Efficacy and safety of low profile stents in Y-stent assisted coil embolization of wide-necked bifurcation aneurysms: a systematic review and meta-analysis.

Low-profile stents may provide significant advantages in Y-stent-assisted coiling due to their miniaturized design and capability to be delivered through a 0.0165-inch microcatheter. We aim to investigate the safety and efficacy of using these newer versions of stents in Y-stent-assisted coiling for the treatment of wide-necked bifurcation aneurysms. We conducted a systematic review of the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2023, following the PRISMA guidelines. Eligible studies included ≥ 5 patients with intracranial wide-necked bifurcation aneurysms treated with Y-stent-assisted coiling using low-profile stents, providing angiographic and clinical outcomes. Two authors independently handled the search and selection. Primary outcomes were immediate and follow-up aneurysm occlusion, procedure-related complications, aneurysm recanalization, and retreatment. Secondary outcomes included technical success, procedure-related morbidity, procedure-related mortality, procedure-related stroke, and in-stent stenosis at follow-up. We analyzed the data using random-effects meta-analysis. In total, 19 studies including 507 patients with 509 aneurysms were included. 95% of the treated aneurysms were managed using the crossing Y-configuration. Technical success rate was 99%. Immediate adequate aneurysm occlusion was 90%. Follow-up angiographies were available for 443 aneurysms. The mean angiographic follow-up duration was 15.6 ± 1.9 months. The rates for follow-up adequate aneurysm occlusion and complete occlusion were 98% and 89%, respectively. After a mean clinical follow-up of 15 ± 2.4 months, a good clinical outcome was observed in 98% of patients. Overall, procedure-related morbidity and mortality rates were 1.3%, and 0.4%, respectively. Low-profile stents in Y-stent-assisted coiling outperform previous stent versions in terms of safety, efficacy, and technical success rates.

Evaluation of short- and long-term results of Y-stent-assisted coiling with Leo stents in endovascular treatment of wide-necked intracranial bifurcation aneurysms.

PURPOSE: This study aimed to evaluate the feasibility, safety, and efficacy of Y-stent-assisted coiling (Y-SAC) using LEO Baby® stents in treating of bifurcation aneurysms. METHODS: Patients who underwent Y-SAC using a braided stent (LEO Baby®, Montmorency, France) for wide-necked intracranial aneurysms between 2009 and 2019 and whose radiological and clinical follow-up data for at least 6 months could be obtained were evaluated. Data were obtained from patient records and analyzed retrospectively. RESULTS: We evaluated 111 patients with a mean age of 56.0 ± 10.8 years (range, 25-88 years). Most of the aneurysms were detected incidentally. Three patients had ruptured aneurysms. LEO Baby deployment and coiling were successful in all patients. Immediate aneurysm occlusion rates were determined as modified Raymond-Roy classification (mRRC) I 95.5% (n = 106), mRRC II 3.6% (n = 4), mRRC IIIa 0.9% (n = 1). In the sixth month, aneurysm occlusion rates were found to be complete and nearly complete in all patients (mRRC I 94.6%, n = 105 and mRRC II 4.5%; n = 5, respectively). Follow-up data of 91 patients for > 2 years were obtained. Of these, 88 had MRRCI obstruction and 3 had MRRC II obstruction. The overall complication rate was 4.8%, and one patient died during the post-procedural follow-up. CONCLUSION: The long-term follow-up results of Y-stenting with LEO Baby revealed that it provides stable closure of the aneurysm sac while preserving the main arterial structures. Therefore, it is a safe, durable, and effective method for treating wide-necked and complex bifurcation aneurysms.

Simultaneous stenting of tightly stenosed patent ductus arteriosus and pulmonary artery bifurcation using two stents (Y stenting): an innovative technique.

Stenting of patent ductus arteriosus (PDA) is a palliative technique that is evolving as an alternative to shunt surgery. Patients with duct-dependant pulmonary circulation and branch pulmonary artery stenosis are often palliated by shunt surgery with repair of branch pulmonary arteries under cardiopulmonary bypass. We present here an 8-month-old male child with duct-dependant pulmonary circulation with bifurcation stenosis who was palliated successfully by transcatheter means. He had stenosed PDA with tight pulmonary artery bifurcation stenosis and underwent successful "Y" stenting of PDA with simultaneous deployment of two stents. He successfully underwent bidirectional Glenn surgery 8 months after the procedure. Simultaneous stenting of bifurcation stenosis of branch pulmonary arteries with two stents has not been described in the literature.

Low-Profile Visualized Intraluminal Support Device for Y-Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms: A Single-Center Experience.

BACKGROUND: The Low-Profile Visualized Intraluminal Support (LVIS) device has been frequently used as an intracranial stent for treating intracranial aneurysms. However, the feasibility and efficacy of LVIS devices in Y-stent-assisted coiling (Y-SAC) have remained contentious. This study aimed to evaluate long-term angiographic and clinical outcomes of Y-SAC using LVIS devices. METHODS: We retrospectively reviewed the clinical presentation and angiography data of patients treated with Y-SAC using LVIS stents. The vascular angle geometry between the parent and the 2 branch vessels, before and after stent deployment and after coiling, were analyzed. Based on the Raymond-Roy Occlusion Classification (RROC), aneurysm occlusion status was classified. Clinical outcomes were assessed using the modified Rankin Scale. RESULTS: Forty patients with 40 aneurysms were included in this study. Immediate postprocedural angiograms showed complete/near-complete occlusion (RROC 1 and 2) in 31 aneurysms (77.5%). The long-term follow-up angiographic studies were available in 32 patients and showed RROC class 1 and 2 in 93.8% of patients. Y-SAC with LVIS devices significantly decreased the angle between the bifurcation branches from 171.90° ± 48.0° (standard deviation) to 130.21° ± 46.3° (standard deviation) (P < 0.0001). Periprocedural complications occurred in 5 patients (12.5%) including 4 in-stent thromboses (10.5%). Thirty-six patients (90.0%) had favorable clinical outcomes at the final follow-up. Univariate analysis showed that World Federation of Neurological Societies grade 3-5, thickness of subarachnoid hemorrhage on head computed tomography, intraprocedural complications, and in-stent thrombosis were predictors of poor outcome. CONCLUSIONS: Y-SAC using the LVIS device for intracranial bifurcation aneurysms is a feasible and relatively safe procedure with favorable long-term angiographic and clinical outcomes.

Reverse Y stenting in the management of vertebrobasilar junction fenestrated aneurysm: A novel technique.

Fenestrated aneurysm at vertebrobasilar junction (VBJ) is very rare and can occur due to non-fusion of longitudinal neural axis forming basilar artery in the early stage of embryonic life. Due to defects in tunica media and weakness in its wall, these fenestrations are more likely to develop an aneurysm. Various treatment strategies are required for the management of these types of aneurysms including simple coiling, stent-assisted coiling, balloon remodeling technique, and more recently kissing flow diverters. Herein, we report the case of ruptured fenestrated VBJ aneurysm which was managed successfully with novel reverse Y stenting with coiling.

PulseRider "jack-up" technique for wide-necked basilar tip aneurysms that incorporate parent arteries: A technical note.

Background: Treatment of intracranial wide-necked bifurcation aneurysms remains challenging. We report a novel PulseRider "jack-up" technique for the treatment of wide-necked basilar tip aneurysms. Case Description: We performed coil embolization in three patients with an unruptured wide-necked basilar tip aneurysm. Aneurysm neck diameters ranged between 7.6 and 11 mm and dome-to-neck ratios ranged from 1.0 to 1.15. All three aneurysms were very shallow with aspect ratios of 0.51-0.69 and incorporated both posterior cerebral arteries into the aneurysm wall. Because each was difficult to embolize using the standard PulseRider procedure, the PulseRider was deployed more proximally than usual and a coil frame constructed above it. Then, the coil was pushed or "jacked up" into the aneurysm with the PulseRider. Adequate embolization was achieved in all three patients. Conclusion: Coil embolization using the PulseRider jack-up technique is effective for treatment of wide-necked basilar tip aneurysms that incorporate parent arteries.

Percutaneous insertion of a novel dedicated metal stent to treat malignant hilar biliary obstruction.

BACKGROUND: Percutaneous bilateral biliary stenting is an established method for the management of unresectable malignant hilar biliary obstruction. AIM: To evaluate the efficacy and safety of a novel uncovered biliary stent, specifically designed for hilar reconstruction. METHODS: This, single-center, retrospective study included 18 patients (mean age 71 ± 11 years; 61.1% male) undergoing percutaneous transhepatic Moving cell stent (MCS) placement for hilar reconstruction using the stent-in-stent technique for malignant biliary strictures, between November 2020 and July 2021. The Patients were diagnosed with cholangiocarcinoma (12/18; 66.6%), gallbladder cancer (5/18; 27.7%), and colorectal liver metastasis (1/18; 5.5%). Primary endpoints were technical (appropriate stent placement) and clinical (relief from jaundice) success. Secondary endpoints included stent patency, overall survival, complication rates and stent-related complications. RESULTS: The technical and clinical success rates were 100% (18/18 cases). According to Kaplan-Meier analysis, the estimated overall patient survival was 80.5% and 60.4% at 6 and 12 mo respectively, while stent patency was 90.9% and 68.2% at 6 mo and 12 mo respectively. The mean stent patency was 172.53 ± 56.20 d and median stent patency was 165 d (range 83-315). Laboratory tests for cholestasis significantly improved after procedure: mean total bilirubin decreased from 15.2 ± 6.0 mg/dL to 1.3 ± 0.4 mg/dL (P < 0.001); mean γGT decreased from 1389 ± 832 U/L to 114.6 ± 53.5 U/L (P < 0.001). One periprocedural complication was reported. Stent-related complications were observed in 5 patients (27.7%), including 1 occlusion (5.5%) and 1 stent migration (5.5 %). CONCLUSION: Percutaneous hilar bifurcation biliary stenting with the MCS resulted in excellent clinical and technical success rates, with acceptable complication rates. Further studies are needed to confirm these initial positive results.

Y-Stent-Assisted Coiling With Low-Profile Neuroform Atlas Stents for Endovascular Treatment of Wide-Necked Complex Intracranial Bifurcation Aneurysms.

BACKGROUND: Y-stent-assisted coiling is one of the eligible techniques for the treatment of complex bifurcation aneurysms. In majority of previous literature, Y-stenting has been performed using stents that could be delivered through large profile microcatheters that are often difficult to manipulate during navigation through sharply angled side branches. Attempts to navigate with these large profile catheters might cause serious complications during Y-stenting procedure. OBJECTIVE: To investigate the safety, feasibility, and efficacy of Y-stent-assisted coiling procedure with Neuroform Atlas stents for the treatment of complex bifurcation aneurysms; Neuroform Atlas is a recently introduced open-cell stent that can be delivered though low-profile microcatheters. METHODS: We identified the patients with intracranial bifurcation aneurysms treated by Y-stent-assisted coiling procedure with Neuroform Atlas stents. We assessed the immediate postoperative and follow-up clinical and angiographic outcomes. We also investigated the periprocedural and delayed complications. RESULTS: A total of 30 aneurysms in 30 patients were included in the study. Y-stenting was successfully performed without any technical complications in all cases (100%). Immediate postprocedural angiography revealed total aneurysm occlusion in 83.3% of patients. The mean angiographic follow-up time was 11.8 mo. The last follow-ups showed complete occlusion in 93.3% of patients. There was no mortality in this study. A procedure-related complication developed in 6.7% and resulted in permanent morbidity in 3.3% of patients. CONCLUSION: Neuroform Atlas stent combines the advantages of low-profile deployment microcatheters with an open-cell structure to achieve a successful Y-stenting procedure. Y-stent-assisted coiling with Neuroform Atlas stents provides a safe and effective endovascular treatment for wide-necked complex bifurcation aneurysms.

False ischaemic penumbras in CT perfusion in patients with carotid artery stenosis and changes following angioplasty and stenting. / Falsas penumbras isquémicas en la TC de perfusión en pacientes con estenosis carotídea y cambios después de la angioplastia y stenting.

INTRODUCTION: Carotid artery stenosis influences CT perfusion (CTP) studies, sometimes manifesting as a false ischaemic penumbra (FIP). This study aims to estimate the incidence of FIP in patients with carotid artery stenosis, establish their relationship with the degree of stenosis, and measure quantitative and qualitative changes in CTP after carotid angioplasty and stenting (CAS). METHODS: Between October 2013 and June 2015, we prospectively selected 26 patients with carotid stenosis who underwent CAS, with CTP being performed 2-10 days before and after CAS. RESULTS: Sixteen patients had unilateral stenosis (11 in the subgroup displaying < 90% stenosis and 5 in the subgroup with ≥ 90% stenosis) and 10 patients had bilateral stenosis. The incidence of FIP in patients with carotid artery stenosis was 38.5%. Risk of FIP increased in direct relation to degree of stenosis, with a relative risk of 11 in the subgroup with ≥ 90% stenosis with respect to the subgroup displaying < 90% stenosis (95% CI, 1.7-71.3; P=.0005). There were statistically significant changes in the parameters CBF, TTP, MTT, and Tmax CTP, which reverted after angioplasty. No significant changes were found in CBV. CONCLUSIONS: Carotid artery stenosis involves changes in CTP parameters. Patients with ≥ 90% stenosis carry a high risk of FIP; CTP studies may therefore be misinterpreted in these cases. Changes in CTP parameters are reverted after CAS.

The Y-stenting technique for pulmonary artery bifurcation stenosis: Initial results and mid-term outcomes.

BACKGROUND: Treatment for main or peripheral PBS is challenging. An interventional approach is generally preferred as surgical angioplasty often results in residual stenosis. However, there is limited data on the mid- and long-term results of the different interventional approaches. The aim of this study is to report on initial and mid-term results of the Y-stenting technique for pulmonary artery bifurcation stenosis (PBS). METHODS: A single centre retrospective study of all Y-stenting procedures for main or peripheral PBS was conducted. Patient and procedural data as well as mid-term outcomes were analysed. RESULTS: 11 Y-stenting procedures were performed, 9 in the main pulmonary bifurcation and 2 in the PA periphery. In 8 patients the bifurcation stents were connected, in 3 patients there was no connection between the stents. Y-stenting creates a geometry close to the physiological PA bifurcation anatomy with complete alignment to the vessel wall without flow separation. Control angiography showed unrestricted blood flow after all procedures. Median right/left ventricle pressure ratio decreased from 0.9 to 0.5. No immediate or delayed adverse events were seen. During a median follow-up of 33.5 months, 2 patients in the non-connected group and 3 patients in the connected group needed a total of 6 re-interventions. No intima proliferation was seen in patients with connected stents. CONCLUSIONS: Y-stenting is a safe and effective treatment for PBS. When both bifurcation stents are connected, this may result in lower rates of in-stent intima proliferation in comparison to other PBS stenting techniques.

A "Train-Track" Technique in Anatomic Reconstruction of SVC Bifurcation Complicated by Cardiac Tamponade: An Introspection.

This report describes a stenting technique used to anatomically reconstruct superior vena cava (SVC) bifurcation in a patient with benign SVC syndrome. After recanalizing the SVC bifurcation, we exchanged two 0.035-in. wires for two 0.018-in. wires, deployed the SVC stent over these two wires ("train-track" technique), and stented each innominate vein over one wire. However, our decisions to recanalize both innominate veins, use the "buddy-wire" technique for SVC dilation, and dilate the SVC to 16 mm before stent deployment likely contributed to SVC tear, which was managed by resuscitation, SVC stent placement, and pericardial drainage. Here, we describe the steps of the train-track technique, which can be adopted to reconstruct other bifurcations; we also discuss the controversial aspects of this case.

Novel solution for luminal access loss into the double-layered LVIS Blue™ construct.

We described a novel solution for a challenging case of double-layered LVIS Blue™ (LB) stent construct retraction into a large cavernous aneurysm. The double-layered LB stent construct was used as a flow diverter for treatment of a large cavernous aneurysm. Our solution comprised a balloon angioplasty and placement of balloon-mounted cardiac-stent construct through the side wall of the LB construct, with eventual placement of a Pipeline Flex inside of the final conduit.

Endovascular treatment of wide-neck intracranial bifurcation aneurysms with 'Y'-configuration, double Neuroform® stents-assisted coiling technique: Experience in a single center.

Background Intracranial wide-neck aneurysms at the arterial bifurcations, especially in the aneurysms where the bifurcating branches emanate directly from the base of the aneurysm, have been particularly difficult on which to perform endovascular treatment. The 'Y'-configuration, double stent-assisted coil embolization is an option for the treatment of these difficult aneurysms, allowing the closure of the aneurysm, preserving the parent arteries. Material and methods In a nine-year period, 546 intracranial aneurysms in 493 patients were treated at our center by endovascular approach. We have reviewed the medical records and arteriographies from November 2007 to January 2017 of 45 patients who were treated using 'Y'-configuration double Neuroform® stent-assisted coil embolization. Results All patients were successfully treated. The location of the aneurysms were: middle cerebral artery (MCA) 20 (44.4%), anterior communicating artery (AComA) 17 (37.7%), basilar four (8.9%), internal carotid artery (ICA) bifurcation three (6.6%) and posterior communicating artery (PComA) one (2.2%). The mRS at hospital discharge was: mRS 0: 42 (93.3%), mRS 1: 1 (2.2%), mRS 2: 1 (2.2%) and mRS 5: 1 (2.2%). The Modified Raymond-Roy Occlusion Classification, in the control at six months, was: Class I: 41 (91.1%), Class II: 2 (4.4%), Class IIIa: 1 (2.2%) and Class IIIb: 1 (2.2%). Forty-four (97.8%) patients had a good outcome (mRS < 2) at six months. One (2.2%) patient had a poor outcome (mRS > 2) at six months that was due to sequelae of SAH. There was no mortality at six months. Conclusions This technique is safe and effective for the endovascular treatment of difficult wide-neck bifurcation aneurysms, allowing the stable closure of the aneurysm, preserving the parent arteries.

Double-barrel Y-configuration Stenting for Flow Diversion of a Giant Recurrent Basilar Apex Aneurysm with the Pipeline Flex Embolization Device.

Giant basilar apex aneurysms are extremely challenging to successfully manage. The Pipeline Flex embolization device (PFED) is a new generation flow-diverting stent with a modified delivery system which allows resheathing of the stent after partial deployment. We describe a case of double-barrel Y-configuration stenting of a giant, recurrent basilar apex aneurysm using the PFED. A 73-year-old male was previously treated for an unruptured 11-mm basilar apex aneurysm with stent-assisted coiling using a Neuroform stent. The aneurysm was retreated twice with repeat coiling. After the third recurrence and persistent aneurysm growth into a giant, symptomatic lesion, we decided to proceed with flow diversion. We performed Y-stenting of the basilar bifurcation using three PFEDs, and was recoiled the aneurysm sac. Due to the low porosity of the flow diverters, a side-by-side double-barrel configuration was necessary in the basilar artery. Without the PFED's resheathable capability, it would not have been possible to perform Y-stenting with flow diverters.

Hybrid, Y-configured, dual stent-assisted coil embolization in the treatment of wide-necked bifurcation aneurysms.

In Y-stenting, stabilization of the first stent may be problematic as in some cases it migrates during second stent insertion. This report evaluates the safety and effectiveness of the technique and presents the long-term results of hybrid, Y-configured, dual stent-assisted coil embolization in the treatment of wide-necked bifurcation aneurysms. We retrospectively evaluated the patients treated endovascularly due to cerebral aneurysms. Twenty patients treated with hybrid Y-stent-assisted coil embolization were enrolled in the study. In hybrid stenting, an open-cell intracranial stent (Neuroform) was used as a first stent to prevent stent migration. A closed-cell stent (Enterprise or Acclino) was used as a second stent and the aneurysm was embolized with coils between the stent struts. In all patients, hybrid Y-stenting and coil embolization were accomplished successfully. No stent migration occurred. Clinically, neither symptomatic neurologic complication nor death was seen. Of 20 wide-necked bifurcation aneurysms, nine were at the basilar tip, while seven were at the middle cerebral artery and three at the anterior communicating artery. In one patient, the aneurysm was at the A2-3 junction of the anterior cerebral artery. One of the patients had a subarachnoid hemorrhage. The mean angiographic follow-up was 25.6 months. No in-stent stenosis was seen in any of the patients and recanalization in only one. Hybrid, Y-configured, dual stent-assisted coil embolization is a safe and effective method in the treatment of wide-necked bifurcation aneurysms to prevent stent migration and aneurysm recanalization, and is a viable alternative to microsurgery.

Endovascular strategy for unruptured cerebral aneurysms.

The treatment of unruptured intracranial aneurysms (UIAs) remains complex and not clearly defined. While for ruptured intracranial aneurysms the management and the treatment option (surgery or endovascular treatment) are well defined by several trials, for asymptomatic UIAs the best management is still currently uncertain. The rationale to treat an UIA is to prevent the rupture and its consequent SAH and all complications derived from hemorrhage or reduce/eliminate neurological palsy. Although this statement is correct, the indication to treat an UIA should be based on a correct balance between the natural history of UIA and treatment risk. Patient's clinical history, aneurysm characteristics, and strategy management influence the natural history of UIAs and treatment outcomes. In the last 10 years and more, two important large multicenter studies were performed in order to analysis of all these factors and to evaluate the best treatment option for UIAs. The aim of this paper is to try to synthesize the possible indications to the endovascular treatment (EVT), when and how to treat an UIA.