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Temporary stent scaffolding during aneurysm coiling
Journal of Clinical Neuroscience 21 (2014) 852–854
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical note
Temporary stent scaffolding during aneurysm coiling Daniel W. Zumofen a,b,⇑, Nikhil Sahasrabudhe b, Howard A. Riina a,b,c, Eytan Raz a, Maksim Shapiro a,c, Tibor Becske a,c, Peter K. Nelson a,b,c a Bernard and Irene Schwartz Interventional Neuroradiology Section, Department of Radiology, NYU Langone Medical Center, New York University School of Medicine, 660 First Avenue, 7th Floor, New York, NY 10016, USA b Department of Neurosurgery, NYU Langone Medical Center, New York University School of Medicine, New York, NY, USA c Department of Neurology, NYU Langone Medical Center, New York University School of Medicine, New York, NY, USA
a r t i c l e
i n f o
Article history: Received 2 October 2013 Accepted 19 October 2013
Keywords: Aneurysm Balloon remodeling Coiling Stent Stent remodeling
a b s t r a c t We report a case of temporary Solitaire FR stent (Covidien, Mansfield, MA, USA) scaffolding to reduce coil herniation during embolization of a large neck anterior communicating artery aneurysm. In contrast to classic stent-assisted coiling, the fully retrievable stent is recaptured prior to detachment of the last coil. The presented technical nuance hence does not require institution of prolonged antiplatelet coverage. But the door is left open for coil-repositioning in case of coil basket instability. Permanent stent redeployment remains a fall-back option if critical hardware conflict occurs. In comparison to classic balloon remodeling, the presented method may offer easier distal access, particularly in tortuous arterial anatomy. Temporary occlusion of the parent artery, side branches, and perforators is also avoided. Given its specific potential advantages, temporary stent scaffolding using the fully retrievable Solitaire FR device may find its niche as a bailout option, primarily in a very specific subset of distally located wide neck aneurysms. Ó 2013 Elsevier Ltd. All rights reserved.
1. Background
2. Case presentation
Endovascular strategies are established alternatives to open surgical clipping for an increasing subset of ruptured and unruptured brain aneurysms [1–4]. Coil embolization of distally located wide neck aneurysms is associated with a comparatively higher rate of coil basket instability, incomplete obliteration, and compaction, and hence higher rates of aneurysm reperfusion and recurrence over time [5]. Balloon remodeling is known for having a risk of ischemic events secondary to the transient flow arrest within the parent artery or trapped branches [6]. Vessel rupture may become a concern particularly during multiple inflations and deflations in small diameter arteries [7]. Also, navigation and positioning of balloon microcatheters in distal segments, notably those supported by a 0.010 guidewire, can be technically challenging [8]. Regarding stent-assisted techniques, the necessity of instituting prolonged antiplatelet coverage following permanent stent deployment is generally felt to complicate patient management particularly in the context of recent aneurysm rupture. Stent remodeling is hence largely limited to the treatment of unruptured large neck aneurysms.
A 52-year-old man was found to have two large intracranial aneurysms, including an 11 mm fetal posterior communicating artery (Pcomm) aneurysm, and a 9 mm multi-lobulated anterior communicating artery (Acomm) aneurysm with a 5 mm neck (Fig. 1A). The Pcomm aneurysm was secured by direct coil embolization in a first session. During a second session, a 6 French, 90 cm Shuttle sheath (Cook Medical, Bloomington, IN, USA) was placed into the distal right common carotid artery. An Excelsior SL-10 straight 2-tip marker microcatheter (Stryker, Kalamazoo, MI, USA) was navigated over a Transend 0.010 microwire (Stryker, Kalamazoo, MI, USA) into the dome of the Acomm aneurysm. Two Target 360 coils (Stryker, Kalamazoo, MI, USA) were successfully delivered. Intravenous heparin was titrated for an activated clotting time of >250 seconds following detachment of the first coil, and discontinued at the end of the procedure. Attempted placement of the third coil resulted in extra-aneurysmal herniation of coil loops, despite repeated repositioning (Fig. 2A). A Marksman 135 cm microcatheter (Covidien, Mansfield, MA, USA) was therefore navigated over a Transend EX .014 Platinum (Stryker, Kalamazoo, MI, USA) microwire into the post-communicating segment of the ipsilateral anterior cerebral artery. A Solitaire FR 4 15 mm stent was then introduced through the Marksman microcatheter and unsheathed across the aneurysm neck, but without detachment. Deployment of the stent allowed a reduction of the
⇑ Corresponding author. Tel.: +1 917 456 2075. E-mail address: [email protected] (D.W. Zumofen). 0967-5868/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jocn.2013.10.009
D.W. Zumofen et al. / Journal of Clinical Neuroscience 21 (2014) 852–854
853
Fig. 1. Cerebral angiogram, right internal carotid injection, lateral (A1, B1, C1) and oblique (A2, B2, C2) view. A large multi-lobulated aneurysm arising from the anterior communicating artery complex and a previously coiled fetal disposition posterior communicating artery aneurysm is seen (A1, A2). The post-embolization angiogram (B1, B2) and 6 month follow-up angiogram (C1, C2) show complete reduction of the herniated coils, complete coil obliteration of the aneurysm, and unimpaired flow in the parent arteries and perforators.
Fig. 2. Cerebral angiogram, right internal carotid injection, magnified oblique view. Coil herniation occurs during initial non-assisted coiling of the wide neck anterior communicating artery aneurysm (A1, A2). Temporary deployment of a Solitaire FR stent across the aneurysm neck reduces the extra-aneurysmal coil loops (B1, B2). The coil basket remains stable after recapture of the Solitaire FR stent and detachment of the last-coil (C).
herniated coil loops. Two additional Target 360 coils were then delivered via the jailed Excelsior SL-10 microcatheter achieving a dense coil mass at the level of the aneurysm neck (Fig. 2B). Prior to detachment of the last coil, the Solitaire FR was recaptured under fluoroscopy into the Marksman microcatheter. The last coil was then detached, and the Excelsior SL-10 microcatheter and the Marksman catheter with the indwelling Solitaire FR stent were removed (Fig. 2C). Post-embolization (Fig. 1B) and 6 month followup (Fig. 1C) angiography showed complete aneurysm occlusion and unimpaired parent artery patency. No antiplatelet medication was administered before, during, or following the procedure. The
patient emerged from general anesthesia at neurologic baseline, and has remained intact since. 3. Discussion Stent-assisted coiling using the Solitaire AB stent (Covidien, Mansfield, MA, USA) was initially described in 2003 [9]. In Europe, the device was subsequently used in large series for classic stentassisted coiling in the anterior and posterior circulation [10,11]. Although the Solitaire AB device has never been approved for the USA market, its derivate, the Solitaire FR stent system obtained
854
D.W. Zumofen et al. / Journal of Clinical Neuroscience 21 (2014) 852–854
Food and Drug Administration approval as a mechanical thrombectomy device to retrieve clots in patients with acute ischemic stroke from large intracranial vessel occlusion. At the time of writing, the Solitaire FR device was the only fully retrievable, self-expanding stent adapted for 2–5.5 mm vessel diameter available in the USA [12]. The concept of temporary stent scaffolding has been discussed at international meetings, and its theoretical advantages have been described [12,13]. Semi-jailing is a variant of temporary stent scaffolding consisting of partial deployment of a stent across the aneurysm neck to facilitate coiling. The concept of bailout stenting to reduce protruding coils loops during the coiling procedure by permanently deploying a stent across the aneurysm neck has also been described [14]. In the presented variant, coiling is performed to the point where evidence of coil basket instability or extraaneurysmal coil herniation occurs; at which point, a Solitaire FR stent is reversibly deployed across the aneurysm neck. This maneuver reduces the herniated coils and stabilizes the coil mass. The aneurysm is then densely packed via the jailed microcatheter. Prior to detachment of the last coil, the fully deployed stent is recaptured under fluoroscopy. Coil dislodgement during retrieval may become of particular concern when small finishing coils are used. Stent retrieval hence needs to be performed with particular care, under continuous fluoroscopic control, and only once a stable coil collar is achieved at the level of the aneurysm neck. In the case of hardware conflict, this method leaves the door open for redeployment of the stent, as well as for recapture and repositioning of the last coil. Alternatively, the catheter can be repositioned into the aneurysm fundus through the stent struts, however this variant impairs stent retrieval prior to detachment of the last coil. In the case of irreversible trapping of coils in the struts of the stent, stent detachment is the immediate bailout. By nature of its reversibility, the presented method offers independence from antiplatelet therapy. Even though large series will be necessary to draw unequivocal conclusions regarding the risk of thromboembolic complications, temporary deployment of the stent under intravenous heparinization appears reasonably safe, particularly as the Solitaire device is known for its comparatively low thrombogenicity [10]. In current practice, we titrate intravenous heparin for an activated clotting time of >250 seconds following detachment of the first coil, but hold back on antiplatelet medication, particularly in the context of subarachnoid hemorrhage, to ease patient management including subsequent procedures for hydrocephalus. The Solitaire FR stent system is a very navigable tool that can safely be deployed in distal arterial segments. The presented method may therefore find consideration as an alternative to open surgery or balloon remodeling, particularly in distal vessels where balloon remodeling is hindered by the relative stiffness of its carrier system, and in locations where prolonged balloon inflation endangers eloquent side branches or perforators.
4. Conclusions Temporary stent scaffolding using the Solitaire FR device may facilitate coil embolization of a very specific subset of large neck aneurysms. This technique should be kept in a neurointerventionalist’s toolbox primarily as a bailout strategy for those situations when open surgical clipping and balloon-assisted techniques fail. The Solitaire FR device is particularly advantageous for stent scaffolding due to its high maneuverability and its unique retrievability. Conflicts of interest/disclosures Maksim Shapiro, Tibor Becske, and Peter K. Nelson are consultant per diem for the Pipeline Embolization Device (Covidien, Mansfield, MA, USA). The other authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Molyneux A, Kerr R, Stratton I, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002;360: 1267–74. [2] Unruptured intracranial aneurysms – risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. New Engl J Med 1998;339:1725–33. [3] McDougall CG, Spetzler RF, Zabramski JM, et al. The Barrow Ruptured Aneurysm Trial. J Neurosurg 2012;116:135–44. [4] Spetzler RF, McDougall CG, Albuquerque FC, et al. The barrow ruptured aneurysm trial: 3-year results. J Neurosurg 2013;119:146–57. [5] Vallee JN, Pierot L, Bonafe A, et al. Endovascular treatment of intracranial widenecked aneurysms using three-dimensional coils: predictors of immediate anatomic and clinical results. AJNR Am J Neuroradiol 2004;25:298–306. [6] Spiotta AM, Bhalla T, Hussain MS, et al. An analysis of inflation times during balloon-assisted aneurysm coil embolization and ischemic complications. Stroke 2011;42:1051–5. [7] Santillan A, Gobin YP, Greenberg ED, et al. Intraprocedural aneurysmal rupture during coil embolization of brain aneurysms: role of balloon-assisted coiling. AJNR Am J Neuroradiol 2012;33:2017–21. [8] Aletich VA, Debrun GM, Misra M, et al. The remodeling technique of balloonassisted Guglielmi detachable coil placement in wide-necked aneurysms: experience at the University of Illinois at Chicago. J Neurosurg 2000;93: 388–96. [9] Henkes H, Flesser A, Brew S, et al. A novel microcatheter-delivered, highlyflexible and fully-retrievable stent, specifically designed for intracranial use. Technical note. Interv Neuroradiol 2003;9:391–3. [10] Klisch J, Clajus C, Sychra V, et al. Coil embolization of anterior circulation aneurysms supported by the Solitaire AB neurovascular remodeling device. Neuroradiology 2010;52:349–59. [11] Klisch J, Eger C, Sychra V, et al. Stent-assisted coil embolization of posterior circulation aneurysms using solitaire ab: preliminary experience. Neurosurgery 2009;65:258–66 [discussion 266]. [12] Kim BM, Kim DJ, Kim DI. Stent application for the treatment of cerebral aneurysms. Neurointervention 2011;6:53–70. [13] Maldonado I, Bonafé A. Stent-assisted techniques for intracranial aneurysms. In: Murai Y, editor. Aneurysm. Croatia: InTech; 2012. p. 291–312. [14] Weber W, Henkes H, Kuhne D. Stent implantation into the basilar artery for supporting endovascular aneurysm treatment. Nervenarzt 2000;71:843–8.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical note
Temporary stent scaffolding during aneurysm coiling Daniel W. Zumofen a,b,⇑, Nikhil Sahasrabudhe b, Howard A. Riina a,b,c, Eytan Raz a, Maksim Shapiro a,c, Tibor Becske a,c, Peter K. Nelson a,b,c a Bernard and Irene Schwartz Interventional Neuroradiology Section, Department of Radiology, NYU Langone Medical Center, New York University School of Medicine, 660 First Avenue, 7th Floor, New York, NY 10016, USA b Department of Neurosurgery, NYU Langone Medical Center, New York University School of Medicine, New York, NY, USA c Department of Neurology, NYU Langone Medical Center, New York University School of Medicine, New York, NY, USA
a r t i c l e
i n f o
Article history: Received 2 October 2013 Accepted 19 October 2013
Keywords: Aneurysm Balloon remodeling Coiling Stent Stent remodeling
a b s t r a c t We report a case of temporary Solitaire FR stent (Covidien, Mansfield, MA, USA) scaffolding to reduce coil herniation during embolization of a large neck anterior communicating artery aneurysm. In contrast to classic stent-assisted coiling, the fully retrievable stent is recaptured prior to detachment of the last coil. The presented technical nuance hence does not require institution of prolonged antiplatelet coverage. But the door is left open for coil-repositioning in case of coil basket instability. Permanent stent redeployment remains a fall-back option if critical hardware conflict occurs. In comparison to classic balloon remodeling, the presented method may offer easier distal access, particularly in tortuous arterial anatomy. Temporary occlusion of the parent artery, side branches, and perforators is also avoided. Given its specific potential advantages, temporary stent scaffolding using the fully retrievable Solitaire FR device may find its niche as a bailout option, primarily in a very specific subset of distally located wide neck aneurysms. Ó 2013 Elsevier Ltd. All rights reserved.
1. Background
2. Case presentation
Endovascular strategies are established alternatives to open surgical clipping for an increasing subset of ruptured and unruptured brain aneurysms [1–4]. Coil embolization of distally located wide neck aneurysms is associated with a comparatively higher rate of coil basket instability, incomplete obliteration, and compaction, and hence higher rates of aneurysm reperfusion and recurrence over time [5]. Balloon remodeling is known for having a risk of ischemic events secondary to the transient flow arrest within the parent artery or trapped branches [6]. Vessel rupture may become a concern particularly during multiple inflations and deflations in small diameter arteries [7]. Also, navigation and positioning of balloon microcatheters in distal segments, notably those supported by a 0.010 guidewire, can be technically challenging [8]. Regarding stent-assisted techniques, the necessity of instituting prolonged antiplatelet coverage following permanent stent deployment is generally felt to complicate patient management particularly in the context of recent aneurysm rupture. Stent remodeling is hence largely limited to the treatment of unruptured large neck aneurysms.
A 52-year-old man was found to have two large intracranial aneurysms, including an 11 mm fetal posterior communicating artery (Pcomm) aneurysm, and a 9 mm multi-lobulated anterior communicating artery (Acomm) aneurysm with a 5 mm neck (Fig. 1A). The Pcomm aneurysm was secured by direct coil embolization in a first session. During a second session, a 6 French, 90 cm Shuttle sheath (Cook Medical, Bloomington, IN, USA) was placed into the distal right common carotid artery. An Excelsior SL-10 straight 2-tip marker microcatheter (Stryker, Kalamazoo, MI, USA) was navigated over a Transend 0.010 microwire (Stryker, Kalamazoo, MI, USA) into the dome of the Acomm aneurysm. Two Target 360 coils (Stryker, Kalamazoo, MI, USA) were successfully delivered. Intravenous heparin was titrated for an activated clotting time of >250 seconds following detachment of the first coil, and discontinued at the end of the procedure. Attempted placement of the third coil resulted in extra-aneurysmal herniation of coil loops, despite repeated repositioning (Fig. 2A). A Marksman 135 cm microcatheter (Covidien, Mansfield, MA, USA) was therefore navigated over a Transend EX .014 Platinum (Stryker, Kalamazoo, MI, USA) microwire into the post-communicating segment of the ipsilateral anterior cerebral artery. A Solitaire FR 4 15 mm stent was then introduced through the Marksman microcatheter and unsheathed across the aneurysm neck, but without detachment. Deployment of the stent allowed a reduction of the
⇑ Corresponding author. Tel.: +1 917 456 2075. E-mail address: [email protected] (D.W. Zumofen). 0967-5868/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jocn.2013.10.009
D.W. Zumofen et al. / Journal of Clinical Neuroscience 21 (2014) 852–854
853
Fig. 1. Cerebral angiogram, right internal carotid injection, lateral (A1, B1, C1) and oblique (A2, B2, C2) view. A large multi-lobulated aneurysm arising from the anterior communicating artery complex and a previously coiled fetal disposition posterior communicating artery aneurysm is seen (A1, A2). The post-embolization angiogram (B1, B2) and 6 month follow-up angiogram (C1, C2) show complete reduction of the herniated coils, complete coil obliteration of the aneurysm, and unimpaired flow in the parent arteries and perforators.
Fig. 2. Cerebral angiogram, right internal carotid injection, magnified oblique view. Coil herniation occurs during initial non-assisted coiling of the wide neck anterior communicating artery aneurysm (A1, A2). Temporary deployment of a Solitaire FR stent across the aneurysm neck reduces the extra-aneurysmal coil loops (B1, B2). The coil basket remains stable after recapture of the Solitaire FR stent and detachment of the last-coil (C).
herniated coil loops. Two additional Target 360 coils were then delivered via the jailed Excelsior SL-10 microcatheter achieving a dense coil mass at the level of the aneurysm neck (Fig. 2B). Prior to detachment of the last coil, the Solitaire FR was recaptured under fluoroscopy into the Marksman microcatheter. The last coil was then detached, and the Excelsior SL-10 microcatheter and the Marksman catheter with the indwelling Solitaire FR stent were removed (Fig. 2C). Post-embolization (Fig. 1B) and 6 month followup (Fig. 1C) angiography showed complete aneurysm occlusion and unimpaired parent artery patency. No antiplatelet medication was administered before, during, or following the procedure. The
patient emerged from general anesthesia at neurologic baseline, and has remained intact since. 3. Discussion Stent-assisted coiling using the Solitaire AB stent (Covidien, Mansfield, MA, USA) was initially described in 2003 [9]. In Europe, the device was subsequently used in large series for classic stentassisted coiling in the anterior and posterior circulation [10,11]. Although the Solitaire AB device has never been approved for the USA market, its derivate, the Solitaire FR stent system obtained
854
D.W. Zumofen et al. / Journal of Clinical Neuroscience 21 (2014) 852–854
Food and Drug Administration approval as a mechanical thrombectomy device to retrieve clots in patients with acute ischemic stroke from large intracranial vessel occlusion. At the time of writing, the Solitaire FR device was the only fully retrievable, self-expanding stent adapted for 2–5.5 mm vessel diameter available in the USA [12]. The concept of temporary stent scaffolding has been discussed at international meetings, and its theoretical advantages have been described [12,13]. Semi-jailing is a variant of temporary stent scaffolding consisting of partial deployment of a stent across the aneurysm neck to facilitate coiling. The concept of bailout stenting to reduce protruding coils loops during the coiling procedure by permanently deploying a stent across the aneurysm neck has also been described [14]. In the presented variant, coiling is performed to the point where evidence of coil basket instability or extraaneurysmal coil herniation occurs; at which point, a Solitaire FR stent is reversibly deployed across the aneurysm neck. This maneuver reduces the herniated coils and stabilizes the coil mass. The aneurysm is then densely packed via the jailed microcatheter. Prior to detachment of the last coil, the fully deployed stent is recaptured under fluoroscopy. Coil dislodgement during retrieval may become of particular concern when small finishing coils are used. Stent retrieval hence needs to be performed with particular care, under continuous fluoroscopic control, and only once a stable coil collar is achieved at the level of the aneurysm neck. In the case of hardware conflict, this method leaves the door open for redeployment of the stent, as well as for recapture and repositioning of the last coil. Alternatively, the catheter can be repositioned into the aneurysm fundus through the stent struts, however this variant impairs stent retrieval prior to detachment of the last coil. In the case of irreversible trapping of coils in the struts of the stent, stent detachment is the immediate bailout. By nature of its reversibility, the presented method offers independence from antiplatelet therapy. Even though large series will be necessary to draw unequivocal conclusions regarding the risk of thromboembolic complications, temporary deployment of the stent under intravenous heparinization appears reasonably safe, particularly as the Solitaire device is known for its comparatively low thrombogenicity [10]. In current practice, we titrate intravenous heparin for an activated clotting time of >250 seconds following detachment of the first coil, but hold back on antiplatelet medication, particularly in the context of subarachnoid hemorrhage, to ease patient management including subsequent procedures for hydrocephalus. The Solitaire FR stent system is a very navigable tool that can safely be deployed in distal arterial segments. The presented method may therefore find consideration as an alternative to open surgery or balloon remodeling, particularly in distal vessels where balloon remodeling is hindered by the relative stiffness of its carrier system, and in locations where prolonged balloon inflation endangers eloquent side branches or perforators.
4. Conclusions Temporary stent scaffolding using the Solitaire FR device may facilitate coil embolization of a very specific subset of large neck aneurysms. This technique should be kept in a neurointerventionalist’s toolbox primarily as a bailout strategy for those situations when open surgical clipping and balloon-assisted techniques fail. The Solitaire FR device is particularly advantageous for stent scaffolding due to its high maneuverability and its unique retrievability. Conflicts of interest/disclosures Maksim Shapiro, Tibor Becske, and Peter K. Nelson are consultant per diem for the Pipeline Embolization Device (Covidien, Mansfield, MA, USA). The other authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Molyneux A, Kerr R, Stratton I, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002;360: 1267–74. [2] Unruptured intracranial aneurysms – risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. New Engl J Med 1998;339:1725–33. [3] McDougall CG, Spetzler RF, Zabramski JM, et al. The Barrow Ruptured Aneurysm Trial. J Neurosurg 2012;116:135–44. [4] Spetzler RF, McDougall CG, Albuquerque FC, et al. The barrow ruptured aneurysm trial: 3-year results. J Neurosurg 2013;119:146–57. [5] Vallee JN, Pierot L, Bonafe A, et al. Endovascular treatment of intracranial widenecked aneurysms using three-dimensional coils: predictors of immediate anatomic and clinical results. AJNR Am J Neuroradiol 2004;25:298–306. [6] Spiotta AM, Bhalla T, Hussain MS, et al. An analysis of inflation times during balloon-assisted aneurysm coil embolization and ischemic complications. Stroke 2011;42:1051–5. [7] Santillan A, Gobin YP, Greenberg ED, et al. Intraprocedural aneurysmal rupture during coil embolization of brain aneurysms: role of balloon-assisted coiling. AJNR Am J Neuroradiol 2012;33:2017–21. [8] Aletich VA, Debrun GM, Misra M, et al. The remodeling technique of balloonassisted Guglielmi detachable coil placement in wide-necked aneurysms: experience at the University of Illinois at Chicago. J Neurosurg 2000;93: 388–96. [9] Henkes H, Flesser A, Brew S, et al. A novel microcatheter-delivered, highlyflexible and fully-retrievable stent, specifically designed for intracranial use. Technical note. Interv Neuroradiol 2003;9:391–3. [10] Klisch J, Clajus C, Sychra V, et al. Coil embolization of anterior circulation aneurysms supported by the Solitaire AB neurovascular remodeling device. Neuroradiology 2010;52:349–59. [11] Klisch J, Eger C, Sychra V, et al. Stent-assisted coil embolization of posterior circulation aneurysms using solitaire ab: preliminary experience. Neurosurgery 2009;65:258–66 [discussion 266]. [12] Kim BM, Kim DJ, Kim DI. Stent application for the treatment of cerebral aneurysms. Neurointervention 2011;6:53–70. [13] Maldonado I, Bonafé A. Stent-assisted techniques for intracranial aneurysms. In: Murai Y, editor. Aneurysm. Croatia: InTech; 2012. p. 291–312. [14] Weber W, Henkes H, Kuhne D. Stent implantation into the basilar artery for supporting endovascular aneurysm treatment. Nervenarzt 2000;71:843–8.