Comaneci-Assisted Coiling of Wide-Necked Intracranial Aneurysm: A Single-Center Preliminary Experience

Abstract

Background: Wide-necked aneurysms remain challenging for both coiling and microsurgical clipping. They often require additional techniques to prevent coil prolapse into the parent artery, such as balloon- and stent-assisted coiling. Comaneci is an expandable and removable stent that acts as a bridging device and does not interfere with the blood flow of the parent artery.

Methods: We retrospectively reviewed our institutional radiological and clinical chart of patients treated for saccular intracranial aneurysm via endovascular Comaneci-assisted coiling. The aim of the study was to report our preliminary experience in Comaneci-assisted coiling of wide-necked intracranial aneurysms.

Results: We included 14 patients in the study. Of these, 11 had a ruptured intracranial aneurysm and were treated with Comaneci-assisted coiling. We registered five minor intraprocedural complications and two intraprocedural failures of the device. At one-year follow-up, a satisfying aneurysm occlusion was observed in 85% of the cases.

Conclusions: Though long-term follow-up data and larger case series are needed, this preliminary study showed the feasibility of the Comaneci-assisted coiling method for both ruptured and unruptured wide-neck intracranial aneurysms, with similar occlusion rates as balloon-assisted coiling. However, we registered high incidence of thromboembolic complications; these were probably related to the lack of heparin administration. The main advantageous application of this technique is likely in cases of ruptured intracranial aneurysms, as there is no need for post-procedural antiplatelet therapy.

Keywords: Comaneci; assisted coiling; embolization; intracranial aneurysm.

Figure 1

Patient number 13 (A–C): ruptured ACOM wide-neck aneurysm. (A) Anteroposterior oblique 2D DSA demonstrating the ACOM aneurysm with a daughter sac pointing superiorly. (B) Unsubtracted image showing the expanded Comaneci device after the first framing coil is deployed. (C) DSA final result demonstrating complete occlusion of the aneurysm and patency of both the ACAs. Patient number 5 (D–F): unruptured PCOM wide-neck aneurysm. (D) Lateral oblique 2D DSA demonstrating the PCOM aneurysm. (E) Unsubtracted image showing the expanded Comaneci device after the first framing coil is deployed. (F) DSA final result demonstrating near-complete occlusion of the aneurysm, with a small neck remnant in the inferior part and patency of ICA. Patient number 3 (G–I): ruptured PICA wide-neck aneurysm. (G) Lateral oblique 2D DSA demonstrating the PICA aneurysm. (H) Unsubtracted image showing the expanded Comaneci device and the 0.017″ microcatheter in the aneurysm sack. (I) DSA final result demonstrating complete occlusion of the aneurysm, with a small neck remnant in the inferior part and patency of PICA. DSA—digital subtracted angiography; PCOM—posterior communicating artery; ICA—internal carotid artery; ACA—anterior cerebral artery; ACOM—anterior communicating artery; PICA—posterior inferior cerebellar artery.

Figure 2

Patient number 11 (A–E): ruptured ACOM wide-neck aneurysm. (A) Lateral oblique 2D DSA demonstrating the ACOM aneurysm with a daughter sac pointing anteriorly. (B,C) Unsubtracted image showing the expanded Comaneci device during the coiling. (D) Lateral oblique 2D DSA showing the clot formation between the meshes of the Comaneci device that required the infusion of Acetylsalicylic acid and Tirofiban. (E) Lateral oblique 2D DSA acquired 30 min after the infusion of Acetylsalicylic acid and Tirofiban demonstrating a complete resolution of the thrombotic complication and a neck remnant of the aneurysm. Patient number 12 (F–J): ruptured ACOM wide-neck aneurysm. (F) Anteroposterior oblique 2D DSA demonstrating the ACOM aneurysm. (G) Anteroposterior oblique 2D DSA demonstrating clot formation between the meshes of Comaneci device that required infusion of Acetylsalicylic acid and Tirofiban. (H) Anteroposterior oblique 2D DSA after removing the Comaneci device, showing the protrusion of the coils in the parent artery and thromboembolic occlusion of the right A2 segment of anterior cerebral artery, which was not yet responsive to medical treatment. (I) Unsubtracted image of the deployment of a rescue Atlas stent. (J) Anteroposterior oblique 2D DSA acquired 30 min after the infusion of Acetylsalicylic acid and Tirofiban, demonstrating the patency of the Atlas stent, the resolution of the clot, and the patency of both anterior cerebral arteries.