , Helena Guerreiro

LIVE CASE 09: David Plateau - SLICE Next Frontiers 2022

10
Vincent COSTALAT , Vitor Mendes Pereira , Federico Cagnazzo , Tufail Patankar , michel piotin , Francisco José Mont' Alverne , BOURCIER romain , Adnan Siddiqui , Dhaval Thakkar , Arianna Rustici , Helena Guerreiro

LIVE CASE 10: Alexandro Pretro - SLICE Next Frontiers 2022

11
Vincent COSTALAT , Vitor Mendes Pereira , Tufail Patankar , Francisco José Mont' Alverne , Adnan Siddiqui , RAPHAEL BLANC , Jean-Christophe GENTRIC

Complication 01 - SLICE Next Frontiers 2022

12
4.5
Vincent COSTALAT , Paolo Machi , Federico Cagnazzo , Tufail Patankar , Adnan Siddiqui , Jean-Christophe GENTRIC , Manisha Joshi

Complication 02 - Slice Next Frontiers 2022

13
Vincent COSTALAT , Vitor Mendes Pereira , Francisco José Mont' Alverne , Waleed Brinjikji , Adnan Siddiqui , RAPHAEL BLANC , Jean-Christophe Gentric

Complication 03 - SLICE Next Frontiers 2022

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