Letter to the Editor

Dear Sir

We have read with interest the e-pub ahead of print of the article entitled “Y-Stent-assisted coil embolization of anterior circulation aneurysms using two solitaire AB devices: a single center experience” by Martínez-Galdámez et al.

We would like to make some comments from the standpoint of vascular neurosurgeons who have recently retreated one of the patients previously treated by this means for an unruptured 20 mm right middle cerebral artery (MCA) aneurysm. The patient came to our recently established unit of neurovascular pathology for follow-up control almost one year after her endovascular treatment with Y stenting and coil embolization of her aneurysm at another institution.

The first thing we did was to surgically clip a mirror left middle cerebral bifurcation aneurysm without incident. In the following weeks even though she was maintained on an aspirin regimen, she started complaining of delayed right hemispheric ischemic symptoms. Perfusion CT confirmed poorer perfusion in the right middle cerebral territory compared to the left and a scheduled angiogram also showed partial recanalization of the coiled aneurysm and severe stenosis of the frontal right MCA branch. In the immediate postangiographic period the patient developed left hemiplegia and her level of consciousness deteriorated. A new angiogram confirmed complete right MCA occlusion which was partially solved endovascularly. The patient was operated and we found that the stents had not only occluded the M2 branches almost completely, and the M1 severely, but also they had perforated the artery walls themselves. The aneurysm was partially recanalized through the M1 flow. We surgically trapped all the construct and excised the coiled aneurysm and the stents embedded in their arteries and we performed an STA M3 bypass. The patient did not recover her previous state: she is now unable to work, still left hemiparetic although she is mentally well.

We would like to stress a few points about this history:

This was a young patient with multiple incidental aneurysms who was unilaterally aggressively treated for one of her aneurysms, leaving her on an aspirin regimen, although she had another mirror aneurysm untreated.

Surgery is still a very good option for unruptured saccular aneurysms mostly in MCA location, and should be taken into account as a first-line treatment.

Endovascular therapies are advancing greatly but some aggressive innovations should not be recommended without larger series, preferably in the context of randomized multicentric studies, with longer follow-ups that clearly state the benefits and risks of these procedures.

It is mandatory to keep well-balanced multidisciplinary teams able to adjust the best tailored treatment for each single patient.

With our best compliments,