Cavernous carotid artery large aneurysm treated with a new flow diverter - Xcalibur aneurysm occlusion device (AOD)

Abstract

We report a case of an unruptured, symptomatic, large right cavernous internal carotid artery aneurysm successfully treated with a new balloon-expandable flow diverter - Xcalibur Aneurysm Occlusion Device (AOD). Follow up imaging performed at six months demonstrated complete exclusion of the aneurysm and regression in dimensions, resulting in resolution of mass effect and clinical improvement.

Keywords: Cavernous segment aneurysm; flow diverter; new device.

Figure 1.

Illustrative images of Xcalibur Aneurysm Occlusive Device. (a and b) Stainless steel construct with ultra-thin polymer covered membrane. (c) Device mounted on a balloon catheter.

Figure 2.

Cross sectional construct of the device. The stainless steel frame of the device is sandwiched between the ultra-thin polymer membrane on the inner and outer sides. The inner layer of the membrane is straight and hydrophobic, while the outer layer is undulating and hydrophilic.

Figure 3.

NCCT head axial section showing the right cavernous hyperdense mass lesion (white arrow).

Figure 4.

MRI brain axial section: (a) FLAIR, (b) T2w, (c) T2*w and (d) post contrast T1w images show partially thrombosed right cavernous segment aneurysm (black arrow). White arrow shows the right cavernous segment ICA.

Figure 5.

Diagnostic angiogram of right ICA: (a) anteroposterior (AP) and (b) lateral view showing cavernous segment aneurysm (black arrow).

Figure 6.

(a and b) Pre-deployment AP and Lateral images; (c and d) post deployment of Xcalibur AOD AP and lateral images. Deployment balloon over which flow diverter is mounted has proximal and distal markers (Thin black arrows). Flow diverter’s proximal and distal markers are shown by thin white arrows. (*) and thick white arrows indicate position of neuron guiding catheter and 7F long sheath, respectively. Traxcess microwire is placed in MCA with the distal end in the M4 segment (thick black arrow). Inset pictures are magnified images of the device.

Figure 7.

Immediate angiogram after deploying Xcalibur AOD. Lateral view angiogram: (a) arterial phase, (b) and (c) venous phase. Anterior view angiogram: (d) arterial phase, (e) and (f) venous phase. Significant stasis in the aneurysm is evident with eclipse formation (black arrow).

Figure 8.

Six months follow up imaging. (a) IV Contrast XperCT shows optimal wall approximation of the device with no obvious in- stent stenosis. (b) T2WI shows complete disappearance of the aneurysm (Black arrow). (c) TOF MRA axial image and (d) TOF MRA MIP 3D reconstructed images show no residual aneurysm. There is signal loss/susceptibility artefact (*) due to flow diverter in the cavernous segment of the right ICA.

Figure 9.

Illustration showing deployment technique of the device in case of significant mismatch between the size of distal and proximal vessel diameter. In this example, the distal vessel diameter is 3.25 mm and the proximal vessel diameter is 4.5 mm. The device size is selected based on the distal vessel diameter. (a) The device is deployed via its own balloon catheter. The distal end of the device is anchored first. Due to mismatch in the size of the vessel diameter, the proximal end of the device is not well opposed to the vessel wall and shows endo-leak. (b and c) Sequential post dilatation is done only in the mid and proximal segments of the device by bigger diameter (4.5 mm) N-chant PDB (Post-Dilatation Balloon) catheter.