Failed WEB Device Deployment and Bailout Technique for Aneurysms

Introduction Intrasaccular flow disruption with WEB device is an effective and safe modality for treatment of wide‐neck bifurcation aneurysms. We describe a case of failed deployment of WEB followed by bailout technique. Materials and methods Pubmed search of case reports and review articles. Results A 55 year old female with history of hypertension and smoking presented with HH‐1/WFNS‐1/MF‐3 subarachnoid hemorrhage. Cerebral angiography showed basilar tip aneurysm measuring 10.4x8.9x11.1 mm, neck of 3.65 mm, with robust R‐PCOM and absent L‐PCOM. After baseline DSA, a 6Fx90 cm guide sheath was parked in the V2 segment of the L‐VA and aneurysm was catheterized using coaxial system of 5F SOFIA‐EX intermediate catheter over VIA‐33 microcatheter and microwire. Measurements were made on orthogonal 2D images and a WEB SL 11x8 mm device was selected and advanced. The device was attempted to be deployed in the dome, however it failed to conform properly. After few attempts to re‐sheathe and re‐deploy, the device failed to flower and took a configuration of a mushroom head inside the aneurysm with an elongated stem extending to mid‐basilar artery. Guide catheter was advanced to distal L‐VA followed by intermediate catheter to distal basilar artery and i we attempt to resheath the device but unable due to small ID of SOFIA. Pulling the device in that configuration was not possible due to concern for basilar artery transection. As a bailout technique, the device was then carefully collapsed into the aneurysm dome by pushing on the microcatheter and delivery wire, and using SOFIA for support while being careful not to breach the dome. Device was then detached. Given significant residual aneurysm, we planned for Y‐stent assisted coiling and gave dual antiplatelet agents enterally. XT‐17 microcatheter was used to catheterize PCAs and we deployed Neuroform Atlas 3x21 mm stents from P1 segments to mid‐basilar artery bilaterally. Stent tines were crossed with a microcatheter and microwire and a total of six Hydrocoils were deposited in the aneurysm.. Final angiogram showed Raymond‐Roy IIIa occlusion with 39% packing density. Patient was extubated and neurologically intact. Conclusion Failed WEB deployment with rigid partial expansion and inability to re‐sheath is a potential complication. Intentional deformation with controlled collapse of the device into the aneurysm dome followed by stent coiling is a possible bailout technique which has not been described before.