Intrasaccular Devices and Evolving Aneurysm Strategies

This session explored the expanding role of intrasaccular flow disruption devices in managing intracranial aneurysms, especially their value in rapid, low-risk interventions. Dr. Xavier Barreau opened with a compelling argument for performing neuroendovascular procedures as day-care interventions, not only reducing system burden but also improving patient comfort. He outlined inclusion criteria such as unruptured aneurysms, absence of comorbidities, and close residential proximity to the treating center.

Dr. Vincent added that intrasaccular flow disruptors, unlike flow diverters, offer minimal parent vessel manipulation, making them ideal for this streamlined workflow. Devices like Contour, WEB, and Artisse can be deployed via radial access with shorter procedure durations and minimal post-op complications.

In my practice, I have not yet adopted aneurysm treatment as a day-care procedure. The proportion of unruptured aneurysms I manage is relatively low, and I have not yet used an intrasaccular device. That said, I am actively waiting for the right case to explore this approach.

The first case was an unruptured right MCA bifurcation aneurysm. Drs. Patankar and Chapot used Sim&Size software simulation to choose a Contour device. A helpful technical tip was shared, pushing the microcatheter after unsheathing the device can flatten its base, avoiding unwanted branch occlusion. While I do not currently use Sim&Size, I rely on the simulation software in our angio suite. Based on my experience with braided stents and flow diverters, I can appreciate how microcatheter manipulation could help optimize device deployment, even though I haven’t yet applied it in the context of intrasaccular tools.

Dr. Vincent highlighted the need for antiplatelet preparation when planning Contour deployment, since platelet aggregation or the need for adjunct stenting may arise.

The second case focused on delayed WEB deformation, five years post-treatment of a ruptured Acom aneurysm. Animal studies suggest that progressive thrombosis and healing-induced retraction may distort device geometry, leading to recurrence. A new tool, the SPRUCE Index, was introduced to predict this risk, though it still awaits validation. I haven’t encountered this complication firsthand, as I’ve never used a WEB device, but predictive tools like this will likely guide my device selection in the future.

A broader discussion followed on balloon usage in aneurysm coiling. While some experts favor routinely parking a balloon across the neck as a safeguard, others have phased this out. The consensus was that inexperienced operators should keep a balloon ready, while experienced hands may reserve it for select cases.

Dr. Vipul Gupta’s live demonstration of this case featured a small recurrent sac at the Acom junction along with the recanalized or regrown aneurysm, which was treated with WEB 5 years back, which he treated with coiling of the smaller sac and a flow diverter from ipsilateral A2 to A1 for the recurrent larger sac. There was a discussion about using stiffer flow diverters to reshape vessel geometry and augment flow diversion. Most faculty felt that while this effect may exist, it is unlikely to be a primary driver of success.

The third case featured an ophthalmic segment aneurysm, where treatment strategy had to balance aneurysm occlusion and ophthalmic artery preservation. Dr. Vincent cited new data showing that covering the ophthalmic artery origin with a flow diverter can result in 7% permanent visual disturbance and 3.9% visual field loss, outcomes not seen when the artery was spared.

Dr. Chapot used balloon-assisted coiling followed by stenting, while Dr. Patankar deployed an Artisse intrasaccular device, achieving comparable outcomes but with a much shorter procedure time. Personally, I have not emphasized ophthalmic artery preservation in my flow diverter procedures. However, Artisse seems more promising than WEB due to its better conformability, and I would certainly like to use it when the right case arises.

The final case, a basilar top aneurysm, introduced a novel strategy by Dr. J. Mocco, appropriately termed "coil-assisted coiling." Using dual microcatheters, he deployed a disc-like Nautilus coil (Endostream Medical Ltd.) to create proximal support, followed by super-soft i-ED Complex Infini coils (Kaneka Medix) for dense packing. The result was complete occlusion with fewer coils. While I have not yet used this strategy, it looks promising, and I would like to try it in suitable cases.

This session highlights how device selection and technical nuance are now more personalized than ever. Whether it’s optimizing procedure times with intrasaccular devices, reducing visual complications, or innovating coil-based support systems, the field is clearly moving toward precision-based and individually tailored aneurysm management.