Double microcatheter reduction using partially deployed Atlas stents in treating a large dysplastic MCA bifurcation aneurysm with Y stent assisted coiling

Treatment of large dysplastic middle cerebral artery (MCA) aneurysms can be challenging.^{1 2} Catheterization of M2 branches at hyperacute angles often requires an ‘around the world’ approach/microcatheter reduction, which can be accomplished with rapid pull³ balloon anchor⁴ and stent anchor⁵ techniques. In this video video 1, Atlas stents (Stryker) are used for double microcatheter reduction along with Y stent assisted coil embolization (Video 1). Steps include (1) catheterization of the more difficult M2 branch with ‘around the world’ maneuver; (2) reduction/stent deployment; (3) similar catheterization of the second M2 branch; (4) microcatheter reduction/stent deployment; (5) coil embolization (jailed). Important nuances include: (1) low threshold for a staged procedure; (2) awareness of the possibility of stent twisting; (3) jailed coiling. Final views show adequate treatment of the aneurysm dome with stent protection of the dysplastic neck without thromboembolic complications. Given the residual near the base, close angiographic follow-up is important.