Distal anchoring techniques for reducing intra-aneurysmal (around-the-world) microcatheter loop prior to stent deployment across large wide-necked aneurysms- an educational review.

purposeEstablishing parent artery access for stent placement across large wide-necked aneurysms can be challenging. 'Around-the-world' technique, forming an intra-aneurysm loop with some form of distal anchoring, has been described in several reports. This comprehensive educational review summarizes the different variations of this technique, with their relative advantages and disadvantages. The review is supported with a technical case description of balloon-anchoring technique, one of the already described techniques in a patient with proximal posterior cerebral artery aneurysm.

methodsA comprehensive literature search was conducted to identify studies describing intra-aneurysmal looping with different distal anchoring techniques. A narrative synthesis of the data obtained from the identified studies was performed.

resultsThirteen retrospective studies with 51 patients and the patient in the current report were included in the review. Different techniques described include balloon anchoring, stent anchoring, coil anchoring, vacuum anchoring, rapid pull-back and wire anchor loop traction techniques. Largest dimension of the aneurysms ranged from 12.3 mm to 29 mm with a mean of 19.9 mm (8 studies, 44 aneurysms). Neck size ranged from 5.2 mm to 15 mm with a mean of 10.4 mm (5 studies, 10 aneurysms). Aneurysms were unruptured in all 6 studies reporting the rupture status. Majority of the studies reported good outcomes with only two patients (3.9%) developing complications (intraparenchymal hematoma- 1, caroticocavernous fistula- 1). The choice of technique in a given case would depend on operator experience, expertise and in some instances, local infrastructure. This study is limited by a potential for publication bias and retrospective nature of the included studies.

conclusionIntra-aneurysmal looping with different technical variations for distal anchoring in the parent artery is an effective technical maneuver for deploying a stent across large wide-necked aneurysms. Comparative efficacy of different techniques and high level recommendations are difficult to provide given the relative infrequency of the situation, limited case numbers published and inconsistent reporting, including under-reporting.