Jean Raymond, MD
François Guilbert, MD
Daniel Roy, MD
Index terms:
Aneurysm, basilar, 17.73
Aneurysm, therapy, 17.1264,
17.1269
Angiography, 17.1248
Interventional procedures, 17.1264,
17.1269
Published online before print
10.1148/radiol.2212010474
Radiology 2001; 221:318 –326
Abbreviation:
GDC ⫽ Guglielmi detachable coil
1
From the Department of Radiology,
Centre Hospitalier de l’Université de
Montréal, Hôpital Notre-Dame, M-8206,
1560 Sherbrooke St East, Montréal,
Québec H2L 4M1, Canada. Received
February 16, 2001; revision requested
April 2; revision received May 11; ac-
cepted June 5. Address correspon-
dence to J.R. (e-mail: je_raymond
@hotmail.com).
©
RSNA, 2001
Author contributions:
Guarantor of integrity of entire study,
J.R.; study concepts, J.R.; study design,
J.R., D.R.; literature research, J.R., D.R.,
F.G.; clinical studies, J.R., D.R., F.G.;
data acquisition, J.R., D.R., F.G.; data
analysis/interpretation, J.R., D.R.; manu-
script preparation, definition of intellec-
tual content, editing, revision/review,
and final version approval, J.R., D.R.,
F.G.
318
Neck-Bridge Device for
Endovascular Treatment of
Wide-Neck Bifurcation
Aneurysms: Initial
Experience1
PURPOSE: To report the authors’ initial experience in treating patients with wide-
neck aneurysms with assistance from a recently developed neck-bridge device
(TriSpan; Target Therapeutics/Boston Scientific, Fremont, Calif).
MATERIALS AND METHODS: Twenty-five patients were examined. Aneurysms
were most frequently at the basilar bifurcation (n ⫽ 19). Sixteen aneurysms were
treated electively: six aneurysms that recurred after coil-only embolization and 10
nontreated aneurysms (including four that had failed coil-only embolization). Nine
aneurysms were treated acutely following subarachnoid hemorrhage. All lesions
except one had a wide neck. A dual-catheter technique was used in 23 patients.
Immediate angiographic results, technical incidents, and complications were re-
corded. Follow-up angiography was performed in 16 patients. Clinical follow-up
ranged from 1 to 12 months.
RESULTS: Neck-bridge device–assisted coil packing was successfully performed in
23 lesions, with complete obliteration in three, residual necks in 13, and a minimal
residual sac in seven patients. Parent vessel protection failed, with coil protrusion
and arterial occlusion, in one of these patients. Other complications that were not
directly related to use of the neck-bridge device included retroperitoneal hema-
toma, rebleeding, coil perforation, and transient embolic arterial occlusion. One
patient died of vasospasm and heart failure. Follow-up angiography revealed com-
plete obliteration in four, a residual neck in one, a persistent residual sac in four, and
recurrent aneurysm in seven patients. One patient had a small occipital infarction 5
weeks after treatment.
CONCLUSION: The described neck-bridge device is useful for assisting coil embo-
lization of wide-neck bifurcation aneurysms.
The endovascular approach is increasingly used for the treatment of intracranial aneu-
rysms. The technique is somewhat limited by the configuration of some of these aneu-
rysms: Endovascular treatment of lesions with a wide (⬎4-mm) neck or an unfavorable
dome-to-neck ratio sometimes is impossible or leads to either angiographic results that are
less than satisfactory or aneurysm recurrence (1–3). Furthermore, attempts at complete
obliteration of wide-neck aneurysms increase the risks of coil protrusion, embolic com-
plications, or parent artery thrombosis (4,5).
The TriSpan (Target Therapeutics/Boston Scientific, Fremont, Calif) is a new device that
can be placed at the neck of aneurysms prior to the Guglielmi detachable coil (GDC)
embolization procedure (6). The device was designed to allow the safe and controlled
placement of platinum coils inserted through a second microcatheter. The purpose of this
article is to report our initial experience in treating patients with wide-neck aneurysms
with assistance from the aneurysm neck-bridge device (TriSpan).
 (including a retrograde approach that
TABLE 1 was attempted without success in one pa-
Patients and Aneurysms Treated with Described Neck-Bridge Device
tient) would be prone to complications
Patient Aneurysm Aneurysm or yield inferior morphologic results (7).
No./Age Aneurysm Size Neck Size Patients and/or their families were in-
(y)/Sex Site* (mm) (mm) Manifestation formed of the use of the device before the
Treated after SAH intervention, and appropriate consent
1/59/F Basilar 14 ⫻ 9 6 SAH grade 2 was obtained according to article 21 of
2/41/F Basilar 23 ⫻ 14 12 SAH grade 1 the Civil Code of Quebec. Permission to
3/48/F Basilar 8 ⫻ 11 8 SAH grade 1
4/47/F Basilar 25 ⫻ 20 12 SAH grade 3 use the neck-bridge device was obtained
5/44/M Basilar 8⫻6 6 SAH grade 1 from the Medical Devices Bureau of
6/58/F Basilar 10 ⫻ 8 5 SAH grade 3 Health Canada under the Special Access
7/54/F Basilar 9⫻8 5 SAH grade 3 Program.
8/61/F Ophthalmic 20 ⫻ 20 8 SAH grade 2
9/67/F SCA 20 ⫻ 18 6 SAH grade 3
Treated electively: recurrence after previous treatment Procedures
10/41/M Basilar 10 ⫻ 10† 11 Third recurrence 6 years after GDC treatment
11/45/F Basilar 8 ⫻ 8† 6 Recurrence 4 years after SAH and GDC The neck-bridge device is made of
treatment
12/46/F Basilar 17 ⫻ 12† 10 Third recurrence 4 years after SAH and GDC
three nitinol loops that are partly cov-
treatment ered by platinum coils to increase ra-
13/63/F Basilar 12 ⫻ 9† 6 Recurrence 2 years after SAH and GDC diopacity. The loops are fixed together at
treatment their struts. When the device is posi-
14/42/M Basilar 6 ⫻ 5† 5 Recurrence 18 months after GDC treatment
tioned at the neck of the aneurysm, the
15/69/F PCA 6 ⫻ 5† 3 Third recurrence 8 years after SAH and GDC
treatment six nitinol strands radiate from the center
Treated electively: nontreated of the neck to protect the parent vessel
16/64/F Basilar 22 ⫻ 16 9 Hydrocephalus and assist in the placement of the coils,
17/54/F Basilar 12 ⫻ 10 6 Syncope which are introduced through a second
18/63/F Basilar 15 ⫻ 12 10 Trigeminal neuralgia
19/60/M Basilar 18 ⫻ 14 8 Temporal AVM microcatheter. As the aneurysm is pro-
20/50/F Basilar 15 ⫻ 10 6 Incidental (SAH in 1975) gressively packed with coils, the device
21/54/F Basilar 12 ⫻ 10 6 Headaches becomes fixed inside the lesion so that it
22/54/F Basilar 8⫻8 5 Headaches can be detached, just like a GDC, at the
23/71/M PICA 10 ⫻ 6 6 Headaches and cerebellar stroke
24/66/F Ophthalmic 18 ⫻ 8 8 Ipsilateral stroke end of treatment. The device necessitates
25/70/F Carotid 14 ⫻ 10‡ 7 Right hemiparesis the use of a 0.018-inch microcatheter
with two tip markers.
Note.—AVM ⫽ arteriovenous malformation, PCA ⫽ posterior communicating artery, PICA ⫽
posterior inferior cerebellar artery, SAH ⫽ subarachnoid hemorhage, SCA ⫽ superior cerebellar All patients were treated while under
artery. general anesthesia. Bilateral femoral ap-
* Basilar and carotid refer to the basilar and carotid bifurcations, respectively. Ophthalmic refers proaches involving the use of 5- and 6-F
to ophthalmic segment of the carotid artery. introducing sheaths permitted placement
† Size of recurrence only.
‡ Patent portion of giant partially thrombosed aneurysm. of the appropriate guiding catheters. For
the basilar bifurcation aneurysms, a cathe-
ter was placed in the two vertebral arteries,
and for the carotid aneurysms, two guiding
catheters were positioned inside the inter-
MATERIALS AND METHODS patients (one after a recurrence) were nal carotid artery. The procedures were per-
treated acutely after subarachnoid hem- formed with full anticoagulation with hep-
Patients
orrhage. In four patients, a previous at- arin, which was maintained until femoral
From January 2000 to March 2001, 25 tempt— before the availability of the sheaths were retrieved the next morning. A
patients at our institution were treated neck-bridge device—at placing a coil in combination of two antiplatelet agents—
with GDCs with the assistance of the the lesion failed. In two ophthalmic ca- clopidogrel 75 mg and acetylsalicylic acid
aneurysm neck-bridge device. The char- rotid artery lesions, this new device was 325 mg—was prescribed daily for 1 month,
acteristics of the patients and their aneu- used to treat the patient without the help and then only acetylsalicylic acid 325 mg/
rysms are summarized in Table 1. Pa- of balloon-assisted techniques because of die was prescribed for 2 months. All proce-
tients were referred for endovascular a deficient circle of Willis. In all other dures were performed by using a single-
treatment because surgery was thought cases, the authors believed, on the basis plane angiographic unit (DFP 2000;
to be difficult or prone to complications. of their previous experiences with lesions Toshiba, Montreal, Quebec, Canada) with-
The most frequent lesions were basilar manifesting similar characteristics, that out three-dimensional reconstruction. In
bifurcation aneurysms (n ⫽ 19). Other safe endovascular treatment would be addition, all patients were examined with
sites included the ophthalmic segment of difficult or impossible or lead to unsatis- computed tomography of the brain, and
the carotid artery (n ⫽ 2), the carotid factory angiographic results. the first 10 patients underwent cerebral an-
bifurcation (n ⫽ 1), the posterior commu- Three-dimensional coil placement was giography, 24 hours after treatment.
nicating artery (n ⫽ 1), and the postero- not routinely attempted, but it failed in The first microcatheter was inserted
inferior (n ⫽ 1) and superior (n ⫽ 1) cer- two cases in which it was tried. In cases into the aneurysm to place the bridge
ebellar arteries. Seven patients were involving the basilar bifurcation, the device at the neck. To select the appro-
treated after recurrences following endo- neck-bridge device was chosen on the priate size of the device, the manufac-
vascular treatment with GDCs only. Nine premise that balloon-assisted techniques turer proposes using a sizing table. Early

Volume 221 䡠 Number 2 New Device for Endovascular Treatment of Wide-Neck Aneurysms 䡠 319
Figure 1. Drawings illustrate endovascular treatment with the aneurysm neck-bridge device. a and b, Deployment of the neck-bridge device (arrow) in
the aneurysm and placement at the neck. c, The second microcatheter permits deposition of the first coil. After coil packing (d), the device is detached (e).
in this experience, we tended to select a
device that was on average 6 mm larger
than the width of the neck. We now tend
to use smaller sizes to optimize the posi-
tion of the device and minimize protru-
sion. When the neck-bridge device was
deployed inside the aneurysm, the carry-
ing microcatheter (Excelsior or FasTracker
18; Target Therapeutics) was slightly re-
trieved to maximize the room available
for opening the neck-bridge device and
to minimize the forces against the aneu-
rysmal walls. Once deployed, the neck-
bridge device and the microcatheter were
gently pulled back to ensure a stable po-
sition, in which the loop markers were
against the walls of the aneurysm and the
stem coil was well centered at the neck
and slightly protruding into the parent
artery (Fig 1, a, b).
The second microcatheter was then in-
troduced inside the aneurysm. An appro-
priate helical coil with a caliber of 0.015
and a diameter identical to or slightly
smaller than the diameter of the aneu-
rysm was then introduced but not de-
tached. The position and stability of this
initial construction were then assessed.
The first coil and/or the neck-bridge de-
320 䡠 Radiology 䡠 November 2001
vice were retrieved and repositioned un-
til satisfactory coverage of the neck and
parent vessel protection were achieved.
When it was necessary to reposition the
neck-bridge device, the coil was retrieved
first, before reintroduction of the neck-
bridge device into the microcatheter, to
prevent snaring of a loop of coil. The first
coil was then detached.
To prevent premature detachment of
the neck-bridge device during electrolytic
detachment of the coils, the proximal
marker of the device was maintained
within the proximal marker of the micro-
catheter. Coils of decreasing sizes were
introduced to pack the aneurysm as com-
pletely as possible. The neck-bridge de-
vice was electrolytically detached from
the pusher wire (which is identical to the
GDC design) at the end of the procedure,
after retrieval of the coiling microcath-
eter (Fig 1, d, e). To detach the neck-
bridge device, the detachment zone is ad-
vanced beyond the microcatheter by
pushing the wire of the neck-bridge de-
vice so that the proximal marker reaches
slightly beyond the proximal marker of
the microcatheter. In two patients, a sin-
gle-catheter technique was attempted:
First, the neck-bridge device was de-
tached, and then aneurysmal coil pack-
ing through the same microcatheter was
performed. All technical complications
(ie, coil protrusion, tilting of the neck-
bridge device, clot emboli, and/or local
femoral complications) were recorded,
regardless of whether they were symp-
tomatic. All clinical changes were noted,
regardless of whether they were related to
the use of the device.
At our institution, follow-up angiogra-
phy, performed 3–12 months after the
procedure, is routinely recommended.
Follow-up angiography was actually per-
formed in 16 patients 2–12 months after
treatment. At the time this article was
written, eight other patients had been
treated too recently but were scheduled
for follow-up testing. One patient died.
Angiographic findings were scored ac-
cording to a previously published classi-
fication system (9) and labeled as com-
plete obliteration, residual neck, residual
aneurysm, or failure. The coil placement
procedures were performed and the re-
sults evaluated by senior authors ( J.R.,
D.R.). Routine clinical follow-up was per-
formed 1 month after the procedure, at
Raymond et al
 TABLE 2
Endovascular Treatment and Results
Neck-Bridge Complications Time of Follow-up* Glasgow
Patient Device Size Outcome
No. (mm) Initial Results Technical Clinical Clinical Angiographic Score
Treated after SAH
1 12 Residual neck None None 10 mo Complete obliteration at 5 mo 1
2 12 Residual None PICA occlusion 7 mo Residual aneurysm at 9 mo 1
aneurysm after balloon
occlusion
3 14 Residual neck Failure, coil SAH‡ 6 mo NA 2
perforation†
4 16 Residual Coil protrusion Infarction 8 mo Recurrence at 8 mo 3
aneurysm
5 8 Complete None None 1 mo NA 1
obliteration
6 8 Complete None Death caused by 1 mo NA 5
obliteration vasospasm
and heart failure
7 8 Residual neck None None 3 mo Residual neck at 3 mo 1
8 16 Residual Failure† None 10 mo Recurrence at 6 mo 1
aneurysm
9 16 Complete None Rebleeding 7 mo NA 1
obliteration
Treated electively: recurrence after previous treatment
10 16 Residual neck Coil protrusion§ None 12 mo Recurrence at 7 mo 1
11 12 Residual neck None Retroperitoneal 12 mo Recurrence at 12 mo 1
hematoma
12 12 Residual neck None None 12 mo Recurrence at 12 mo 1
13 10 Residual neck Tilt㛳 None 4 mo NA 1
14 10 Residual neck None None 7 mo NA 1
15 8 Residual neck None None 1 mo NA 1
Treated electively: nontreated
16 16 Residual Coil protrusion§ None 12 mo Residual aneurysm at 4 mo 1
aneurysm
17 12 Residual neck None None 11 mo Complete obliteration at 4 mo 1
18 12 Residual neck None None 11 mo Complete obliteration at 4 mo 1
19 16 Residual None None 9 mo Residual aneurysm at 2 mo 1
aneurysm
20 10 Residual neck None None 4 mo NA 1
21 12 Residual None Infarction at 5 wk 2 mo Residual aneurysm at 2 mo 1
aneurysm
22 10 Residual None None 2 mo NA 1
aneurysm
23 10 Residual Tilt㛳 PICA occlusion‡ 7 mo Recurrence at 10 mo 1
aneurysm
24 14 Residual neck Protrusion None 11 mo Complete obliteration at 4 mo 1
25 14 Residual neck None None 12 mo Recurrence at 12 mo 1
* Time of follow-up after endovascular treatment with aneurysm neck-bridge device assistance. The findings of angiographic follow-up, if performed,
also are listed. NA ⫽ not available.
† Patients treated with double-coil (patient 3) or balloon-assisted (patient 8) techniques after aneurysm neck-bridge device failure.
‡ Not directly related to use of the aneurysm neck-bridge device.
§ Protrusion of one GDC loop in posterior cerebral artery.
㛳 Tilting of aneurysm neck-bridge device after detachment by using single-catheter technique.

the time of follow-up angiography, and
by means of telephone interviews con-
ducted 1–12 months later with a stan-
dard questionnaire designed to evaluate
the Glasgow outcome score.
RESULTS
The morphologic results and clinical evo-
lutions of the patients are summarized in
Table 2 and are illustrated in Figures 2– 4.
Technical Difficulties
The neck-bridge device was easily loaded
into the microcatheter, but a little more
friction was encountered, as compared
with that encountered with standard plat-
inum coils. The apparatus while con-
strained inside the microcatheter is more
rigid than wires and helical coils, and
straightening of the distal segment of the
microcatheter with forward movement of
its tip was observed in many cases. For this
reason, the tip of the first microcatheter
should be kept in the proximal portion of
the sac or near the neck. Introduction and
deployment of the neck-bridge device in-
side the aneurysms were straightforward
in the nontreated patients with regular-
shaped aneurysms but more difficult in the
nontreated patients with irregular aneu-
rysms (patient 24) and in the patients with
recurrences (patients 10 –15). The causes of
difficulties included (a) minimal room for
deployment of the device (patient 11), (b)
residual coils from previous embolization
procedures, (c) acute angle between the
aneurysm and the parent artery leading

Volume 221 䡠 Number 2 New Device for Endovascular Treatment of Wide-Neck Aneurysms 䡠 321
Figure 2. Angiograms show use of the neck-bridge device in a wide-neck basilar bifurcation aneurysm. (a) Initial posteroanterior vertebral and
(b) lateral angiograms show the position of the neck-bridge device (arrow in b) (Fig 2 continues).
to eccentric positioning of the device or
unsatisfactory deployment (patient 8),
and (d) difficulty in achieving a clear un-
derstanding of the position of the device
components and their relationship with
the aneurysmal neck and origins of the
arterial branches.
Visibility of the components of the
neck-bridge device that are not covered
with platinum is suboptimal (Fig 2), and
this poor visibility caused difficulties in
interpreting the position of the device, at
least early in our experience. The device
could, however, be positioned at the
neck of the aneurysm with minimal ma-
nipulations in 23 of the 25 patients. If the
device was deployed in an unsatisfactory
position, it could always be retrieved and
easily replaced. In two patients, the de-
vice could not be used because the angle
between the carotid artery and the aneu-
rysm was too acute for adequate deposi-
tion (patient 8) or because of the sessile
nature of the aneurysm (patient 3). One
of these patients was successfully treated
with a balloon-assisted technique; in the
other, a double-coil technique was used
(8).
The neck-bridge device, once properly
placed, was stable and supported coil dep-
osition in 21 patients in whom a dual-cath-
eter technique was used. In patient 17, in
whom the selected device may have been
too small, downward migration of one of
the device loops occurred at deposition of
the third helical coil. This loop could be
322 䡠 Radiology 䡠 November 2001
replaced inside the neck of the aneurysm
by simply advancing the device. In the two
patients in whom the single-catheter tech-
nique was attempted (patients 15 and 23),
tilting of the device, which no longer
served its purpose, occurred at subsequent
coil packing of the aneurysm. The neck-
bridge device permitted satisfactory pack-
ing of aneurysms with helical coils. The
protection afforded by the device is rela-
tive, however: Some coils with a diameter
smaller than that of the loops of the neck-
bridge device could still protrude inside the
parent artery near the end of embolization
and thus had to be repositioned before de-
tachment. In two patients, it was decided
to leave one loop of coil protruding into
the posterior cerebral artery, and there
were no clinical consequences.
Complications
Some complications were not directly
related to the use of the neck-bridge de-
vice. Patient 11 developed a large retro-
peritoneal hematoma during the 24-hour
anticoagulation period that followed
treatment; this complication necessi-
tated two transfusions without sequelae.
Patient 23 had occlusion of the posterior
inferior cerebellar artery 24 hours after
treatment. Since the neck-bridge device,
which was detached from the start by
using a single-catheter technique, was
buried within the coil mass, which only
partially occluded the aneurysmal sac,
this complication was not believed to be
related to the use of the device. The pa-
tient recovered from a small cerebellar
stroke within a few days and had a good
outcome (Glasgow outcome score, 1). Pa-
tient 9, who was treated acutely after sub-
arachnoid hemorrhage, had rebleeding 1
hour after complete obliteration of the
lesion. Follow-up angiography did not re-
veal a cause for this event. The patient
had acute intracranial hypertension, was
treated with ventricular drainage and
thrombolysis of intraventricular clots,
and recovered (Glasgow outcome score, 1
at 8 months).
Patient 2, who had a large ruptured basi-
lar bifurcation aneurysm, had no compli-
cations after endovascular treatment with
the neck-bridge device. She had an embolic
stroke of the left posterior inferior cerebel-
lar arterial territory after bilateral vertebral
artery balloon occlusion performed at 1
month because of a persisting residual an-
eurysm; her outcome was good (Glasgow
outcome score, 1). Patient 3 had a sessile
wide-neck basilar bifurcation aneurysm
that had recently bled. The 14-mm neck-
bridge device could not be properly posi-
tioned at the neck and was easily retrieved
without complication. A double-coil tech-
nique permitted packing with three other
coils, but coil perforation occurred and
treatment with protamine sulphate and in-
terlocking detachable coils (Target Thera-
peutics) resulted in subarachnoid hemor-
rhage and left posterior cerebral artery
Raymond et al
Figure 2 (continued). (c) Posteroanterior and (d) lateral angiograms show deployment of the first coil (arrow). (e) Posteroanterior vertebral and
(f) lateral angiograms show complete obliteration of the aneurysm at 7 months.

occlusion. The patient recovered but still
had dysphasia and hemianopia at 6
months after treatment (Glasgow outcome
score, 2).
Complications that may have been di-
rectly related to the use of the neck-
bridge device occurred in two patients.
Patient 21 had transient cortical blind-
ness 5 weeks after treatment, 1 week after
therapy with clopidogrel was stopped.
Despite a normal neuro-ophthalmologic
examination, magnetic resonance (MR)
imaging depicted a small right occipital
infarction, and control angiography re-
vealed a small crescent of residual aneu-
rysm that was unchanged since treat-
ment. The stem of the neck-bridge device
was eccentrically positioned against the
lateral wall of the basilar artery (Fig 3).
The second patient (patient 4) was
treated acutely after a grade 3 subarach-
noid hemorrhage that was caused by the
rupture of a giant recurrent aneurysm, 4
years after endovascular treatment per-
formed at another facility. The neck-
bridge device, which was excessively
oversized, protruded at the level of the
superior cerebellar arteries. Attempts to
place a last coil at the neck caused dis-
placement of a previously detached coil
that had a diameter smaller than that of
the neck-bridge device loops. This coil
caused thrombotic occlusion of the right
posterior cerebral and superior cerebellar
arteries, with secondary thalamic and
cerebellar infarctions despite intraarterial

Volume 221 䡠 Number 2 New Device for Endovascular Treatment of Wide-Neck Aneurysms 䡠 323
thrombolysis. At the time this article was
written, the patient was slowly recover-
ing but remained disabled owing to left
upper arm monoplegia and cognitive def-
icits (Glasgow outcome score, 3). Patient
6, who was treated during the acute
phase of subarachnoid hemorrhage, died
of vasospasm and heart failure.

Angiographic Results
Angiographic results are summarized
in Table 2. The initial angiographic re-
sults were believed to be satisfactory in
17 patients: There were residual necks in
14 patients, and the aneurysm was com-
pletely obliterated in three. There was
minimal opacification of the aneurysmal
sac in eight patients. There were two fail-
ures to deploy the neck-bridge device. In
patient 24, 24-hour follow-up angiogra-
phy revealed minimal new protrusion of
the neck-bridge device inside the carotid
artery, without stenosis or complications.
There was no visible clot formation ei-
ther at the neck of the aneurysms or at
the level of the stem coil hanging in the
parent artery in any patient at 24 hours.
Angiographic follow-up studies were avail- Figure 3. Embolic complication following use of aneurysm neck-
able for 16 patients: at 3 months or bridge device. A, Posteroanterior vertebral angiogram shows the initial
longer for 14 patients and at 2 months in position of the neck-bridge device; the arrow points to the stem marker.
B, Posteroanterior vertebral angiogram shows the immediate results of
two patients. Opacification of a small
the neck-bridge device–assisted endovascular procedure: a lower stem
portion of the aneurysmal sac persisted (thick arrow) position and the strut of the device crossing the origin of
in four patients and necessitated repeat the posterior cerebral artery (thin arrow). C, Follow-up posteroanterior
treatment in two: at 3 months and by vertebral angiogram obtained 2 months after the procedure shows the
means of additional coil packing in pa- eccentric position of the stem marker (arrow). D, T2-weighted MR image
tient 16 and at 1 month and by means of (repetition time msec/echo time msec, 3,500/90) obtained in the same
patient 2 months after treatment, after transient cortical blindness,
bilateral proximal vertebral occlusion in
shows a small occipital infarction (arrows).
patient 2. Four patients, three of whom
had residual aneurysms initially, had a
recurrence at follow-up angiography.
In addition, three patients who were may not be favorable for this approach has been designed to address this problem.
treated for recurrences still had a recur- (9 –12). Some wide-neck basilar bifurca- This device has several advantages: It is
rence after repeat treatment with neck- tion aneurysms are within this category introduced through a microcatheter that
bridge device assistance 7 (patient 10) (4,5). Temporary occlusion of the parent can be manipulated with ease, as com-
and 12 (patients 11 and 12) months later. artery during coil deposition (ie, balloon- pared with the effort sometimes required
The patient treated with a balloon-as- assisted technique), as reported by Moret with balloon catheters or stents. A single
sisted technique after neck-bridge device (2,7,13), may permit the successful oblit- device—rather than two balloons—is used
failure had a large recurrent sac at 6 eration of lesions that cannot be treated for bifurcation aneurysms. Once this de-
months. Four patients with residual necks otherwise. Another more recent develop- vice is placed at the neck of the aneurysm,
immediately after treatment showed com- ment is the placement of a stent across it provides protection for the entire proce-
plete obliteration of the aneurysm, includ- the aneurysm neck before coil placement dure and thus minimizes maneuvers such
ing the necks, at follow-up angiography (14,15). as multiple cycles of balloon inflations and
performed 4 – 6 months later (Fig 4). However, most aneurysms occur at bi- deflations. In addition, temporary parent
furcations, which have a geometric config- vessel occlusion, which may increase
DISCUSSION uration that does not allow the routine thromboembolic complications (5), is not
application of these techniques. Other necessary. Support for coil deposition is
Endovascular Treatment of
technical advances, such as three-dimen- constant, and a period of observation for
Wide-Neck Aneurysms
sional coils or double-coil techniques, may coil stability after balloon deflation and be-
Because of the high risks associated permit the introduction of coils inside an- fore detachment is not needed. Balloon-
with surgery at certain anatomic sites, eurysms, but they do not offer protection assisted techniques are, however, better
patients are sometimes referred for endo- against coil protrusion through the neck. suited for lateral wall aneurysms; in these
vascular treatment, even though the The described aneurysm neck-bridge de- cases, the angle between the parent artery
morphologic features of the aneurysms vice is a new detachable instrument that and the aneurysm may be too acute for

324 䡠 Radiology 䡠 November 2001 Raymond et al

 Figure 4. Complete obliteration at follow-up angiography. (a) Posteroanterior angiogram obtained immediately after coil placement
shows a residual neck (arrows). (b) Posteroanterior angiogram obtained 5 months after endovascular treatment shows complete occlusion.
satisfactory deployment and positioning of
the neck-bridge device.
Use of the neck-bridge device may ne-
cessitate conceptual changes in the way
we treat wide-neck aneurysms. Critical
issues that must be considered before coil
placement in these difficult lesions in-
clude (a) the need to build a supporting
structure to bridge the neck for future
packing with coils, (b) respect of the lu-
men of the parent artery and its branches
to prevent complications, and (c) suffi-
cient coil packing at the neck to ensure
satisfactory initial and long-term results.
Without parent vessel protection, it is
difficult to predict the outcome of the
procedure at the time of deposition of
the first coil. Once committed to pursu-
ing this treatment, the operator can en-
counter problems after deposition of
multiple coils. The described aneurysm
neck-bridge device permits one to target
the neck of the aneurysm first. If the de-
vice is properly positioned at the neck,
packing of the lesion can proceed with
greater confidence.
Indications
We initially used this device in patients
who presented electively with large aneu-
rysms with wide necks and in patients with
recurrent aneurysms found at angiography
during the follow-up years after initial
GDC embolization. The design of this
neck-bridge device is ideal for basilar bifur-
Volume 221 䡠 Number 2
cations. It can also be used in ophthalmic
aneurysms, but the angle between the axis
of the parent artery and the neck of the
aneurysm should not be so small as to
jeopardize the safe delivery or satisfactory
placement of all segments of the device.
Recurrent aneurysms after endovascular
treatment are frequent, particularly in
wide-neck bifurcation aneurysms or when
initial angiographic results are unsatisfac-
tory. Because surgical clipping of previ-
ously coiled basilar aneurysms may be dif-
ficult or prone to complications (16,17), so
far we have elected to re-treat patients who
have recurrent lesions with additional em-
bolizations (9,12). The anatomy of the re-
current lesion is often less favorable for coil
placement than the anatomy of the initial
lesion. Because the neck-bridge device is
designed to support coils at the neck, it
could improve the immediate results of re-
peat treatments and decrease the incidence
of second recurrences (9,12).
Complications
The consequences of treating previ-
ously untreatable wide-neck aneurysms
remain to be determined. Although the
device should protect the parent vessel,
more aggressive treatments with use of
two catheters and the large amount of
metal that is in contact with blood flow
at the neck may lead to more frequent
complications than those associated with
GDC embolization in small-neck aneu-
New Device for Endovascular Treatment of Wide-Neck Aneurysms
rysms. Some complications may be re-
lated to the use of two microcatheters:
Thromboembolic complications and dis-
sections may be increased (4,5), and local
femoral complications may be doubled
because of the need for two approaches.
Protrusion of the stem coil inside the par-
ent artery is a specific concern. Slight pro-
trusion probably is of no consequence,
but stenosis of the branches of the bifur-
cation can lead to thromboembolic com-
plications and should be avoided. To pre-
vent these events, sizing of the device is
critical.
We are still in the steep part of the
learning curve for using this neck-bridge
device. The sizing table provided by the
manufacturer has yet to be validated
with clinical experience. The suggested
sizes in the table are based on animal
experiment results and geometric extrap-
olations, and they do not take into ac-
count the shape of the aneurysm, the size
of the parent artery, or the angles be-
tween the artery and its branches— criti-
cal factors in the optimal positioning of
the device (12). The use of anticoagula-
tion during the procedure is routine at
our institution, even acutely after sub-
arachnoid hemorrhage. A discussion re-
garding the empiric use of heparin was
beyond the scope of this article. We be-
lieve long interventions with use of mul-
tiple microcatheters, the presence of the
stem, and the number of coils in contact
䡠 325
with blood flow in wide-neck aneurysms
are sufficient reasons to operate with sys-
temic anticoagulation. However, in the
current series, two complications might
have been related to the use of systemic
anticoagulation: a retroperitoneal hema-
toma and rebleeding despite satisfactory
coil packing.
The design of the aneurysm neck-bridge
device is such that a short portion of the
struts of the loops and the stem coil often
had to be placed inside the parent artery
bifurcation (Figs 1–3). This position did not
cause embolic complications in 17 of 18
patients in whom it was observed for fol-
low-up periods of 1 month to 1 year; how-
ever, it may have led to an embolic event 5
weeks after treatment in patient 21. The
antiplatelet regimen that we used after
treatment is empiric, but it was inspired
from experiences with stents in invasive
cardiology (18). Longer follow-up periods
with larger numbers of patients are neces-
sary to assess the safety of this new method
and the incidence of long-term embolic
complications.
Morphologic Results and
Recurrences
The described neck-bridge device per-
mitted treatment of aneurysms that would
have been untreatable otherwise. We think
that we achieved satisfactory angiographic
results, considering the morphologic fea-
tures of these lesions. Because of selection
of difficult cases, this series cannot be com-
pared to other endovascular or surgical se-
ries. The use of the neck-bridge device may
permit increased coil packing at the neck
and thus favor thrombosis and neointima
formation, which are important factors in
aneurysmal healing after embolization
(19,20). The completely obliterated aneu-
rysms at follow-up angiography in four pa-
tients in whom immediate angiographic
results had shown residual necks were an
encouraging observation. The effects of us-
ing the neck-bridge device on long-term
angiographic results will be difficult to as-
sess in clinical practice, because the instru-
ment probably will be used selectively in
lesions with a high propensity for recur-
rence. The procedure is still a form of me-
tallic coil embolization and is therefore
subject to the deficient healing response
326 䡠 Radiology 䡠 November 2001
that is sometimes associated with this type
of treatment (21,22).
In conclusion, the aneurysm neck-
bridge device permitted endovascular
treatment of wide-neck aneurysms with-
out the need for more complex balloon-
assisted techniques. We believe this new
device will be an important adjunct to
treatment of difficult bifurcation aneu-
rysms.
References
1. Fernandez Zubillaga A, Guglielmi G,
Vinuela F, Duckwiler GR. Endovascular
occlusion of intracranial aneurysms with
electrically detachable coils: correlation
of aneurysm neck size and treatment re-
sults. AJNR Am J Neuroradiol 1994; 15:
815– 820.
2. Moret J, Cognard C, Weill A, Castaings L,
Rey A. The “remodeling technique” in
the treatment of wide neck intracranial
aneurysms. Intervent Neuroradiol 1997;
3:21–35.
3. DeBrun GM, Aletich VA, Kehrli P, Misra
M, Ausman JI, Charbel F. Selection of ce-
rebral aneurysms for treatment using
Guglielmi detachable coils: the preliminary
University of Illinois at Chicago experi-
ence. Neurosurgery 1998; 43:1281–1295.
4. Lefkowitz MA, Gobin YP, Akiba Y, et al.
Balloon-assisted Guglielmi detachable
coiling of wide-necked aneurysms. II.
Clinical results. Neurosurgery 1999; 45:
531–538.
5. Pelz DM, Lownie SP, Fox AJ. Thromboem-
bolic events associated with the treatment
of cerebral aneurysms with Guglielmi de-
tachable coils. AJNR Am J Neuroradiol
1998; 19:1541–1547.
6. Aquilla ST, Rappe AH, Villar F, Virmani R,
Strother CM. Evaluation of the TriSpan
neck bridge device for the treatment of
wide-necked aneurysm: an experimental
study in canines. Stroke 2001; 32:492–
497.
7. Moret J, Ross IB, Weill A, Piotin M. The
retrograde approach: a consideration for
the endovascular treatment of aneu-
rysms. AJNR Am J Neuroradiol 2000; 21:
262–268.
8. Baxter BW, Rosso D, Lownie SP. Double
microcatheter technique for detachable
coil treatment of large, wide-necked in-
tracranial aneurysms. AJNR Am J Neuro-
radiol 1998; 19:1176 –1178.
9. Raymond J, Roy D. Safety and efficacy of
endovascular treatment of acutely rup-
tured aneurysms. Neurosurgery 1997; 41:
1235–1244.
10. Murayama Y, Vinuela F, Duckwiler GR,
Gobin YP, Guglielmi G. Embolization of
incidental aneurysms by using the
Guglielmi detachable coil system. J Neu-
rosurg 1999; 90:207–214.
11. Roy D, Raymond J, Bouthillier A, Boja-
nowski MW, Moumdjian R, L’Espérance
G. Endovascular treatment of ophthalmic
segment aneurysms with Guglielmi de-
tachable coils. AJNR Am J Neuroradiol
1997; 18:1207–1215.
12. Raymond J, Roy D, Bojanowski M,
Moumdjian R, L’Espérance G. Endovas-
cular treatment of acutely ruptured and
unruptured aneurysms of the basilar bi-
furcation. J Neurosurg 1997; 86:211–219.
13. Akiba Y, Murayama Y, Vinuela F, Lefko-
witz A, Duckwiler GR, Gobin YP. Balloon-
assisted Guglielmi detachable coiling of
wide-necked aneurysms. I. Experimental
evaluation. Neurosurgery 1999; 45:519 –
530.
14. Turjman F, Massoud TF, Ji C, Guglielmi G,
Vinuela F, Robert J. Combined stent im-
plantation and endosaccular coil place-
ment for treatment of experimental wide-
necked aneurysms: a feasibility study in
swine. AJNR Am J Neuroradiol 1995; 15:
1087–1090.
15. Wakhloo AK, Lanzino G, Lieber BB, Hop-
kins LN. Stents for intracranial aneurysms:
the beginning of a new endovascular era?
Neurosurgery 1998; 43:377–379.
16. Civit T, Auque J, Marchal JC, Bracard S,
Picard L, Hepner H. Aneurysm clipping
after endovascular treatment with coils: a
report of eight patients. Neurosurgery
1996; 38:955–960.
17. Gurian JH, Martin NA, King WA, Duck-
wiler GR, Guglielmi G, Vinuela F. Neuro-
surgical management of cerebral aneurysms
following unsuccessful or incomplete en-
dovascular embolization. J Neurosurg 1995;
83:843–853.
18. Qureshi AI, Luft AR, Sharma M, Guter-
man LR, Hopkins LN. Prevention and
treatment of thromboembolic and isch-
emic complications associated with en-
dovascular procedures. I. Pathophysio-
logical and pharmacological features.
Neurosurgery 2000; 46:1344 –1359.
19. Raymond J, Venne D, Allas S, et al. Heal-
ing mechanisms in experimental aneu-
rysms. I. Vascular smooth muscle cells
and neointima formation. J Neuroradiol
1999; 26:7–20.
20. Raymond J, Desfaits AC, Roy D. Fibrinogen
and vascular smooth muscle cell grafts pro-
mote healing of experimental aneurysms
treated by embolization. Stroke 1999; 30:
1657–1664.
21. Reul J, Weis J, Spetzger U, Konert T, Fricke
C, Thron A. Long-term angiographic and
histopathologic findings in experimental
aneurysms of the carotid bifurcation em-
bolized with platinum and tungsten
coils. AJNR Am J Neuroradiol 1997; 18:
35– 42.
22. Bavinski G, Talazoglu V, Killer M, et al.
Gross and microscopic histopathological
findings in aneurysms of the human
brain treated with Guglielmi detachable
coils. J Neurosurg 1999; 91:284 –293.
Raymond et al