 Hi everybody, I'm going to talk about intracircular devices and the role of intracircular devices in brain aneurysm. The aim of this presentation is to kind of assist you where the benefits of the technology is in treating some of the aneurysms that you will see in your practice. But I'm going to mainly concentrate on the benefits of intracircular devices and there are mainly two of them, web or contour and discuss mainly with the benefits of these intracircular devices. I'm not going to talk much on the next end because my friend Dr. Guilagal is going to cover this in his presentation. Let me tell you what my practice is first, you know, I would treat aneurysms with coiling or with balloons and coiling and that's what I do most of the times, elective or acute. I prefer coil with balloon and I pretty much use 90% of aneurysms in my practice treated with balloons or probably more. If I can't coil an aneurysm with the balloon, then I probably will use intracircular devices like web or contour and if I can't do that, then I will consider surgery as an option. My standard technique of treatment or using intracircular approach is coil an aneurysm with or without balloon or using intracircular device. As I said, surgery or any about techniques are not possible or complex aneurysms unless you have given all the options and if you can't treat them by standard techniques, which I've said about, then you use flow diverters. Now, it's very important that you see these MC aneurysms, they, it's the same location but look at these different types of aneurysms, they're not the same, they're all different, they're only different treatment and if you look at this, you know, I like Gwyneth Paltrow. I mean, they both are extremely pretty women but I prefer Gwyneth to the other lady, try to forget her name anyway. But the point that I'm trying to make is that some aneurysms will need stent, some aneurysms are going to need surgery. Every time you treat an aneurysm, you, you focus into what is the best for that aneurysm. So let's look at this grade one subarachnoid hemorrhage with the small hemorrhage and you can see this is because of a blister aneurysm in the MCA bifurcation. Not an easy option, different options can be considered here. Here you can see the 3D showing the blister aneurysm and you can see that I have, you can see the middle cerebral artery, inferior branch, blister aneurysm and a plan was to drop a stent across and always, always put coils in the aneurysm. So you can see then here, there is a microwave and catheter across the aneurysm and then the plan is, as you can see, I've dropped a stent and then I have dropped a silk stent across a baby silk blister and then I have coiled the aneurysm and it's important in my practice I would use coiling because I know there is a risk that these aneurysms will rupture if we don't put coils and protect the aneurysm. But then it comes with a cost here you can see I've lost the upper branch and I had to kind of rescue that with different techniques and eventually it opened up there was some still some sluggish flow but you can see this patient has good collateralization and he did very well as you can see on the follow-up CT scan. Here is another patient is a 45 year old grade 1 subarach with a blister aneurysm in the MCA and you can see that very clearly the plan would be to drop a flow diverter and put some coils using a jailed micro-catheter and again you can see you got a stent across you got a jailed micro-catheter and you put some coils and close the aneurysm and you got a reasonably good result which stays like that many years down the line and the patient is cured. Another aneurysm MCA bifurcation very widening I was contemplating if I could get a flow diverter across or whether I can get an intracecular device I wasn't very happy to use intracecular device here because I thought it will not give me a good result and I have based as always on baby leo stent across the aneurysm as you can see here and again a jailed catheter and coil the aneurysm and you know this aneurysm is going to get cured with this treatment. So important point that I want to hear on the slide for everybody to realize that the mortality morbidity is very low with coilings if you then put stents into the picture that it increases but not significantly but definitely there is an increase and if you start making the procedures complex you increase the mortality and morbidity of the procedure but you have to remember that the overall the complete occlusion rates are still very low including surgery we're talking only about 50% complete occlusion rates. Before we talk about the endovascular intracecular device is about stent assisted coiling well it is a complex procedure we cannot deny that and it will need anti-platelets sometimes you need one or two stents you need to be good you need to be experienced and there can be difficulties you see the various publications will go different complications but overall the complication rate is around 10 to 11% as you can see various publications where you can get joint occlusions even though symptomatic problems are less you can still see the complication rate are in the range of 11% with the morbidity of around 3 to 4% so why do I need an intracecular device because to prevent any stent any metal in the vessel and you can see there are different intracecular devices but effectively we are talking about intracecular device which is contour or web the intracecular devices are mainly used for wide-neck complex analysis so we provide prevent stents it's a safe procedure and it has certain definite advantages but there are some disadvantages also and main thing is you don't want any anti-platelets which is a big advantage but it's still a new evolving technology so what is a feature of interest good intracecular device the the important thing is a safe and effective device easy to use easy to deploy and it should not be invisible an important thing the occlusion rate should match the stenting results everybody should be able to use it so which is the most popular one well the most popular one is the web as you can see started in 2010 to 2017 I came in somewhere on 2012 and you can see that it has improved and has made a significant difference in terms of the technology that has improved over time in our 17 system at lower profile and can treat small aneurysms indication mainly for me or the last 200 or more cases that I've done now it's a wide-neck unruptured and ruptured aneurysms recurrent aneurysms complex aneurysms the most important thing I've learned is when is when you don't use web partially thrombos aneurysm for example I find them as very difficult issues and I don't think in my ex and web does a great job and the size is not right and the shape is not right when you got a rupture point in the neck and of course you need to think about cost if we can coil the aneurysm in 200 pounds wow do you want to put 2000 pounds just give an example I know where of course 9000 pounds at least to 12000 pounds and you got to be careful avoided junk devices because increasing the cost so let's look at different ways people are using web you can use web on its own you can use web with a stand or it can use web with a coils I personally or don't do these two things but he often sometimes I might use coils certainly don't intend to use web with a stand and it's not in my practice let's look at this mc aneurysm here it's a wide neck mca unruptured aneurysm simple to trade you might want to use different devices web makes it located easy you go in drop the basket and you treat the aneurysm as you can see here I feel it's completely gone you can use web in a smaller aneurysms now because of the 17 system here is a tiny aneurysm and you can see the fall of the aneurysm is gone here is a large aneurysm where you know that you might have to use some coils and you can cook the aneurysm and you can treat the aneurysm by placing some coils distantly with a catheter and cock the aneurysm with the web and treat the aneurysm and the aneurysm is completely occluded and you can be very quick in terms of treating these large aneurysms if you look at all the data which has been published with the safety we all know that it is the mortality mobility is very low web is safe no question very safe you can treat it and it's reasonably easy to do now compared to when we started in 2012 to the occlusion rates also has now because of web we have this new occlusion system of our scale where you have the adequate occlusion which includes complete occlusion with the remnant and there is a lot of debate about this some people will say it's not necessarily the right thing to do but again if you look at the the adequate occlusion rates are in the range of around 80% so it's not 100% and the retreatment rate in patient with web is around 9% and some centers this can vary you know in my own experience it's around 10% in my and my center let's look at the case here he's a young guy he's great for subarach he's got an mca aneurysm this hematoma was gonna go in they wanted to take it out and if they want to take it out you want to treat this aneurysm you want to be very quick you want to get a good result you can just go in drop a web in close the aneurysm and patient can go in for hematoma removal and you can see the follow looks extremely good if you can't coil or you can't clip or you can't web well you can use other devices called pulse rider device what is a pulse rider it's a neck a bridging device which is got a metal end so obviously is not a true intra sacular device you can go through the device and treat the aneurysm as you can see here this is an acomb aneurysm and this patient unfortunately had an mc aneurysm so you got two aneurysm they don't look different this looks like good for web this doesn't look like good for web so what do you do you can drop a web your into this aneurysm treat the aneurysm with web and then you go on the right side mc aneurysm you then drop the device as you can see here the pulse rider is dropped across and you can see the markers of the device here very nicely there's a stem here drop the device across go inside and call the aneurysm and that's what we've done and the job was done and it looks pretty good what are the indications for pulse rider well basically you know some recurrences like web recurrences some post clipping post calling recurrences it could be used an alternative for t or y standing but you know there is a disadvantage you need anti-platelets you know you it doesn't have any flow diverter properties there's no long term data and it's not been done much in acute cases okay so we not to be need to be very careful when we use the device what about peak on as well it's again when you don't want to wear you could think about an alter device or pulse rider you can have a peak on us again it is a disadvantage because you have to give anti-platelets so let's look at a case here you got a wide neck mc aneurysm you drop the device into the neck of the aneurysm and you can coil the aneurysm and you can do a great job look at that and it looks perfect what about this one look at this mc aneurysm and you can see this mc aneurysm you drop the device and then you can coil the aneurysm and it looks pretty good and you've got a follow-up that looks very good again the data shows that it is very safe but the occlusion rates are still around 80 percent so not hundred percent but adequate occlusion is around 80% in this device is about these devices pulse rider or peak on us they do not offer flow diversion they only good for like stent assisted coiling and they don't reduce the risk of rickers necessarily they are not bad alternative for why standing or t-standing when you're particularly thinking of all patients some patients which are poor access and you know you're not gonna get a t-stand or y-stand or a web end and you might think of these as an options they need long-term anti-platelets and that's a disadvantage let's look at web one other than you know you've got a great five-subjected hemorrhage you have a CT that shows the blood you can see the aneurysm here you can see it's a wide-naked aneurysm very wide-naked aneurysm clearly gonna be a complicated one but if you have a web you can drop the web in the aneurysm and you can see that complete occlusion at two years with no flow within the aneurysm and that's really pretty good and the technology has got better with this young lady with a Acom aneurysm that you can see and you can see I've gone in even though a little bit of irregular shape of this aneurysm managed to drop web end and then the web has a cause complete occlusion this lady has spasms and you can see others when you brought in for angioplasty you can see the aneurysm was still occluded and it shows the angioplasty there and occlusion of the aneurysm so web is very effective with complete occlusion rates although very less around 33% but adequate occlusion seems to be still around 80% but we all know web has problems what are the main problem one is a sizing sizing is a big problem sometimes is difficult to track there's other issues with the catheter but one of the biggest problem which I'm gonna show and I can't highlight all the problems but you can see that the sizing can be sure here is a case done by one of my colleagues where you can see the MC aneurysm and then you've been web put in but you can see that this it is it's small it's under filling and because of that this aneurysm is not protected so I had to go in and then try and get some coils around and then I have protected the aneurysm and I close that as you can see the aneurysm is protected now and you can see this coils coils coils and you protect the aneurysm and then you can see when you're happy with it you stop and then you can see the stasis then and the follow-up shows occlusion of the aneurysm let's look at another case here this was when I was proctoring a basilar termination it was a slightly old size then you can see this restriction of the flow in the left B1 and we had to drop an Atlas 10 there and then you got a good flow and that I understand some people actually do it intentionally I personally don't think that's a good idea because it's too expensive and you need to think whether you really want to do that when you have when you're anyway going to use 10 is web a perfect device but I say if effective easy can you see it long term anti-platelets or not but it is not easy to size the occlusion rates are still not that great in terms when you compare it with 10s and it's not an easy device in terms of like you need some experience and learning go so what do we need an intersecler device which is easy to see size deploy put into aneurysm has a combined properties where it works like a web and a float avatar safe as a web effective as a standing and anybody can do it so he's contouring yes contour is a very good alternative it's got double braiding at the neck and it basically is still safe and it's very effective much more than web as you can see it's a 19 on device it's got a limited sizes that we have so we can deploy it in the neck of the aneurysm and here you can see that the device is being placed in the neck of the aneurysm as you can see and then you can kind of bring it and open it and bring it to the neck and deploy it and if you want to see what the floor diversion is as you can see there is a floor diversion very good the contrast is injected it it goes around the device when you compare a web with a contour where a contour is a neck bridging device whereas web occupies the volume of the aneurysm but you can see a good example here I see a termination aneurysm in a lady which had previously coil and you can see that the device has been placed at the neck of the aneurysm and the device immediate stasis is seen within the aneurysm and the aneurysm appears occluded it looks a pretty good result and six months you have a complete occlusion of the aneurysm 12 months again and a two year in the aneurysm is completely occluded we published our data recently and we can see occlusion rates are much higher in contour compared to the web so for me contour and web they both are safe this web contour seems to show similar to what we would see a floor diversion a progressive occlusion of the aneurysm it's easy to size easy to deploy takes away all the pain that you had web and this gives you much better occlusion rates and it's not easy to use this is another ICA termination aneurysm that you can see and you can see there is a device that has been placed across the neck and you can see immediate stasis there and then a six month follow up occlusion and you can see the device is stable it doesn't move and has complete occlusion so can we do better than this well we can because we can need an interstitial device that we can use in acute where you don't need any stands you don't need any anti-platelets it's safe well this is a case lent to me by my colleagues from Canada it's a basilar aneurysm that you can see and then it's got CTA which was coiled and then there's obviously come with recurrence and then you can see the you know massive recurrence and these are difficult again you would probably consider stent but well you have different options you might think of a floor diverter contour then there is a what we could use is a next and we'd call I'm not going to talk in detail because Gula is going to talk in detail in this talk but look at this you get a device that sits at the neck you go through the device and it's a very similar device to contour slightly less braiding but you can go through it so that you can then coil and you can treat the aneurysm so it's a big advantage of next end which can be effectively used in acute aneurysm still and here you can see this aneurysm has got significant recurrence you can drop put some coils at the top and then they have dropped the next end in the bottom of the aneurysm here and then they've continued to coil the aneurysm and that has got excellent to good result of the now aneurysm it's a complete occlusion and you can see on the follow-up there is complete occlusion of the aneurysm and the endogram shows also complete occlusion as you can see so intracircular devices work mean in summary we it's a safety and effective treatment it's a good treatment for many aneurysms it's it's web is also safe contour is also safe but effectively you what I'm trying to say here is all these intracircular devices are significantly making a big difference in terms of the management they're safe they effective and progressively web being the initial device but now contour and extend seem to be making a much more effective treatment and safer option than even web there are the devices that we can think and assure but they are certainly not pure intracircular devices but they also can work in specific conditions thank you very much