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BACKGROUND: Crossing Y-stent-assisted coiling (CYSAC) is a feasible yet technically challenging technique for the treatment of wide-neck bifurcation aneurysms (WNBAs). OBJECTIVE: To present mid-term results of Y-stent-assisted coiling (YSAC) using the LVIS EVO stent and to describe our "drill turn" technique for stent crossing. METHODS: This retrospective, observational study included 37 consecutive patients treated with YSAC using LVIS EVO stents at five centres between September 2020 and March 2023. RESULTS: Immediately after treatment, 31 of the 37 patients (83.8%) achieved Raymond-Roy occlusion classification (RROC) Class I occlusion, while 5 patients (13.5%) had Class II and 1 patient (2.7%) had Class III occlusion. The mean follow-up period was 32.8 months (range: 11-41 months), and all patients underwent follow-up imaging after ≥ 6 months. On follow-up imaging, 34 patients (92%), including all those with immediate RROC Class I occlusion, 2 with Class II, and 1 with Class III, showed Class I occlusion. One patient with RROC Class II occlusion demonstrated a gradual decrease in residual filling, while one large partially thrombosed middle cerebral artery aneurysm and one large basilar tip aneurysm (8%) with residual neck filling remained unchanged on the 6-month digital subtraction angiograph. CONCLUSION: Utilizing the described drill turn technique, CYSAC with LVIS EVO stents was found to be feasible and safe for WNBA treatment, with high and stable occlusion rates observed during mid-term follow-up.

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Low-profile stents may provide significant advantages in Y-stent-assisted coiling due to their miniaturized design and capability to be delivered through a 0.0165-inch microcatheter. We aim to investigate the safety and efficacy of using these newer versions of stents in Y-stent-assisted coiling for the treatment of wide-necked bifurcation aneurysms. We conducted a systematic review of the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2023, following the PRISMA guidelines. Eligible studies included ≥ 5 patients with intracranial wide-necked bifurcation aneurysms treated with Y-stent-assisted coiling using low-profile stents, providing angiographic and clinical outcomes. Two authors independently handled the search and selection. Primary outcomes were immediate and follow-up aneurysm occlusion, procedure-related complications, aneurysm recanalization, and retreatment. Secondary outcomes included technical success, procedure-related morbidity, procedure-related mortality, procedure-related stroke, and in-stent stenosis at follow-up. We analyzed the data using random-effects meta-analysis. In total, 19 studies including 507 patients with 509 aneurysms were included. 95% of the treated aneurysms were managed using the crossing Y-configuration. Technical success rate was 99%. Immediate adequate aneurysm occlusion was 90%. Follow-up angiographies were available for 443 aneurysms. The mean angiographic follow-up duration was 15.6 ± 1.9 months. The rates for follow-up adequate aneurysm occlusion and complete occlusion were 98% and 89%, respectively. After a mean clinical follow-up of 15 ± 2.4 months, a good clinical outcome was observed in 98% of patients. Overall, procedure-related morbidity and mortality rates were 1.3%, and 0.4%, respectively. Low-profile stents in Y-stent-assisted coiling outperform previous stent versions in terms of safety, efficacy, and technical success rates.

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Malignant lesions of tracheal bifurcation usually lead to respiratory failure and risk of mortality. Airway stenting is the only minimally invasive method for these patients. The authors present a patient with T4N3M0 left-sided lung cancer (inoperable stage IIIc) complicated by respiratory failure due to tracheal bifurcation obstruction. Bilateral stenting by self-expanding stents with perforated coatings was effective for airway recanalization and provided subsequent chemotherapy.

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BACKGROUND AND PURPOSE: Stent-assisted coiling of wide neck bifurcation aneurysms in the anterior communicating segment and basilar tip region can be performed with varying stent configurations, including single stenting or Y-stenting. Y-stenting requires two stents and thus incurs greater cost and procedural complexity than single-stent constructs. The influence of first stent type on the need for Y-stenting remains unknown. MATERIALS AND METHODS: Clinical and angiographic data were retrospectively obtained for patients that underwent stent-assisted coiling for basilar tip or anterior communicating aneurysms at a high-volume center. Patients were included in this study if stent-assisted coiling was performed using Neuroform Atlas or LVIS Jr stents. A multivariate binary logistic regression was performed to measure the influence of first stent type on the need for Y-stenting. RESULTS: Stent-assisted coiling was used to treat 82 aneurysms in 81 patients during the study period, and Y-stenting was performed in 18.3% (15/82) of cases. In multivariate logistic regression analysis, use of LVIS Jr. as the first stent did not significantly influence the need for subsequent Y-stenting after controlling for aneurysm morphology (OR 0.65, 95% CI 0.18-2.43). CONCLUSION: Controlling for aneurysm morphology and location, the use of Y-stenting for stent-assisted coiling was not independently influenced by the choice of LVIS Jr or Neuroform Atlas as the first stent. A larger cohort may reveal differences between these two stents, particularly for aneurysms with large neck sizes.

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We present the case of a young woman transferred to our center with acute hypoxic respiratory failure due to an obstructing subcarinal mass. We review the management and rationale of this respiratory failure at different stages of her hospital course. We describe the approach and rationale in both the intensive care unit as well as the bronchoscopy suite. Finally, we discuss how the use of a novel hybrid Y stent effectively palliated her symptoms.

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The triplicate A2 variant is one of several common anomalies of the anterior cerebral artery. An anterior communicating artery aneurysm with triplicate A2 variant in close proximity to the aneurysm neck is challenging to treat due to potential unilateral/bilateral corpus callosum or parietal lobe infarction. Alternate simultaneous bilateral carotid angiography can differentiate triplicate A2 branches through time-difference alternate injection of contrast into the carotid arteries bilaterally, which can enhance anatomic understanding of complex anterior communicating artery aneurysms during complex endovascular treatment. In this case, a complex aneurysm with an associated triplicate A2 variant was treated successfully with Y-stent-assisted coil embolization using alternate simultaneous bilateral carotid angiography.

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AIMS: Percutaneous coronary intervention with Y-stenting of coronary bifurcation disease is not commonly undertaken. The procedural and medium-term clinical outcomes of coronary bifurcation lesions treated with the proximal to distal Y stent technique by a single experienced operator were reviewed. METHODS: A total of 167 consecutive procedures using either provisional Y strategies or full-coverage options performed at Auckland City Hospital, New Zealand, between January 2013 and July 2018 were included in this retrospective observational study. All medical records and coronary angiograms were reviewed. RESULTS: Three-year clinical follow-up data were available in 162 of 167 patients. The primary endpoint, defined as the composite of cardiovascular death, spontaneous myocardial infarction (MI), target-lesion revascularization (TLR), target-vessel nontarget-lesion revascularization (nontarget-lesion TVR), and stent thrombosis (ST) occurred in 25 patients (15%) at 3 years. Secondary endpoints were all-cause mortality (12%), including cardiovascular mortality (6%), noncardiovascular mortality (4%), undetermined death (2%), spontaneous MI (7%), TLR (1%), nontarget-lesion TVR (0%), and ST (0.6%). CONCLUSIONS: The proximal to distal Y-stent technique is a widely applicable approach to bifurcation lesions, with good medium-term clinical outcomes when used in a heterogeneous group of clinical and anatomical scenarios. Complications related to the stented site were infrequent. Randomized, controlled trials are needed to assess its efficacy compared with other bifurcation interventional techniques.

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The Woven Endobridge (WEB) device can be an effective and simple treatment modality for wide-neck bifurcation intracranial aneurysms. We present a case of a shallow basilar tip aneurysm treated with the WEB device that required stabilization with Y-stent through radial access.

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OBJECTIVE: Endosaccular treatment is the backbone of endovascular treatment for acutely ruptured aneurysms. Stent-assisted coiling is a niche technique in this context. Data on X-stenting or Y-stenting (dual crossing stenting, DCS) in the acute phase after subarachnoid hemorrhage (aSAH) are scarce, and the impact of stent properties on the outcome is unknown. We retrospectively evaluated the clinical and imaging results of DCS in patients treated for aSAH. METHODS: Patients with aSAH treated with DCS were evaluated retrospectively. Patient and procedural characteristics were evaluated to determine clinical outcomes, associated complications, and follow-up imaging findings. RESULTS: Sixteen procedures (16 patients; 10 women, mean age 55.8) were performed within 3.2 ± 2.6 days (range 1-10 days) of aSAH. Only the latest generation of intracranial stents (dual Neuroform Atlas-12 cases, dual Leo Baby-2 cases, Neuroform Atlas with Acclino Flex, or Leo Baby-2 cases) were used. Technical success rate was 100%; however, 25% of the procedures were complicated, leading to adverse events in 3 procedures (18.8%; 2 stent thrombosis, 1aneurysm rupture). Procedure-related morbidity and mortality and overall permanent morbidity and mortality were 6.3%, none, 6.3%, and 12.5%, respectively. No additional neurologic events were noted on a mean clinical follow-up of 160 ± 156 (range: 1-540) days. CONCLUSIONS: Our findings and the patient-by-patient data we extracted from the literature suggest that DCS can be performed with new-generation, low-profile stents in aSAH if a definite procedural risk is acceptable for a specific patient. New-generation open-cell stent combinations appear as a viable choice for DCS in aSAH.

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BACKGROUND: Stent-assisted coil embolization of wide-necked bifurcation aneurysms often employs a Y configuration stent. A similar stent configuration, termed kissing/double-barrel (KDB), is used often at the aortoiliac bifurcation. Studies of KDB stents in aortoiliac disease show that rates of thromboembolic complications vary with the cross-sectional geometry of the stent pair, a function of the radial crush resistive force of each stent. We assessed cross-sectional geometry of intracranial stent pairs in an in vitro model of the basilar artery using flat-panel computed tomography. METHODS: In a silicone model of a wide-necked basilar tip aneurysm, 6 simulated KDB stent deployment trials were performed using combinations of 5 stents (Enterprise 1, Enterprise 2, Neuroform Atlas, LVIS, LVIS Jr.). Flat-panel computed tomography reconstructions were used to assess cross-sectional stent geometry. Relative conformability, defined by ovalization and D-ratio, radial crush resistive force (predicted vs. actual), and radial mismatch fraction were compared by stent type (braided vs. laser-cut). RESULTS: Several distinct forms of cross-sectional stent geometry were observed. Braided stents had lower ovalization and D-ratio (P = 0.015) than laser-cut stents. The Neuroform Atlas/LVIS combination yielded the lowest radial mismatch fraction (19.7% vs. mean 44.3% ± 0.7%). Braided stents tended to have a deployed stent radius closer to the expected (nominal) diameter (i.e., higher relative crush resistive force) than laser-cut stents (measured vs. nominal diameter discrepancy +38.6% ± 21.1% vs. -10.7% ±16.1%, P = 0.14). CONCLUSIONS: In constant anatomy, cross-sectional geometry of the KDB stent configuration will vary depending on the design and structure of the stents employed.

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Successful embolization of a basilar bifurcation aneurysm associated with a persistent primitive hypoglossal artery (PPHA) using Y-stent-assisted coiling.

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BACKGROUND: Central airway obstruction and fistula are treated with a tracheobronchial Y stent. In the currently used self-expandable metal Y stents, the delivery system is 8 mm in diameter and requires either a 9 mm tracheal tube or rigid bronchoscope to enable airway control during insertion. In this study we present a novel technique of laryngeal mask airway (LMA) assisted Y stent insertion, enabling airway control during deployment of the Y stent. METHODS: All procedures using LMA in assisting Y stent insertions between 2014-2020 were reviewed. Data collected included demographics, clinical diagnosis and disease characteristics, indication, procedural success rates, clinical outcome and survival. RESULTS: A total of 10 patients with a median age of 61.5 years (range 37-73) underwent LMA assisted Y stent insertion. Indications for stent insertion were malignant disease with central airway obstruction or fistula. In all cases airway patency was achieved leading to improvement of symptoms and performance status. No procedural complications were reported. The median survival was 4.5 weeks (range: 2-26). CONCLUSIONS: LMA assisted Y stent insertion enables airway control during the procedure. In comparison to silicone Y stent insertion, the procedure is less cumbersome, shorter in duration and does not require the use of general anesthesia or rigid bronchoscopy. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: LMA assisted Y stent insertion enables airway control during the implantation of metallic self-expanding Y stent. The procedure does not require the use of general anesthesia or rigid bronchoscopy. WHAT THIS STUDY ADDS: In this study we present the technique and outcomes of LMA assisted Y stent insertion. This method of Y stent insertion provides an additional treatment option for patients with central airway obstruction and fistula.

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BACKGROUND: The objective of this study was to present the long-term safety and effectiveness of strand remodelling with a hypercompliant balloon. METHODS: Patients with complex wide-neck bifurcation aneurysms (WNBAs) who underwent strand remodelling with a hypercompliant balloon via Y-stent-assisted coil embolization (Y-SACE) between September 2016 and January 2020 were included in the study. The feasibility, safety, effectiveness, and complication rates of the strand remodelling technique were investigated. RESULTS: A total of 12 patients (6 females, 6 males) were included in this study. Significant expansion was obtained in the intersection zone after remodelling. No regression was observed in the expansion rates during follow-up. There was no additional morbidity or mortality. No delayed thromboembolic complications occurred in our patients during long-term follow-up. CONCLUSIONS: Performing strand remodelling to reduce thromboembolic complications triggered by structural faults caused by the Y-stent configuration is feasible, safe, and effective. This new approach can aid in the prevention of thromboembolic complications in Y-SACE.

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CLINICAL ISSUE: Intracranial aneurysms most commonly occur at bifurcation sites. In case of dealing with broad based aneurysms, the risk of accidental vessel occlusion during embolization should not be underestimated. Therefore, several devices are available, e.g. WEB device and barrelsStent. Besides that, a special technique gives the opportunity to place two stents into each other or next to each other into both branches of a bifurcation. Over 300 patients included in 18 studies were treated with Y­stenting (e.g., Medline/Embase) showing a good clinical outcome in 92%. A complete occlusion was achieved in 91%. The rate of neurologic deficits was 4%, the procedure-caused mortality was 2%. Furthermore, 12% of the patients sustained a stroke during the intervention. Ruptured aneurysm was found in 19%. CONCLUSION: All in all, a high occlusion rate and a low rate of mortality and stroke were shown by using Y­stenting.

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BACKGROUND: The LVIS Jr device holds a number of advantages but poses unique technical challenges compared to such, especially, complex multistent constructs. We report our experience with the technical feasibility and early to mid-term outcomes of Y-stent-assisted coiling with the LVIS Jr using a simple, single microcatheter technique. METHODS: Using a departmental database, we retrospectively reviewed a single surgeon's experience with Y-stent-assisted coiling with LVIS Jr over a three-year period. Eighteen aneurysms in 17 patients were treated over this period. We assessed the technical success of the procedures, the initial and follow-up radiographic success with the modified Raymond-Roy occlusion score and follow-up clinical outcome with the modified Rankin scale. RESULTS: All stents were successfully deployed, and 17 of 18 aneurysms were successfully coiled at the initial treatment for a technical success rate of 94.4%. Of the 17 aneurysms with follow-up imaging, all were modified Raymond-Roy grade 1 or 2. One aneurysm required retreatment for coil compaction and a growing neck. There were two immediate postprocedure symptomatic strokes and one delayed stroke related to antiplatelet non-compliance. The two immediate symptomatic strokes recovered to neurological baseline with no residual deficits by the time of discharge. The long-term morbidity rate was 5.5%. The mortality rate was 0%. All patients had a modified Rankin Scale ≤ 2 at most recent follow-up. CONCLUSION: Treatment with LVIS Jr Y-stent constructs via a single microcatheter technique is technically feasible with good radiographic and clinical outcomes.

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A 70-year-old woman diagnosed with advanced, non-resectable programmed cell death ligand 1-positive-non-small-cell lung carcinoma was treated with pembrolizumab as first-line therapy. Soon after therapy initiation, she presented with severe dyspnea, and chest computed tomography revealed a soft tissue mass in the lower trachea of the right main bronchus. During bronchoscopy, she became severely hypoxic, and we performed endoscopic tumor ablation and Dumon Y-stent placement. We considered this severe deterioration caused by pseudoprogression, and suggest that it is necessary to perform bronchoscopy and to prepare for the bronchial intervention when treating patients with immune checkpoint inhibitors.

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BACKGROUND AND PURPOSE: Complex wide-neck intracranial aneurysms are challenging to treat. We report a multicenter experience using the LVIS Jr stent for "Y-stent"-assisted coiling embolization of wide-neck bifurcation aneurysms. METHODS: Seven centers provided retrospective data on patients who underwent Y-stenting. Technical complications, immediate posttreatment angiographic results, clinical outcomes, and imaging follow-up were assessed. RESULTS: Thirty patients/aneurysms were treated: 15 basilar tip, 8 middle cerebral artery, 4 anterior communicating artery, 1 pericallosal, and 2 posterior inferior cerebellar artery aneurysms. The mean aneurysm size was 11 mm and the mean dome-to-neck ratio was 1.3 mm. Twenty-four aneurysms were unruptured and treated electively, and 6 were acutely ruptured. Fifty-eight LVIS Jr stents were successfully deployed without any technical issue. One pro-cedural and transient in-stent thrombosis resolved with the intravenous infusion of a glycoprotein IIb/IIIa inhibitor. Five periprocedural complications (within 30 days) occurred: 2 periprocedural neurological complications (1 small temporal stroke that presented with transient aphasia and 1 posterior cerebral artery infarct) and 3 nonneurological periprocedural complications (2 retroperitoneal hematomas, and 1 patient developed a disseminated intravascular coagulopathy). One permanent complication (3.3%) directly related to Y-stenting was reported in the patient who suffered the posterior cerebral artery infarct. Immediate complete obliteration (Raymond-Roy Occlusion Classification [RROC] I-II) was achieved in 26 cases (89.6%). Twenty-four patients had clinical and imaging follow-up (mean 5.2 months). Complete angiographic occlusion (RROC I-II) was observed in 23 patients (96%). A good functional outcome with a modified Rankin Scale score ≤2 was achieved in 26 cases. CONCLUSIONS: In this multicenter case series, Y-stent-assisted coiling of wide-neck aneurysms with the LVIS Jr device was feasible and relatively safe. Follow-up imaging demonstrated very low recanalization rates.

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Long-awaited positive trial data have shown the efficacy of endovascular treatment in patients with ischemic stroke who arrive at the hospital within the first 6 hours with large-vessel occlusion of the anterior circulation. With the introduction of stent retrievers (SRs) for mechanical thrombectomy, efficient and safe large-artery recanalization treatment can be achieved. However, sometimes there are patients who do not attain complete flow restoration following attempts with traditional maneuvers. The authors present the case of a 57-year-old man with acute ischemic stroke due to an M1 embolus that extended into both M2 trunks. This patient was successfully treated with an innovative technique in which a Solitaire SR (Covidien) and a Catch SR (Balt) were used in a "Y" configuration, for which the authors coined the term "Y-stent retriever."

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Recently, several authors have reported stenting into the right upper lobe bronchus using bifurcated stents, but little has been reported on stenting into the right middle or lower lobe bronchus. We report a case with metastatic uterine leiomyosarcoma, who was successfully treated by rigid bronchoscopic intervention, including silicone Y-stenting on the carina between the right middle lobe bronchus and the lower lobe bronchus.

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OBJECTIVE: The objective of this study was to determine the efficiency and safety of Y configuration stent-assisted coiling with double-closed stents for wide-necked intracranial aneurysms located at arterial bifurcations thorough analysis of a multicenter case series. MATERIALS AND METHODS: A retrospective chart review was done on 10 patients who underwent endovascular treatment of wide-necked intracranial aneurysms with Y-configuration stent-assisted coil embolization in three centers from August 2011 to March 2014. The degree of aneurysmal occlusion was assessed using the Raymond scale. Clinical outcomes were assessed before operation, at discharge, and at the last follow-up visit using the Glasgow outcome scale. RESULTS: The 10 patients included 6 females and 4 males with a mean age of 58.6 years. Indications for treatment included 6 unruptured intracranial aneurysms and 4 ruptured intracranial aneurysms. Five aneurysms were located at the basilar artery bifurcation, four aneurysms were located in an anterior communicating artery, and one aneurysm was in the pericallosal artery. The mean size of the 10 aneurysms was 9.7 mm. All aneurysms had a dome-to-neck ratio of < 1.5 (mean, 0.89). Immediate complications included one thromboembolic event out of the 10 cases. Immediate posttreatment angiograms showed complete occlusion in 1 aneurysm and residual necks in 9 aneurysms. Follow-up results showed 8 complete occlusions and 2 residual necks. No delayed complications were observed during the follow-up period (mean: 20 months). CONCLUSION: Y configuration using double-closed cell stents is feasible and safe in selected patients. This method is an acceptable option for managing complex wide-necked bifurcations.