Name:
10.3171/2022.7.FOCVID2247
Description:
10.3171/2022.7.FOCVID2247
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Duration:
T00H07M22S
Embed URL:
https://stream.cadmore.media/player/e3fa4d4c-e4b9-434e-9114-c26b329c55e1
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https://cadmoreoriginalmedia.blob.core.windows.net/e3fa4d4c-e4b9-434e-9114-c26b329c55e1/9. 22-47.mp4?sv=2019-02-02&sr=c&sig=lUfi5HX6QxKG7esR%2BNJJ9zwi0hiS4F7CiPcFqv8noHc%3D&st=2024-05-07T01%3A53%3A56Z&se=2024-05-07T03%3A58%3A56Z&sp=r
Upload Date:
2022-09-13T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
TYLER LAZARO: Hello. I'm lead author, Tyler Lazaro from Baylor College of Medicine. And I'll be discussing a case of flow diversion for dissecting PICA aneurysm. None of the contributing authors of this video have any financial disclosures. The patient is a 47-year-old woman with a previously coiled ruptured left PICA aneurysm and subsequent recurrent left PICA aneurysm status post additional coiling who presented for routine follow-up cerebral angiography.
TYLER LAZARO: AP and lateral projections of a left vertebral artery injection are shown here, revealing a 2-mm fusiform dilation at the base of the previously coiled left PICA aneurysm, which is at the junction of the anterior and lateral medullary segments. And so the diagnosis in this case is a recurrent 2- mm dissecting left posterior inferior cerebellar artery aneurysm. A quick word on PICA aneurysms.
TYLER LAZARO: They are considered high-risk aneurysms with a greater propensity for rupture than anterior circulation aneurysms. They most often occur at the take-off from the vertebral artery or proximal segments of the PICA. In addition, the diameter of the PICA artery is quite diminutive at approximately 1.8 mm, which tapers to a smaller diameter more distally. This has previously made endovascular intervention, particularly flow diversion, very challenging.
TYLER LAZARO: In our case, we are also dealing with a dissecting PICA aneurysm, which are rare, usually involving segments distal to p2, and carry an even higher risk of rupture. Given the natural history of dissecting PICA aneurysms and the multiple recurrences in this patient, retreatment was recommended. With the availability of the Silk Vista Baby in mind, parent vessel reconstruction with flow diversion was offered to the patient.
TYLER LAZARO: Were this not an option, stenting or the use of standard flow diverter would be considered at a high risk for parent vessel thrombosis, given the narrow diameter of the more distal PICA segments as previously discussed, which would be a poor outcome in a patient with an unruptured recurrence and who is neurologically intact. Moreover, while vessel deconstruction and revascularization with surgery was an option, there were several considerations that favored endovascular flow diversion in this case.
TYLER LAZARO: For one, the surgical morbidity and risk to both PICA territories as in a PICA-PICA bypass could be avoided. In addition, the use of dual antiplatelet therapy was not contraindicated relative to the patient's medical history or as in the setting of subarachnoid hemorrhage due to aneurysm rupture. Lastly, after discussion of the open and endovascular options, the patient had a strong preference for endovascular therapy.
TYLER LAZARO: We planned to load the patient with dual antiplatelet therapy with aspirin and Plavix 1 week prior to intervention and confirm with platelet function testing. In this case, we planned to approach this left PICA aneurysm through a left radial artery approach with a 6- Fr sheath, as this would allow us to easily cannulate the left vertebral artery and establish a coaxial system. After accessing the PICA past the aneurysm, we would then deploy a 2.25 × 15–mm Silk Vista Flow Diverter across the diseased segment of the vessel.
TYLER LAZARO: The Silk Vista Baby is the newest iteration of the Silk Flow Diverter. It is very low profile, delivered through a 0.017 catheter and designed for treatment of aneurysms in vessels 1.5- 3.5 mm in diameter. It is not currently approved for aneurysm treatment by the US FDA; thus, IRB approval for compassionate use of this device must be obtained. Initial case reports and case series demonstrate safety and show efficacy, with the consensus opinion stating that it is ideally suited for distal aneurysms.
TYLER LAZARO: Now on to our case. First, the left radial artery is accessed and a 6-Fr slender sheath is placed. The left vertebral artery is easily selected, and a Catalyst 5 distal access catheter is tracked up through the artery under roadmap guidance. An initial diagnostic angiogram is obtained with AP and lateral views, and aneurysm views are set up in preparation for device deployment.
TYLER LAZARO: A more lateral view on the left and AP view on the right. Next, a Synchro 10 wire and Phenom 17 microcatheter are placed through the distal access catheter to establish a coaxial system. And the wire is navigated past the aneurysm into the lateral medullary segment. The microcatheter is then tracked past the aneurysm as well.
TYLER LAZARO: The device is then placed in position in the distal lateral medullary segment and deployed. As the device is being unsheathed, notice how easily the microcatheter tracks along the device. Here, the microcatheter has reached the proximal marker on the device, with good apposition across the neck of the aneurysm seen in red.
TYLER LAZARO: However, a run after the device is completely deployed then showed an area of focal stenosis across the proximal opening of the stent. A wire was navigated through the device past the aneurysm once again and a 4 × 7–mm TransForm Balloon was inflated across the area of stenosis under continuous fluoroscopy. A run after the angioplasty shows improved but moderates stenosis and some contrast statis within the aneurysm.
TYLER LAZARO: Left AP and lateral vertebral artery runs show no evidence of distal emboli or other complications. Overall, this patient did well, was neurologically intact after the procedure, and discharged home on post procedure day 1 on dual antiplatelet therapy. A 1-year follow-up angiogram showed complete obliteration of the aneurysm. Here, magnified lateral and AP projections are seen with no evidence of residual or recurrent aneurysm.
TYLER LAZARO: In addition, the previously seen stenosis within the proximal segment of the device has completely resolved. In conclusion, the Baby Silk Vista adds another tool to the armamentarium for small-vessel aneurysms, with high rates of aneurysm occlusion. What's more is that this device is very low profile, and thus is suitable for distal artery access with a 0.017 microcatheter and can be deployed with a coaxial technique without the need for more support.
TYLER LAZARO: We hope you enjoyed our video and thank you for watching.