Y-stent-assisted coiling for large wide-neck dysplastic middle cerebral artery bifurcation aneurysm: An update to procedural technique

Background: The endovascular treatment of complex middle cerebral artery (MCA) aneurysms, particularly dysplastic large MCA bifurcation aneurysms, can pose significant technical challenges. We aim to present three cases illustrating the technical nuances and challenges often encountered in Y-stent-assisted coiling (Y-SAC) for such aneurysms and provide an update on technical nuances. Methods: We present three consecutive cases of dysplastic MCA aneurysms, each >10 mm with a wide neck. We successfully performed Y-SAC in all cases on the first attempt using the “around the world” technique and used Neuroform Atlas Stent (Stryker Neurovascular, California, USA) as a distal anchor to reduce the microcatheter loop. Immediate final digital subtraction angiography showed adequate occlusion of all aneurysms. Results: All patients tolerated the procedure well and were discharged home on postoperative day (POD) 1 in all cases. The first patient required a second coiling at the aneurysm neck 6 months after initial treatment, with complete protection of the dome. The second patient’s 6-month follow-up angiogram showed complete occlusion of the aneurysm with patency of all MCA branches. Unfortunately, the third patient failed to comply with dual antiplatelet therapy after discharge and developed stent thrombosis 3 months postprocedure and passed away. Conclusion: Y-SAC is a reasonable option for large, wide-neck, MCA bifurcation aneurysms in patients who are not fit for microsurgical clipping and/or bypass surgery. Complex endovascular techniques, including aneurysm encircling and the “Atlas Stent Anchor” technique, may be necessary to complete the procedure successfully.