So, I have a lot of cases and videos per instructions to go over the technique. A lot of these points I'll discuss as we go along and discuss cases. Adjunctive device uses is becoming more frequent because of the technical innovations in access, micro wires, technology, and ease of use. And previously, aneurysms which were considered inaccessible or untreatable endovascularly are being treated today. Where I come from, we have a very good balance of clipping, coiling, endovascular. We work in a team, excellent vascular neurosurgeons. But there are new devices coming and our techniques are being refined. There is some evidence in the literature that a higher packing density may be achieved by the use of adjunctive devices. But I will not go into the literature, just a few more words, slides, and then we'll go right into the cases. There are specific technical considerations when using an adjunctive device and we'll talk about that. Most importantly is when to use a device, which one to use, how to use it, et cetera. So briefly as an overview for balloons, we have single lumen, double lumen, the micro wire that goes through can be a 14 or a 10, stents open, closed cell versus the new braided stents like the Elvis, side wall versus bifurcation, and then for bifurcation, which branch to choose. I will not show standard run-of-the-mill cases, but rather more cases where we can have a debate on technique or choice. I'll quickly go over the balloons. This is an ascent balloon by Codman. It's a double lumen balloon with an 014 wire. These are the two things that are important to remember. The sizing chart are available in your, should be available in your lab if you're using that. The Scepter-C is also a double lumen 014 balloon and all of these balloons come in a compliant and a super compliant version, and that just means how well the balloon conforms to the parent vessel or the vessel that the balloon is in. This is a transform single lumen 014. It's one of the newer balloons, again, in compliant and super compliant in different sizes, and the previously or one of the most frequently used balloons was the single lumen 10 wire hyperglide and hyperform balloons. Now this is, on the top is just a standard double lumen balloon, and on the bottom is a standard single lumen balloon. In the double lumen balloon, it's important that you have a side port for continuous flush of the second lumen. In a single lumen balloon, obviously you don't have a side port because the port is used to inflate the balloon. Balloon prep is important, and you should review individual vendors, literature, brochures, et cetera. For prep for a single lumen balloon, you connect the syringe to the side port, always with contrast. So the contrast with the newer balloons can be 50, 60, 70 percent contrast, which improves visibility. You flush back through the RHB, forward through the shaft of the catheter. It's important to know where the markers are. And after you've really thoroughly flushed the balloon and the shaft with the contrast mixture, then you insert the wire, flush again, inflate the balloon, check the balloon under fluoro, put it under water, pull the wire back, and then use it. And then we'll go over that in the stations. By the way, this is probably the most hands-on course that is done annually compared to this. The others are fairly bland with the rich experience that you'll get. Just to go over stents, you know about the Neuroform. There's Neuroform Easy, Neuroform 3, Tip, No-Tip. It's an open-cell stent, which means it cannot be re-sheathed. Codman Enterprise, one of the first closed-cell stents, it can be re-sheathed. One diameter size goes up to 4.5 millimeters, but different lengths. And the new Elvis, which is under HDE, is a braided stent. The most important thing to remember when we choose devices and mix and match is access. And Dr. Harrington mentioned that earlier about the one-to-one ratio, et cetera. It's important to know, before we put these devices in, the length and the internal diameter of the guide catheters, the ID and the OD of the distal access catheters. For example, you can see the ID is 044, but the OD is 057. Same with the microcatheters. When we think of Prowler or SL10, we think of an 0165 catheter, which means it can go through a catheter just bigger than the 0165. But it is important to know that when we're – this ID is important, but what is important more is the outer diameter, because that will determine which two catheters or devices you can put concurrently. For example, if you start with a guide catheter, most of these are 070 to 072 guide catheters. Neuron, for example, chaperone, the envoy DA's Navien is 072. So we start with this ID of the guide catheter. And then let's say if you put a DAC in here, even the smallest DAC, which is 044, but the outer diameter is 057, will take up all this room. So if you have to use a DAC to place a balloon in a distal anatomy, then you should know that with that DAC, there's no room even for the smallest micro catheter to go beside it. You don't have to memorize it, but this chart is important to realize before we get it. Now let's say you have a DAC and then you have an XT27 or a Marathon. The outer diameter, which is 038, the inner diameter is 027. So you put an XT27 in a DAC. You cannot add a micro catheter with the DAC because that, even the smallest micro catheter, the OD is 31. It will not fit in. Again, if you're not using, you can make a smaller DAC, the 32 DACs, but then you won't have the ease of navigating the catheter through it. Another important thing to remember is the RHV length is 7.5 centimeters. So for sizing, and I'll talk about the length in a minute, check the ID of the largest or the guide catheter. Check the OD and the ID of the intermediate catheter if used. Check the OD of the micro catheter. We are all focused on the ID that a Prowler Plus Select we need for an Enterprise, Neuroform we need XT27, Marathon, et cetera, but make sure you check the OD if you're using parallel technique or intend to use more than one device. For the length, start with the longest catheter, which is typically your delivery catheter for the stent or the micro catheter, which is typically 150 centimeter. Start working back from that and subtract the length of every other catheter that you use as well as the RHV. For example, micro catheter is 150 centimeter, guide catheter is, let's say, 95 centimeter neuron, and let's say you need to use a DAC or an intermediate catheter, which are typically 136 centimeter. So if you add 136 centimeter and you start backwards from 150 centimeter, you're only left with 14 centimeters of working length. So if you're in distal anatomy, that means the whole system has to move very distally. You cannot leave the guide catheter down and then plan on taking the DAC all the way up because you'll run out of length. Add to that the RHVs and you may be left with very little amount of working length. All of these exercises should happen prior to the procedure. There's no... I was just going to say, there are different length RHVs as well, so just so that they know. For instance, I use a smaller RHV that's only five centimeters. So yeah, that's good, but make sure you add those. Know whatever you like to use. Whatever RHV you're using. Make sure you understand that. You should get the five centimeter one. That's a good point. It's actually, it's a good RHV. There's no worse feeling than putting all this up and then realizing, shit, I'm out of length and you're hubbed all the way or the device doesn't fit. All right, we're going to jump right into the cases and I'll start with a run of the mill top of the basilar large aneurysm and I'll show the video. So, this is a basilar apex aneurysm and I'll play it again. Can anyone tell me what's happening here? I'm going to start picking on people because I brought the sheet with me. All right, University of Buffalo is my favorite. Leonardo. Good. So, it's thrombosed in a fashion that it's gone through and through and what's left is this circular remnant with wide neck base and both PCAs coming out of the base of the aneurysm. I'll show the lateral. So, one PCA, other PCA, thrombus goes from one wall all the way to the other wall. Patient presented with mild headaches, no neuro deficits, mostly asymptomatic, often on headaches. You can see the partial thrombus. This was a CTA. So, the first challenge here before we go to the coiling part is access. Look at the left vertebral artery. Loops down, loops back up and so, what kind of, first of all, let me get to the next one. And this is the top of the basilar, both PCAs coming out. There's a PCOM on the left side, no PCOM on the right side. So, balloon, stent, flow diverter, anyone? All right. How about, who's the fellow with Dr. Arthur? Andre. What do you think? Does this need an adjunctive device? Yes. Okay. Would you use a balloon or a stent? I think in Memphis we get a sequent web. If you think of the sequent web, except there's already a web in the center of the aneurysm. So, then which vessel to choose? Which side branch? Left PCA, right PCA? There's a PCOM on the left. The right, good. Now, the other challenge is, and again, Jay mentioned earlier, the vessel comes out of the base of the aneurysm. We have a very tortuous origin. When we put a wire through it and we try to push it, there's a chance that it'll prolapse into the aneurysm. Now, can we do a loopity-loop maneuver here? No, because there's a clot in the center. So, the first thing is, we have to be cognizant of this fact. Now, how do we avoid that scenario, in this case, where the center of the aneurysm is clotted? You need to get close to the aneurysm, right, because we have to deploy a stent, and if you have slack access down below, you lose one-to-one, and you lose the deployment of the stent in a precise fashion. This is the arch. The right vertebral is also tortuous. This vertebral is tortuous. So, which guide catheter to choose here? UPMC. I'm sorry? So, how long is that? So, the 80 shuttle will get up to here. Navion is how long? 115. So, that'll get up to probably there, right? And why would you do that? Okay. All right. So, those were kind of our plans. We said, if we use, if the Navion is 115, the delivery catheter, the XT-27, is 150, right? You add a couple of 5 centimeter Dr. J RHVs in there, you get 10 centimeter. So, you're left with about 20 centimeter of working length. And from there, you have to deploy the stent. The stent shaft is 186, I think, for a neuroform. But the catheter itself is 150. The stent, I'm going to use a 2 centimeter stent here because I don't want it to collapse. And so, what I'm trying to get is you're left with about 20 centimeters of working length alone. So, that means the Navion has to go higher, or this guide catheter has to go higher. So, we did all that math. And what we decided to do was, I'll show you. We said, well, we're going to try and straighten this out with a neuron, go up, because the last thing I want is short length at the top. So, I'm going to play this video here. All right. So, and there's a fenestration in the proximal basilar. So, this is an XT-27 with a 014 transcend wire. And the curve is not the best, but you'll see the problem here. We tried different curves. I'll go. This is a shortened version. It took about half an hour or more just to get into the PCA. And because we were losing our curves, we could get up to about this point with our catheters, the guide catheter, before we were getting hubbed. So, we still have a lot of length. We keep going with the, is this thing playing? All right. We keep going with the wire and get the XT-27 closer. But the wire does not want to make the, seems like it stops on its own. Anyway, you see the challenge that there's cloth in the center. It's like a tire here, like a Batman, Batmobile tire. So, you see the wire prolapses into the aneurysm. We try maneuver. We use the wire finally to get out into the right PCA. And when we put the micro catheter, try to follow it, even with distal access, it flies into the aneurysm. It's not playing. So, I'll go forward slowly. The XT-27 for the neuro form. And the reason to use the neuro form, can anyone, there we go. Can anyone fathom why we use the neuro form as opposed to, for example, the enterprise? No, we use the neuro form because the neck is so wide. And this is just the first stage to wait, let it endothelialize. And if we have to go through it through the left side, we want an open cell design. Oh, it's neuro form there, as opposed to an enterprise, which is harder to cross. So, anyway, catheter prolapses. And we've been at it for some time. So, what is the next step? Yeah. At that point, your catheter's already shut up in the aneurysm, are you? I mean, I don't know that you've really avoided messing with the thrombus. Like, you've already kind of banged it up a bit, right? Right. So, you're saying do the loop? Except the loop, and I showed you the lateral, the loop, the circle is this way. so you're going, and I'll show the video. So we change the wire, we use a stiffer wire. We change it to a Fathom 16 because we have an 014. Remember the sizing I mentioned? We have an 014 and XC27, a big differential. So we go to the Fathom 16, and we get across, and then, so we try the Fathom 16, it did not work. So, right, so that's why it's important to remember the size, the ID of the micro catheters. There's an XC27, we have an 014, and we put another 010 wire. So now we have an 024 wire system through an XC27 catheter. So we buddy wire, and there's the smaller wire coming up, follows, and we advance the wire out into the PCA, and then using both of them, then it's easier to track the XC27. Renee Chappot has a paper on that, doing, like, once you get one wire, the second wire tends to follow the first wire. Right, if you have one wire through, whether it's down here in the neck, if you have a buddy wire, the other wire will follow through. I think this is a great picture of how putting a device changes the geometry. I mean, look where the micro catheter is along the basilar, and it's pretty impressive. Right, so I was gonna come to that. The geometry is changed. Now, when we wanna put the neuroform, we don't want it to do this kind of number. We want it to take this curve. So we take the slack off, and we deploy the neuroform, or any stent, for that matter. We do it very, very slowly. I like Dr. Harrington's analogy about making love. By the way, I'm gonna take that back and use it in reverse, and make love like I use coils, because otherwise my case would be very short. So, we have to maintain a little bit of forward pressure on it, so it takes that curve of the vessel. All right, so there's the neuroform. I think it's a 2 1⁄2 by 20. It has a tip, so it's important to know all your markers. Marker, distal tip of the XT27. Lead wire, bumper for the stent, stent, stent, proximal bumper. And as I deploy that, again, we go fairly slowly in our deployment. Maintain forward pressure. I know that once the system is moved out, the vessel will relax. So, we want to maintain that across, evenly distributed across the neck of the aneurysm. There we go. So, once the stent is deployed, you can see from there to there. So, it's got good anchor, nice coverage, and it also marks the position on the lateral where our coils can come. So, this is going into the right PCA. I want to get my microcatheter across this circle all the way to the other and start coiling from here back, keeping in mind that the PCA is marking my distal axon. And all of this center is thrombus. Now, keep an eye on the thrombus in the center. We got coils, large OD coils, like 014 coils, whether it's a Delta Max, Presidio, XL. The catheter's obviously gone through it. It's not jailed. One, we put another one, and we stop flow that is circling back to the PCA. But notice this center donut in the aneurysm. Notice this circle that the coils are starting to go into the thrombus. So, the more I put, the more likelihood that I'm gonna start squishing that thrombus up. And at this point, we stop because what's happening is the coils are encroaching into the donut. So, we're gonna stop right there. We're not gonna do anything, leave this. This thrombus center, as I said, it started from one wall and gone to the other, and hopefully it thrombus more. And we stopped. The patient came back. She went home. She came back three, four days later. Started having some nausea. I was concerned that the thrombus is coming down. We did a CTA, and more of the aneurysm had thrombosed. So, she's coming back for an angio. If it thromboses on its own, good. Otherwise, we do the stent. I'm gonna speed up a little bit. 54-year-old grade four subarachnoid hemorrhage. Sidewall blister aneurysm at the origin of the aica. So, let's see here. Go down the Capital Institute of Neurosciences. There you go. What do you think? It would be very difficult to do this. Coil, stent, balloon? I think stent's probably what you're gonna need to do because trying to put coils in there is just so friable. Right, good. So, again, we don't tend to use, like I've already been said by the other faculty, we're leery of using stents in acutely ruptured cases. But this here is no choice. And the goal here is, obviously, so what stent? Probably an Enterprise. I guess if you had the Elvis, you could use that in this situation. Why Enterprise over the Neuroform? It's the closed-cell design. Right, so you can partially sheath deploy it because you're gonna jail this, right? All right, so access in this case wasn't bad, but again, planning is important. We know we're gonna use a stent. My concern was that we have such a shallow depth of the aneurysm that when we put the smallest coil out, which is a two millimeter, I don't want the aneurysm to rupture. So, we do need to stent it. And I'll just go on the video. I'm showing this to show where the guide catheter is, which is down there. All right, so we do different views under keep giving puffs till we identify the best view. So, there is the Enterprise Microwire. There is the Prowler Select Plus. And for stents, I always go further out than where I'm going to target because it's easier to then take the slack out and just gently pull back, then try to go forward. So, I go forward. That's another point to make about putting a stent there. Everybody, when you go out to PCA for that, to go as far as you think you can because of watermelon seeding. Yeah, right. If you wanna do the longer stent than you normally would do, say, for a prolonged sidewall aneurysm, because it's gonna push down into the bathroom. Right. Answer? Yeah. Just to sort of throw out there for discussion purposes, this is a very good and reasonable way to treat this, but it's also worth saying that this is something that could be surgically approached as well. And so, it's not, like, in the context of, yeah. Grade four or whatever. Yeah, it's totally reasonable. I just want, like, sort of for the crowd to, because a lot of times in the modern era, we're like, and me too, our thought is posterior circulation, that's out now. That's not an option. But based on what it looks like there, it looks like a middle foster transcentorial would actually look right on the aneurysm and would be potentially pretty treatable. So, just throwing it out there for thinking. If you think it's a real blister, you may not want to try. That's true. That's true, and that I don't know, if it's a true blister. Well, it goes the same thing with coiling it. Right. Yeah. There's no difference. The difference in the operating room is you can stop the bleeding. And you've got a stent, you've got plavix, you've got, you know, in my shop it would be heparin. And I wouldn't disagree. I mean, this is one, six dozen after the other. What I'll tell you what I would do here is I would inject that pica approximately with neurophysiologic monitoring and do a provocative test because I think I would plan on losing that pica. Ica. Ica. I'm sorry, Ica. And, you know, save for some hearing loss. And we actually just did a similar case with this with something elective. And did sodium amytol, the patient awake, and then asleep, the bears went out, you know. Right. We were, this is a great, great form. We were, when we went in, we were pretty sure we'd probably lose the ica. But anyway, keep going. This is the micro catheter. We used a synchro wire in this case. And it's important to keep an eye on the wire, tip of the wire, rather than what's happening down here. So even when I'm advancing, I'm only watching the tip of the wire because if that goes through. The other thing about plavix and aspirin. So this patient had been on aspirin and plavix previously. He got platelets for the ventriculostomy. Did do acumatrix. We did check his PRUs when we went in. We did give IV RioPro after we deployed the stent. So the micro catheter is in the aneurysm. This is the marker for the enterprise. Again, we want to center it right over the aneurysm. And there's the enterprises deployed. And then what I did here was, because I was afraid that this is such a shallow neck, I used a balloon, put the delivery system out, took a balloon up to put in the center of the stent just in case the aneurysm ruptured. I have a balloon there to control the bleeding. So this is a transform balloon positioned right over the aneurysm through the enterprise. And then I deploy the first coil. And then you see the balloon going up. I went too fast. So there's the first coil, first run. The ica is open. There's the balloon. It keeps the catheter tacked in place, keeps the enterprise against the neck of the aneurysm. And I put in, I think two or three coils protected the aneurysm. The ica is still filling, but we were, we had planned that we were probably, we may lose the ica, but we stopped at this point. And he's craked and pegged out to a rehab now. I'm gonna go fast. Yeah, that's like, that's a good outcome. Yeah. Yeah. Yeah, so that's a good topic. The problem with, I think, to use flow diverter, and I'm gonna show more blister aneurysms. Problem using flow diverter in ruptured aneurysm is that you have to, the problem is a rupture of the aneurysm. You have to make sure that that is controlled. So if you use flow diverter, I think it's important to probably put some coils around it or in the neck of the aneurysm. And I'll show another case which may help with that. So 63-year-old, grade three, small ruptured anterior coroid aneurysm. Again, balloon, stent, anyone? This is the proximal anatomy. Arch is okay, but the carotid's got some loops, a little bit of spasm athero, maybe FMD. Where would we position the guide catheter here? This is a sidewall IC aneurysm. Montreal, we got someone from Montreal. Okay, that's a good point. What else? Indiana. No one? Wisconsin. Yeah, I'm actually not sure how I would approach this. All right, well, we have to coil the aneurysm, so we have to use, it's a little shallow, wide-neck ruptured aneurysm, a lot of tortuosity. And I don't want to dissect all this artery out. This case, we say, well, we'll put a guide catheter here. It's not a neuron. We use an older Envoy MPC-XB so that it sits in this curve down here. And I plan to use a balloon, not a stent, again, for reasons of what we already discussed. So. I have a question. Do you use a shuttle or an aeroplex as well there? This was just an XB Envoy. It's, again, you can use whatever you're comfortable with, but I firmly believe what Jay said earlier. Keep things very simple, very straightforward, very comfortable. This is the trans, and I'll show you what happened. This is a transform balloon. I picked the vessel where the distal wire's going to go. Tomorrow I'll showcase where, what happens when you don't keep an eye on the distal wire. So we position the balloon first. The balloon always goes first. The microcatheter follows. This is a synchro. Again, we don't have much room in the aneurysm for the microcatheter to crack. So, yeah, you have to keep an eye on the wires. The microcatheter's in place, balloon's in place. We get the first coil up, and I inflate the balloon, but I don't see the balloon inflating, which means that when we were prepping, we screwed it up. So, no chances. Take everything out, reprep, reaccess, and I pull the microcatheter back so when I'm dragging and reinserting the balloon, it doesn't accidentally go through the roof. Reposition, there's the balloon inflated. It pins the microcatheter. The first coil, soft coil, it tries to come out. We keep the balloon inflated, and I do, generally I deflate the balloon to make sure if the coil is coming out or not before I keep it in place and push a bunch of coils in. So, the balloon's deflated, reinflated, and we go slow, put the coils, put three or four coils in, inflate and deflate the balloon every time. This is 70% contrast. Any questions? This is the final run, we stop here. No point in pushing it, the aneurysm's controlled, haven't caused any disasters. Did you say you jailed that microcatheter first, or you said balloon always- I put the balloon, I positioned the balloon first, and that's what's recommended, and I go with the microcatheter. It's not, they're not totally out. There's microcatheters also in the guide. It's just, I positioned the balloon first, then navigated the microcatheter, but the balloon wasn't prepped right, so I had to pull it, pull the microcatheter back a little bit. How are we doing? Are we okay? 44-year-old, worsening headache, ACOM aneurysm, elective coiling, patient enrolled in feet, randomized to 14 coils, premedicated with dual antiplatelet therapy, but missed Plavix dose on the day prior to coiling. I didn't tell Jay that, but that's what happened. So, this is her aneurysm, and forward-pointing rhinoceros, she's a young woman. We actually wanted this aneurysm clipped. She's pretty, she didn't want it clipped. We said, okay, we'll try it with, it might require some adjunctive device. Now, when we use an adjunctive device, it's important, and we talked about bifurcation versus sidewall, it's important to choose the right vessel which you are going to protect. So, for an ACOM, this patient does have a small contralateral A1. Even though it's easier to go through here and go to the other ACA, because this turn is pretty tight, but that doesn't serve any purpose. You have to put the device in the vessel that needs protected. In other words, you cannot protect this vessel by putting a stand on this side, or a balloon on this side. The coils will herniate out it, or they can herniate around it, and get that vessel. So, you have to protect the vessel that is at risk, that's where you put the device. In this case, it requires making this U-turn into that ipsilateral A1 segment. We use a single puncture, six French sheath, Neuron 070, transform, and a... So, there is our planned route, and you see the wire come up here, and this is, again, edited, so... Obviously, it didn't go just like that. It took some time, but we made the turn. Keep an eye on the distal wire. And then you'll see the balloon come up down here. Keep an eye on the wire. We try to anchor it in there, and you'll see the wire jump, but we have, this is magged up, we can see where the wire is. At that point, you have to go slow so that the balloon makes that turn and sits right in the neck of the aneurysm where you want it to protect. So there's the balloon's position, and again, the anatomy is distorted because of the device in the parent vessel. With the balloon in place, we put the first coil, and again, the balloon is inflated at this. At the first coil, we don't need a whole lot of support because it's a bigger coil, bigger than the neck of the aneurysm. It's a XL014 coil, and you can see one coil pretty much fills the whole aneurysm. We're keeping an eye right here, which is the neck of the aneurysm. And again, at this point, when the coil is going in, and I'm worried about the neck of the aneurysm, it's more important to look at the parent vessel than the dome of the aneurysm. Obviously, you wanna see the coil take shape, but you don't want to lose the interface between the vessel and the aneurysm. You want to keep that in profile so you see if the coils are herniating back or not. All right, this is coil number one, and the balloon's partially inflated. It's a four millimeter balloon in a two millimeter vessel, so it's obviously not inflated to nominal diameter. After that, the framing coil, we immediately drop down. At this point, what I don't want is, again, don't wanna hit the ball in the water. We just wanna fill enough and get out of there. We keep the balloon in. It's shoved in a little bit more forward because as we get closer to the neck of the aneurysm, there's more likelihood that the coils will herniate up, and the balloon is kept right where I think the coils are gonna come back. These are all cases that went well. Tomorrow I will show you that those did not. We inflate the balloons very gently. It's like taking your hands off and making sure the coils stay in place. I'll skip the next video. Again, access, we have to plan which vessel to choose. We position right at the neck. Make sure the balloon makes that turn. Coil number one. Two, this is what it looks like with the balloon pushing down into the neck, and then pre, post, follow-up. All right, this is another case. Again, randomized to feed all. My single objective when I go to work is to enroll a patient in feet. This 73-year-old wide-necked MC aneurysm had a previous history of a right MC bifurcation aneurysm that thrombosed and the patient had a stroke. We were following this aneurysm that was growing in size. Typically, I would say 90% of these get clipped, but now with the web device coming in, we're changing our paradigms a little bit, so now my objective is to enroll everyone in web, just so Adam knows. Wide-necked six-millimeter aneurysm, patient enrolled in feed trial, pre-medicated with aspirin and Plavix. This is a case, so you can see both, I'm gonna talk fast, see both MCs coming out. It's still wide-necked vessels that are incorporated into the base of the aneurysm. Here's the anatomy. This is a case where today, and especially when Elvis is out, is a good case for Scepter and Elvis Jr. I didn't wanna put a stent in right off the bat in this patient. It's a wide-necked aneurysm, eight-millimeter, six-millimeter neck. I skipped that, so. First, which vessel to choose? I wanted to choose this vessel because it's a little bit hidden behind, and on our 3D assessment, I thought there was a shelf that would protect the other M2. So, there is the balloon. Now, this is not a super-compliant balloon. Again, this would be a better case for a super-compliant than a compliant because when you put the super-compliant here in inflatable, it'll pooch into the neck of the aneurysm better than a compliant. Yeah, now, we didn't have it at that time. I just wanted to make it harder. That's why, yeah. So, we get the wire out in the M2. We get the balloon up, get the microcatheter up. At that time, there was only actually one size for a compliant balloon. Now, they have smaller sizes, which are also super-compliant. I could have used a hyperglide super-compliant, but I'll show you why I did not. So, anyway, the balloon's in place. The microcatheter's in place. Next, we put a coil in. The balloon's there. I'm gonna speed it up. The balloon's partially inflated. The coil goes in, and you can see the other M2 is more separate than the one that we chose, and that's why we chose that one. We put the coil. It's, again, a big coil. The balloon, you can see the axis of the balloon in relation to the microcatheter. It's still tilted a little bit towards the... Can you talk a little bit about your heparinization protocol? The patient's fully heparinized, weight-based. We give 60 to 70 per kilo, and then we maintain an ACT 250 or above. The patient's also premedicated with aspirin and Plavix. The heparin before the balloon goes up? The heparin is after the puncture. So, we put the coil in, and you can see the balloon's partially deflated, and I'm getting a little uneasy because the coils are coming towards the other M2. So, I deploy that coil, and I deploy another one, and then I'm getting nervous, so I keep the balloon in position, and that's why an O1-4 is important, a balloon that takes an O1-4. I keep the balloon in position, take out the O1-4 wire, exchange it, put an exchange, and put the balloon out, and exchange it with an XT27, and then put a neuroform. So, it's a pseudosepter Elvis, and the reason I did the exchange was because I did not want to lose my axis next to the coils once I had that axis. So, then the neuroform goes in, deployed from the M2 to the mid-M1, there, and then I put a few more coils in, and call it a day. So, this pre-post, I think this is a follow-up at six months. All right, we go fast. Another ruptured aneurysm, previously clipped ACOM. This is the clip, no left ACA. So, wide neck, both complex anatomy, because both A2s are coming close to the neck of the aneurysm. Yes? I have a question. I missed that part there. So, you were coiling with the balloon up with the O1-4 wire through it. Was that an exchange-length wire, or? Yeah, so the transform, and the scepter, and the stent, they all use O1-4 wires. Initially, I had a transcend-14 regular-length wire through it. Once I decided to put the stent in, I put an exchange-length synchro, keeping the balloon where it was, because I did not want to lose position. Today, for example, or next month, if that case, if I was coiling it, and I had to use a stent, or I wanted to avoid a stent, because patient compliance issue, et cetera, I would probably use a scepter-C. To start with, and if I wanted to put a stent in, put the Elvis Jr. through the scepter. Comments? No, one thing you can, it works better with the super-compliant, but if you have the transform in position, let's say you're worried about stability of the coil mass, you don't want to pull the balloon out at all. You can, through an O-7-0 catheter, fit a O-2-1 catheter next to the transform, so you can go up with a Prowler Select Plus and a synchro, and then deploy, yeah, and so what I've had to do, like the case that I mentioned the other time, is you basically sneak by the balloon while it's inflated, then you can deploy the enterprise, because it's closed-cell, while the balloon's open. Then you deflate the balloon while the enterprise pops open, and it doesn't get caught, because it's closed-celled, and then you can pull the balloon out. It's like a rescue maneuver. There you go. All right, this is a super-compliant case. I've got more videos, because that's what I thought would help, but I'm going to go fast through this one. So, A-2, A-2, big white neck, previous clips, no other A-1. The problem here was of projection. So, with any projection, I could not throw the clips off of this inferior, the left A-2. The plan was, and in this here, we've already positioned the transform super-compliant, is here, the micro-catheters in the aneurysm. I start a coil, just to see what the neck looks like, and you can see the coil immediately herniates out. So, there's no question that the coil, by itself, is not going to stay in there. So, now here, the balloon is inflated. It's a super-compliant, so you can see it pooching into the base of the aneurysm. And even with that, the coil was trying to come out into the other A-2. Now, my worry here is, so this is a better picture. You can see how the balloon's inflated asymmetrically towards the neck of the aneurysm. My concern here is that I don't see this A-2 very well, and if I cannot see it well, I'm not sure where the balloons inflating are going to, and I don't want to inflate the balloon right into the A-2. So, I put one coil in, deflated. This is the second coil. You see the balloon inflating. Now, here, what I wanted to do was, because I'm worried where the A-2 is, I inflate the balloon partially in the A-1, and then cork it and push it forward. So, I know the inflated balloon is inflated more than the diameter of the A-2. So, when I push it forward, it will go and cork into the A-2, and I know where I am. This is the wire going behind into the other A-2. All right, so the balloon, and then we inflate the balloon, and you can see the coil is going out where I cannot see it. It's going behind the clip, which is not satisfactory. So, I pull back, deflate the balloon. Again, I'm not gonna risk putting a coil in where I cannot see it, obviously. Pull the balloon back, re-access the aneurysm in another pocket, re-inflate the balloon partially, cork it and push it forward, so that it corks into the origin of the contralateral A-2. Again, choice of the vessel is important. In this case, I don't want to put the balloon up here, because this, I can see pretty well. The other vessel, I cannot see well. So, I want to protect the vessel, which is hidden behind that, and which has a greater risk of being occluded. So, I inflate the balloon, turn, rotate the II to see if I can get a better projection, and then start again. Partially inflate, push it forward, cork it into the A-2, then inflate it, so it inflate towards the aneurysm, and then coil it. So, here you can see the picture of the balloon inflated going down. Partially deflated, pre and post. All right, we're going to run through some pictures fast. So, 58 year old, grade four, ruptured A-com, very wide neck. Ipsilateral A-2, contralateral A-2. The patient has a contralateral A-1. So, the vessel, which is the vessel that needs to be protected here in coiling this aneurysm, the left or the right A-2? That guy, what's your name, buddy? This is the ipsilateral A-2. There's a contralateral A-1, contralateral A-2, wide neck aneurysm, vessel coming from the aneurysm, separate from the vessel itself. So, which one do we need to protect, left or right? The left one, the one that's coming from the aneurysm. This is the contralateral. So, in this case, because the turn is such, of such tortuosity, it's a complete U-turn through the aneurysm, it's a ruptured aneurysm, I don't think I can make that turn. In this case, I do come with the balloon from the contralateral side, but I still will protect, put it in the vessel that's most at risk. I will not put it in the ipsilateral and hope that it'll protect the contralateral A-2, it won't. So, the balloon is positioned across, and all we wanna do is just create a scaffold for the coils to sit on. So, here's the balloon coming from the right, here's the microcatheter in the left. Here, you can see the balloon end on, and you can see how it's doing enough to keep the coils in the aneurysm. Inflate, deflate, and this is the post, and we stop at this point. Seven-year follow-up, recurrence, the neck is getting exposed, and at this point, the patient, we were able to control, he recovered well. What to do next? Clip, coil, or anything else? This is the anatomy. All right, I'll find someone, let's see. Got the list here. Puerto Rico. Anyone? Yes, sir. Question, please. What, question is what, it's recurred six years after initial, what to do next? Watch it, coil it, clip it? I think that clipping, or coiling is. All right, so I'll just go for, we clipped it. This is, this was, I said we cannot, he's already done six years, clipped it. There was a little flow in trabangio, which sealed off day two, so he did well. So acute phase, he was a grade four. You know, we protected enough, he lasted six years, but the recurrent remnant was growing, and he got it clipped. This is another case, ruptured. P1, P2 junction, PCOM. There is the right ICA occluded. So to coil this aneurysm, it's important to protect, it's very important to protect this PCOM, right? Because the ICA, I don't remember the high grade stenosis, or was occluded, a little pimple on the P1, P2 junction, or where the three meet, PCOM, P1, P2. So, we decided to stent coil it. Get the micro wire catheter. Again, in all these cases, I generally use a stent that I can resheet, which is an enterprise. Now when we push forward, you can see the whole system prolapsing into the aneurysm, so we immediately relax it. Get the enterprise partially, and the coil is going into the right P1. We have another view which shows that they're laying along the side. So we reposition, the stent is already in place, as you can see. And this goes around that into the proximal P1, but looks okay. This is a, that was a follow up. Last case, or second last case. Do we have time, or am I done? You got it, you're out of time. All right. I'm sorry, how do you, do you stent it down, so it's just across the top there? I stent it down into the PCOM here, because. Why don't you stent across? Well, because the right ICA had a very high grade stenosis. I was afraid if I stent across and lose the PCOM, the right hemisphere is impacted. So the PCOM was feeding the right MCA. All right. Thank you.

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