Case Review
History
• 43-year-old female.
• Present history: Found SAH in 2016 and underwent simple coil embolization of left A2 aneurysm with a daughter sac. Two-year follow up angiography in 2019 showed the aneurysm relapse.
• PE: (-).
• 43岁女性。
• 现病史：2016年蛛网膜下腔出血，发现左侧A2段动脉瘤伴子瘤，行单纯栓塞治疗。两年后（2019年）随访血管造影提示动脉瘤复发。
• 体格检查：(-)。
Figure 1 GIF. Two-year follow-up angiography shows a post-embolization left A2 bifurcation aneurysm with irregular neck relapse. 两年后随访血管造影见左侧A2段分叉部动脉瘤栓塞术后，瘤颈复发。
1
Treatment strategy
• Re-embolization with stent-assisted coiling.
• 再次治疗，计划行支架辅助栓塞术。
Figure 2 GIF. 3d-reconstruction. 3d重建。
2
Operation
Figure 3. Measurement. 测量。
Figure 4 GIF. 6F Envoy DA. Prowler Plus microcatheter was navigated to the left A3. 6F Envoy DA导管。将Prowler Plus微导管置于左侧大脑前动脉A3段。
Figure 5 GIF. Solitarie 4*20mm was deployed in the parent artery. 于载瘤动脉释放Solitarie 4*20mm支架。
Figure 6 GIF. Rotational angiography was performed to find a working projection for coiling. 旋转血管造影寻找栓塞工作角度。
Figure 7 GIF. A Microplex-10 4mm*10cm coil was inserted for framing. Then general heparinization and Tirofiban (Xinweining) 10ml were administrated. 填入一枚Microplex-10 4mm*10cm弹簧圈成篮。然后行全身肝素化并给予替罗非班（欣维宁）10ml。
Figure 8 GIF. One Hypersoft 3mm*8cm coil,one Hypersoft 3mm*4cm coil,one Hypersoft 2mm*6cm coil. 填入Hypersoft 3mm*8cm、Hypersoft 3mm*4cm弹簧圈、Hypersoft 2mm*6cm弹簧圈各一枚。
Figure 9 GIF. After inserting a Hypersoft 2mm*4cm coil, the microcatheter tip was pushed out of the aneurysm sac. 填入一枚Hypersoft 2mm*4cm弹簧圈后，微导管头端被推出动脉瘤腔。
Video 1. The microcatheter tip was re-navigated to the aneurysm sac guided by the microwire. 微导管头端在微导丝引导下重新进入动脉瘤腔。
Video 2. One Hypersoft 1mm*3cm coil,one Hypersoft 1mm*2cm coil. 填入Hypersoft 1mm*2cm，1mm*2cm弹簧圈各一枚。
Figure 10 GIF. Post-operative angiography shows intact of intracranial vessels. Tirofiban (Xinweining) 5ml and Nimodipine 1ml were administrated. 术后血管造影提示颅内血管显影良好。给予替罗非班（欣维宁）5ml、尼莫地平1ml。
Figure 11. Post-operative CT shows contrast medium retention in the left hemisphere. 术后CT提示左侧半球造影剂滞留。
Figure 12. Post-operative multi-mode high resolution MRI. 术后多模态高分辨率磁共振。
3
Post-operation
• No neurologic deficit or peri-operative complication.
• Medication: Aspirin 100mg qd, Clopidogrel 75mg qd (stop after 3 months).
• 无神经功能缺损症状或围手术期并发症。
• 药物：阿司匹林100mg qd，氯吡格雷75mg gd（3个月后停用）。
Figure 13. No evident change of the parent artery angle is noted after simple coiling embolization of the aneurysm. 单纯栓塞术后载瘤动脉角度无明显变化。
Figure 14. After stent implantation of relapsed aneurysm, the parent artery angle increased immediately, which increased significantly after embolization and during follow up. No evident aneurysm recurrence is noted during follow up. 5 year DSA follow up was scheduled. None medication. 复发动脉瘤支架植入后载瘤动脉角度立即增大，栓塞术后及随访均可见其明显增大。随访期间未见明确动脉瘤复发。计划5年后再随访复查DSA。不再予以药物治疗。
4
Summary
• Simple coiling embolization without parent artery angle remodeling may contribute to aneurysm relapse.
• After stent-assisted coiling of relapsed aneurysm, parent artery angle remodeling by Solitaire stent converted an apical aneurysm to a sidewall aneurysm, reducing the recurrence risk of the relasped aneurysm.
• 单纯栓塞无载瘤动脉角度重构，可能导致动脉瘤复发。
• 复发动脉瘤支架辅助栓塞术后，Solitaire支架重塑载瘤动脉角度，将顶端动脉瘤转变为侧壁动脉瘤，从而降低了动脉瘤再次复发的风险。
