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. 2019 Mar 31;25(5):530–538. doi: 10.1177/1591019919839196

The Silk Vista Baby: Initial experience and report of two cases

Pervinder Bhogal 1,✉, Ken Wong 1, Christopher Uff 2, John Wadley 2, Hegoda LD Makalanda 1
PMCID: PMC6777101  PMID: 30931672

Abstract

In this report, we present two cases using a novel flow diverter, the Silk Vista Baby, to treat aneurysms successfully, both ruptured and unruptured, that would have been difficult to treat using alternative flow diverters. We describe the clinical and radiological features, outcome and the unique features of the Silk Vista Baby flow diverter.

Keywords: Flow diversion, Vista, dissection, subarachnoid haemorrhage

Introduction

The introduction of flow diverting technology represented a major shift in the way that intracranial aneurysms could be treated. These devices share common design features such as a braided wire design and increased metal coverage, approximately 30–40%, compared to conventional stents,1,2 and it is believed that this allows the redirection of blood flow into the normal vessel as well as promoting thrombosis within the aneurysm and neo-endothelialisation along the flow diverter stent (FDS) braids3 resulting in eventual reconstruction of the parent artery.

A wide variety of different FDSs are currently available, each with unique properties; however, until recently few devices existed that have been designed specifically to target smaller vessels. Newer devices designed specifically to target smaller parent vessels, such as the FRED Jnr (Microvention, Tustin, CA, USA), the p48 (phenox, Bochum, Germany) and the Silk Vista Baby (Balt, Montmorency, France), have entered the market.

Here we present two cases, one unruptured and one ruptured, treated using the Silk Vista Baby, which we believe are the first reports of this innovative new FDS.

The Silk Vista Baby flow diverter

The Silk Vista Baby flow diverter (Figure 1) is constructed from 48 braided drawn filled tubes (DFTs) with each DFT strand constructed from platinum filled nitinol tube. The DFT construction of the device gives the device excellent visibility along its entire length as well as providing consistent opening radial force. The Silk Vista Baby is unique in that it can be deployed through a 0.17 inch microcatheter and currently the Headway 17 soft (Microvention, Tustin, CA, USA) is the recommended catheter. The device is available in a variety of sizes and lengths and is designed for implantation into parent vessels with diameters ranging from1.5 mm to 3.5 mm. In our limited experience we believe the Silk Vista Baby should be considered in cases in which the aneurysms arise from the distal vasculature, the access is tortuous and the aneurysms arise from smaller parent vessels.

Figure 1.

Figure 1.

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The Silk Vista Baby shown partially unsheathed (a) and unconstrained (b).

A comparison of the Silk Vista Baby with the FRED Jnr (Microvention, Aliso Viejo, CA, USA) and p48 (phenox, Bochum, Germany) is provided in Table 1.

Table 1.

Physical properties, recommended vessel size and delivery microcatheter size of the Silk Vista Baby, p48MW and FRED Jnr flow diverters stents.

Stent Construct No. of wires Diameter range Stent length range Vessel size Delivery catheter
Silk Vista Baby Single layer DFT 48 2.25–3–5 mm 10.5–26 mm 1.5–3.5 mm 0.17
p48MW Single layer DFT 48 2–3 mm 9–18 mm 1.75–3 mm 0.21
FRED Jnr Dual layer nitinol 36 + 16 2–3 mm 11/15–27/32 mm 2–3 mm 0.21
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Case 1

A 31-year-old woman initially presented to our tertiary referral unit in 2015 with acute subarachnoid haemorrhage (SAH) (Figure 2(a)). Angiography demonstrated a large (13 mm in maximum dimension), multilobulated aneurysm of the posterior communicating (PCOM) artery that was treated with balloon assisted coiling (Figure 2(b and c)) following which the patient made a good recovery.

Figure 2.

Figure 2.

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The patient originally presented in 2015 with acute onset headache subtle subarachnoid haemorrhage in the left Sylvian fissure (a). Angiography revealed multiple aneurysms including a large, left-sided, multilobulated posterior communicating aneurysm (b) that was thought to be the culprit of the acute presentation and was coiled using balloon assistance (c).

In addition to the PCOM aneurysm, several other aneurysms were identified including two adjacent aneurysms arising from the division of the callosomarginal and pericallosal arteries (Figure 3(a and b)) on the right and a smaller mirror aneurysm on the left. Pericallosal aneurysms have previously been shown to have a higher risk of rupture4,5 as have aneurysms with higher size ratios.6,7 After discussion in the multidisciplinary team meeting and with the patient, treatment of the aneurysms arising from the right anterior cerebral artery (ACA) with flow diversion was planned.

Figure 3.

Figure 3.

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Angiography of the right internal carotid artery revealed the two aneurysms arising at the division of the callosomarginal and pericallosal arteries (a) and (b). A single 2.25 × 20 mm Silk Vista Baby flow diverter was deployed across both aneurysms and on-table Xper computed tomography confirmed good apposition of the Silk Vista Baby to the arterial walls (c). The device can be seen clearly along its entire length using standard fluoroscopy (d). Angiography performed at the end of the procedure revealed decreased flow and stagnation within the aneurysms (e, white arrow). There was slow anterograde flow within the pericallosal artery and the anterior internal frontal artery (e, black arrows) with retrograde filling by pial collaterals (e, black arrow heads).

One week prior to the procedure the patient was started on dual ant-platelet medication (prasugrel 10 mg and aspirin 75 mg daily). Under general anaesthesia and using a right common femoral approach a 6 Fr Benchmark catheter (Penumbra, Almeida, CA, USA) was tracked into the right petrous internal carotid artery (ICA). Angiography demonstrated the two aneurysms that measured approximately 3 × 3 mm and 2 × 3 mm. Both aneurysms had unfavourable aspect ratios (approximately 1.2 for both aneurysms) for coiling alone and therefore the deployment of a single flow diverter was felt to be safer and technically easier than balloon and stent-assisted coiling of two aneurysms arising from the distal ACA. After full heparinisation to maintain the activated clotting time at 2.5 times baseline, a Headway 17 microcatheter (Microvention, Aliso Viejo, CA, USA) was tracked over a Hybrid 1214 microwire (Balt, Montmorency, France) into the distal callosomarginal artery. The parent artery diameter was measured as 1.5 mm at the distal landing zone and 1.9 mm proximally, and therefore the smallest diameter (2.25 mm diameter) Silk Vista Baby FDS was chosen and deployed without complications (Figure 3(c and d)). Angiography post-deployment demonstrated contrast stagnation within both aneurysms (Figure 3(e), white arrow). There was slow anterograde filling within the pericallosal artery (Figure 3(e), black arrow) and the anterior internal frontal artery (Figure 3(e), black arrow), which filled retrogradely by way of middle cerebral artery (MCA) pial collaterals (Figure 3(e), black arrow heads). The patient awoke at baseline neurology and was discharged several days postprocedure. There were no delayed complications.

The 6-month intravenous digital subtraction angiography (DSA) demonstrated complete occlusion of the aneurysms with no evidence of infarction or haemorrhage on the 6 month magnetic resonance imaging (MRI) scan (Figure 4).

Figure 4.

Figure 4.

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The axial T2-weighted magnetic resonance imaging (MRI) performed at 6 months showed no evidence of infarction within the territory of the right anterior cerebral artery (Figure 3(a and b)). The 6-month follow-up intravenous digital subtraction angiography showed filling in the pericallosal artery and the anterior internal frontal artery (Figure 3(c), white arrows) with filling also seen on the time of flight MRI (Figure 3(d)).

Case 2

A 35-year-old female patient presented to the emergency department with acute onset headache and loss of consciousness. On admission to the emergency department her Glasgow coma score (GCS) was 3 and she was immediately intubated. She was known to have Marfan’s syndrome and had previously had metallic valve replacement of both her mitral and aortic valves, for which she took warfarin, as well as a chronic type A dissection of the aorta.

An acute SAH was suspected and therefore, a computed tomography (CT) scan of the brain and CT angiogram were performed. This demonstrated diffuse SAH, predominantly located in the posterior fossa, with hydrocephalus (Figure 5(a)). The CT angiogram demonstrated irregularity of the left V4 portion of the vertebral artery with formation of a pseudoaneurysm as well as the chronic type A dissection of the aorta (Figure 5(b), white arrows). Both vertebral arteries were seen to be extremely ectatic on the CT angiogram (Figure 5(b), dashed white arrows, (c), white arrows). The intracranial CT angiogram demonstrated bilateral PCOM arteries, larger on the left (Figure 5(d), white arrow). After insertion of an external ventricular drain and supportive measures her GCS rapidly improved and after discussion with the family endovascular treatment of the dissection was planned. Although both deconstructive and reconstructive measures were discussed a reconstructive approach was favoured given the young age of the patient and lack of clinical or radiological infarction involving the medulla or cerebellum. Similarly, given the high risk of vertebral artery dissection during the case and the tortuous anatomy it was felt that an approach that carried the highest chance of success from a single operation should be performed. For this reason a stent-in-stent technique, as has been described previously,8 was not chosen given the risk of continued aneurysm growth and the potential need for retreatment.

Figure 5.

Figure 5.

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A large volume of subarachnoid haemorrhage was seen within the posterior fossa (a) and a dissection was suspected given the known history of Marfan’s disease. The patient was known to have had metallic heart valve replacement (b, black arrow) and chronic type A aortic dissection with visible dissection flap (b, white arrows). The left vertebral artery was noted to be extremely ectatic (b, dashed white arrow) as was the right vertebral artery (c, white arrows). The presence of a good calibre posterior communicating artery on the left was noted on the computed tomography angiogram (d, long white arrow).

With the patient under general anaesthesia and using an ultrasound-guided micropuncture a 6 Fr short sheath was placed in the right common femoral artery. A 6 Fr Benchmark guide catheter (Penumbra, Almeida, CA, USA) was tracked into the V1 portion of the left vertebral artery. Angiography revealed a very tortuous and ectatic cervical vertebral artery (Figure 6(a)). The pseudoaneurysm of the V4 segment of the vertebral artery could also be clearly seen (Figure 6(b) and (c)). There was no evidence of the anterior or lateral spinal arteries arising from the left V4 segment.

Figure 6.

Figure 6.

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Catheter angiography of the left vertebral artery confirmed an extremely tortuous and ectatic vessel (a). Angiography of the intracranial vertebral artery demonstrated the pseudoaneurysm (b) and (c). The distal V4 segment measured 1.9 mm in diameter with the proximal V4 portion measuring 3.5 mm in diameter.

After tracking the Benchmark guide catheter into a stable position in the proximal V2 portion a Fargo mini (Balt, Montmorency, France) intermediate catheter was tracked into V2/3 portion over a Headway 17 (Microvention, Aliso Viejo, CA, USA) and Synchro 2 (Stryker Neurovascular, Kalamazoo, USA) microwire combination. The distal landing zone, in the distal V4 segment of the vertebral artery, measured 1.9 mm and the proximal landing zone measured 3.5 mm). Two Silk Vista Baby flow diverters (2.75 × 25 mm and 3.25 × 20 mm) were placed across the site of the dissection in a telescoped manner with greatest metal coverage at the site of the dissection (Figure 7(a) and (b)). This resulted in immediate contrast stagnation in the pseudoaneurysm. On deployment of the first flow diverter an intravenous weight adapted bolus dose of abciximab was given in addition to 500 mg aspirin intravenously. Four hours postoperatively 60 mg prasugrel was given by way of the nasogastric tube. At 24 hours postoperatively the patient was started on aspirin 75 mg and prasugrel 10 mg daily, which is to be continued for 6 months followed by aspirin life-long. Anti-coagulation with intravenous heparin was also started on day 3 postoperatively in order to prevent thrombosis on the metallic heart valves. This was followed by conversion back to warfarin 10 days postoperatively.

Figure 7.

Figure 7.

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On-table high resolution Xper computed tomography (CT) scan performed at the end of the procedure demonstrated dual layer coverage at the site of the dissection with good contrast flow through the stent construct (a). A delayed intravenous digital subtraction angiography performed 4 weeks postoperatively demonstrated patency of the left vertebral artery and stable stent construct with no evidence of persistent pseudoaneurysm (b). A CT scan did not demonstrate any evidence of medullary or cerebellar infarction (c).

The patient made a good recovery and returned to baseline neurology (mRS 0) with no evidence of infarction or repeat haemorrhage on the delayed 4-week CT scan (Figure 4c). The vertebral artery remained patent on intravenous DSA performed at 4 weeks postoperatively. Given the underlying Marfan’s disease and aortic dissection delayed catheter angiography is not planned.

Discussion

The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial in 2013 demonstrated 73.6% aneurysm occlusion at 6 months9 with progressive aneurysm occlusion seen reaching 95.2% (60/63) at the 5-year follow-up.10 Initially, flow diverter treatment of aneurysms proximal to the circle of Willis was favoured as there was concern regarding the fate of covered branches and in particular small calibre vessels that supply highly eloquent brain territories such as the anterior choroidal artery or the lenticulostriate arteries. For this reason many of the aneurysms treated in PUFS arose from the ICA and in particular the cavernous and ophthalmic segments (73.1%). Since PUFS numerous reports on the use of flow diversion more distally have been published11–29 and a recent meta-analysis has been performed by Yan et al.30 that included 26 non-comparative studies (572 aneurysms). Overall, the technical success rate of the FDS treatment was 96% (95% confidence interval (CI) 0.93–1.00). At last follow-up the complete occlusion rate was 70% (95% CI 0.64–0.76). The procedure-related morbidity was 9% (95% CI 0.07–0.12) and mortality was 4% (95% CI 0.00–0.08). The overall long-term good clinical outcome was 96% (95% CI 0.93–0.99).

The use of FDSs in the distal circulation is possible and represents an alternative treatment option; however, it should be noted that many of the devices used in the these publications are likely to have been oversized. Oversizing of the FDS, because of its braided structure, will result in lengthening of the device.31 This elongation can make it difficult to predict accurately the proximal landing zone of the device. Furthermore, the metal coverage varies as a parabolic function of the ratio between the vessel and the device, with the typical oversized mismatch resulting in reduced metal coverage.31,32 This effect could theoretically result in reduced aneurysm occlusion due to increased porosity at the aneurysm neck and slowed neo-endothelialisation. There is thus a need to develop dedicated devices to target the smaller calibre vessels of the intracranial circulation distal to the circle of Willis. It is worthwhile noting that the work of Yan and colleagues30 showed a higher rate of aneurysm occlusion for telescoped FDSs compared with single FDSs (68% vs. 85%, P = 0.07), and it is possible that this may have been a result of the altered porosity of oversized stents which could be reduced by dedicated FDSs designed for smaller vessels such as the Silk Vista Baby.

In cases of vertebral artery dissection one must consider the arterial supply of the pontomedullary junction that can be supplied by the vertebral artery, the vertebrobasilar junction as well as the postero-inferior cerebellar artery (PICA). The lateral spinal artery and the anterior spinal artery can also arise from this region and therefore a careful inspection of the angiogram is mandatory. Mercier et al.33 analysed the pontomedulalry region of 25 brains and deduced several different possible origins for the perforating arteries as well as the lateral spinal artery. In the presence of an antero-inferior cerebellar artery (AICA)–PICA arising from the basilar trunk the PICA will never give rise to perforating arteries or the lateral spinal artery but will supply blood to part of the ipsilateral cerebellar hemisphere. If the PICA emerges extradurally at C1, it never gives rise to perforating arteries for the lateral surface of the brain stem but it will give rise to the pial branches that will supply the posterior surface of the medullar oblongata and will give rise to the lateral spinal artery. If the PICA arises from the intradural vertebral artery, as in our case, it will be the source of perforating arteries to the lateral surface of the brain stem as well as the supply of blood to the cerebellum. Although one may consider an infarction to have occurred at the time of the dissection if small perforating arteries did originate from the pathological segment this cannot be said with complete certainty and cases of infarction have been reported after trapping and occlusion.34–36 In the recent systematic review and meta-analysis performed by Sönmez et al.37 the perioperative morbidity rates for patients with ruptured dissecting vertebral artery aneurysms were similar between the reconstructive and deconstructive groups (7.0% vs. 14.0%, P = 0.82). Perioperative mortality was 13.0% (95% CI 8.0–22.0%) in the deconstructive group versus 7.0% (95% CI 3.0–15.0%) in the reconstructive group (P = 0.82). The long-term good clinical outcome rates were similar between the reconstructive (88.0%; 95% CI 79.0–94.0%) and deconstructive (83.0%; 95% CI 62.0–94.0%, P = 0.19) groups. The re-bleeding rates between the deconstructive (9.0%; 95% CI 4.0–20.0%) and reconstructive (7.0%; 95% CI 3.0–14.0%) techniques were also similar (P = 0.75). These results are despite better occlusion rates on the immediate and long-term follow-up angiography for deconstructive methods.

In the past flow diversion was not routinely considered for the distal circulation due to the relatively superficial anatomy and good accessibility for neurosurgical clipping. Similarly, the delivery of devices by way of larger delivery catheters, typically 0.027 inch internal diameter (ID), to the distal circulation was considered technically challenging.38 The Silk Vista Baby is unique among FDSs in that it can be deployed via a 0.017 inch ID microcatheter meaning navigation into the distal MCA and ACA should be more feasible. In our experience this has been one of the principle advantages of the device, and in cases with vascular difficult access, as seen in both our cases, it is doubtful that a 0.027 inch ID microcatheter could have been safely navigated into position for FDS deployment. Furthermore, given the reduced calibre of the true lumen in this case, tracking a larger microcatheter across the dissection in case 2 may have carried an added procedural risk. The ability to use smaller, more navigable, microcatheters may result in faster navigation and hence lower radiation times, although this requires further investigation.

Conclusion

The Silk Vista Baby is one of a new breed of FDSs designed to meet the needs of treating aneurysms arising from smaller diameter parent arteries. The excellent visibility and navigability of the device through 0.17 microcatheters makes it ideally suited to the treatment of distal aneurysms and where there is marked tortuosity of the access vessels.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: PB is a consultant for Phenox. The other authors report no conflicts of interest.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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