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WEB DEVICE – MY FIRST EXPERIENCE DR. VIVEK SINGH, DR. SURYANANDAN PRASAD, DR. VIGNESH Department of radiodiagnosis Sgpgims, lucknow
• 52 year female presented with SAH, Hunt & Hess grade 3 and GCS of 12/15. • On CTA - ~ 8 x 6. 6 mm aneurysm with wide neck in the ACOM region (Fig 1 a, b, c, d). 1 a 1 b 1 c 1 d
• Embolization planned with WEB device. • Web device - 9 x 5 mm; Microcatheter - VIA 27. • Carotid long sheath kept at the CCA level with Sophia 6 F (Microvention, USA) as distal access catheter at ICA bifurcation. • With Via 27 at the neck of the aneurysm (Fig 1 e), Web device unsheathed (Fig 1 f), and angiogram taken to check filling of both A 2. 1 e 1 f
• Resheathing and repositioning done as per required • When satisfactory positioning achieved, we waited for 30 min to check any thrombus formation; 3 D angiograms taken to look for both A 2 ostia and finally device as electrolytically detached (Fig 1 g, h). 1 g 1 h
• There was slight movement post detachment, repeat angiogram after some time showed some filling defect in one of the A 2 with sluggish flow (Fig 2 a). • Intra-arterial tirofiban administered at the site of thrombus • Repeat cannulation done with aim of balloon angioplasty or stenting if needed (Fig 2 b). • But no obvious compression of the ostia noted; post tirofiban injection thrombus had resolved and flow had been restored (Fig 2 c). • Some filling of the neck region noted which we thought is good at initial phase to keep both A 2 filling and this would occlude slowly (Fig 2 c).
• • Patient extubated; No new neurological deficit noted. Patient was started on Tab ecosprin 150 mg once daily. Discharged after 1 week in stable condition At 3 months follow up - no neurological deficit; MRA - no filling of the aneurysm, some narrowing of one of the A 2 at the aneurysm level but distal opacification of both A 2 are fine (Fig 3 a, b, c)
• Ecosprin is still continued and DSA follow-up to be done at 6 months. . learnt: Lesson 1. For 9 mm WEB device, Via 27 is small microcatheter as resheathing becomes a difficult job - One should use Via 33. 2. Wide neck aneurysm would require antiplatelets as thrombus formation is more at the exposed neck level Antiplatelets can be given on table or loaded before-hand. 3. Planning before-hand is important in selecting correct size of device - Both good 2 D & 3 D angiograms required for calculations.