Cross treatment between the C.H.U of Montpellier and the Beijing Tiantan's Hospital with the Pr. Miao Team - SLICE Next Frontiers 2023 - Venise DELUI

The Chinese Dragon`s expertise land on the 90 minutes` Posterior Communicating Artery Aneurysms SLICE 2023 Platform…

 Montpellier unites Neuroworld`s poles

Does anyone know what happened over there in the French breathtaking magical coastal city, Montpellier, this April??! Simple concise answer… SLICE 2023 rocked!

The worldwide neurointerventional SLICE hit again with an incredible session of diverse constructive on fire debates about posterior communicating artery (Pcom) aneurysms. This year was extra-outstanding due to the honorable Chinese participation through the cross treatment between the C.H.U of Montpellier and the Beijing Tiantan`s Hospital Live case session.

SLICE`s curiosity discovers Far East of Asia … was that a logic move? Yes!... Thousands of years` history of Chinese medicine self-confidently answers!

Around 3000 years of history from traditional Chinese medicine till recent advanced breakthrough elucidates the fascinating medical experience`s significance of this world`s area. Additionally, according to official records, China is the largest population with over 1.43 billion people and third largest country by total land area in the world. Furthermore, China is currently well-known for its well-developed healthcare system. Accordingly, these were enough reasons to trigger SLICE`s curiosity.

We all know about the Pcom aneurysms, but it can absolutely get too complex. A catchy session with on fire discussions, however, which recommendations to deal with these scenarios to take away home?! The panel advises!

1 -  Accurate Preplanning using different 3D advanced imaging modalities and DSA. In addition, precisely identifying the pathology (Size, shape, and small tributaries) and plan accordingly. Be aware of available tools and keep in mind more than one backup plan.

2 -  Start with the simple direct intervention (like coiling whether simple or assisted) and upgrade or edit according to operation`s circumstances or follow up results.

3 -  For coiling +/- stent or balloon: Suitable for acute phase and can be approached from anterior or posterior circulation. Risk of recurrence or rebleeding (due to manipulation of dome or incomplete embolization or dome filling). Wide neck aneurysms are a challenge to keep coils stable without its migration and balloon or Stent protection should be considered. However, the latter carries thromboembolism risks or in-stent stenosis. While coiling, try the best to preserve the underlying or feeding vessel`s patency. Two common predictive factors of long-term stability are small Pcom and dome to neck ratio <2. [1,2]

4 -  For Flow diverter: Suitable for recurrences as second line as it is purely endoluminal with no dome manipulation. It can be combined with coiling only before deployment (After deployment, you can coil from the other way because microcatheter can’t get through stent braids). Two common predictive anatomic failure factors are fetal Pcom arise from neck or artery coming from aneurysm. Disadvantages are that it is not used for acute phase, requires dual antiplatelet medications postoperative (However, new devices have a lower thrombogenic coating which require only single antiplatelet medication post operative), indeterminate latency period between deployment and aneurysm cure, and can require more than one stent for complete cure which is not that recommended due to increase metal coverage and thrombogenicity probability [3]. Proper sizing and planning before deployment and complete coverage with no apposition issue. Avoid Pcom occlusion for sure, especially mid, and medial portion due to perforators occlusion consequently (Premammillary or mammillothalamic arteries mainly). According to official research, coverage of A1 segment is safe if Anterior communicating artery is patent. Anatomic considerations is a case-by-case decision and well explained throughout the session. In literature, it was suggested that control angiography with persistence of contrast till late venous phase ensures effectiveness (indicates lower intra-aneurysmal pressure) [4]. Try to preserve vessels as much as possible and use stent resheathing and other tips and tricks mentioned in the video to avoid shortening, misplacement or apposition issues (Causes Endo leak). Additionally, avoid oversizing.

5 -  Intravascular web: Suitable for wide neck bifurcation aneurysms of more than 3-4 mm neck size. Advantages are direct and faster with less thromboembolic complications, avoids antiplatelet post procedure and good neck coverage which optimizes occlusion rates during follow up. Moreover, Proper selection and size is mandatory with recommended Oversizing to be 1 mm more than average aneurysmal width for a sufficient seal [5].

In conclusion, it is noteworthy that treatment plan must be formulated on an individual basis with overall estimation of each modality`s risks and benefits without any bias. Finally, it is undoubtedly advised to watch the whole session as it is amazingly fruitful, which will improve your experience and be a great chance to see experts from different world`s schools.

References: 

1 -  Golshani K, Ferrell A, Zomorodi A, Smith TP, Britz GW. A review of the management of posterior communicating artery aneurysms in the modern era. Surgical neurology international. 2010;1. 

2 -  Cho YD, Lee WJ, Kim KM, Kang HS, Kim JE, Han MH. Stent-assisted coil embolization of posterior communicating artery aneurysms. American Journal of Neuroradiology. 2013 Nov 1;34(11):2171-6. 

3 -  Bonney PA, Connor M, Fujii T, Singh P, Koch MJ, Stapleton CJ, Mack WJ, Walcott BP. Failure of flow diverter therapy: predictors and management strategies. Neurosurgery. 2020 Jan 1;86(Supplement_1):S64-73. 

4 -  Vivanco-Suarez J, Rodriguez-Calienes A, Kan PT, Wakhloo AK, Pereira VM, Hanel R, Lopes DK, Galecio-Castillo M, Anil S, Farooqui M, Puri AS. Flow Diverter Performance in Aneurysms Arising From the Posterior Communicating Artery: A Systematic Review and Meta-Analysis. Neurosurgery. 2022 May 17:10-227. 

5 -   Aguiar G, Caroff J, Mihalea C, Cortese J, Girot JB, Elawady A, Martinez JV, Ikka L, Gallas S, Chalumeau V, Ozanne A. WEB device for treatment of posterior communicating artery aneurysms. Journal of NeuroInterventional Surgery. 2022 Apr 1;14(4):362-5.