Double waffle-cone technique using twin Solitaire detachable stents for treatment of an ultra-wide necked aneurysm

Several stent-supported coiling techniques have been devised for treating wide-necked bifurcation aneurysms including the Y-stent and waffle-cone constructs. The Y-stent technique is not technically possible with obtusely oriented daughter vessels, and the waffle-cone method is inadequate for aneurysms with necks exceeding the stent's maximal expansion diameter. We describe here the novel use of the Solitaire electrolytically detachable slotted stent (Solitaire, ev3, Irvine, CA, USA) featuring large-sized cells to fashion a concentric "double waffle-cone" construct. This method enabled the doubling of the neck coverage to treat an ultra-wide necked middle cerebral aneurysm with obtusely oriented daughter branches. The technique relies on the intra-cell crossing of the first stent using the second stent delivery microcatheter and fine tuning the relative position with the aid of cross-sectional cone-beam computed tomographic angiography to achieve optimal coverage of the neck prior to detachment of the stents in position. A retrievable stent with large cells such as the Solitaire device is optimal for this application given the need for relative adjustment of the deployment before final stent release to avoid under- or over-penetration of the distal stent struts into the aneurysm dome. An additional advantage of this approach over the kissing-stent technique is the absence of intraluminal stent struts, which was confirmed here by down-the-barrel cross-sectional imaging. The double waffle-cone construct enabled the successful coiling of the aneurysm with no post-procedural ischemic events detected on diffusion-weighted MRI and with stable complete embolization and no residual filling or in-stent stenosis at 6 month follow-up.