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Following its CE-mark approval and European commercial launch in September this year, the SwiftPAC neuroembolisation coil (Penumbra) stands as a useful tool in the endovascular treatment of a number of traditionally neurosurgical conditions—including intracranial aneurysms, carotid cavernous fistulas (CCFs) and chronic subdural haematomas (cSDHs). Here, Fritz Wodarg (University Medical Center Schleswig Holstein, Kiel, Germany) provides NeuroNews with some key insights into the management of cSDH patients via middle meningeal artery embolisation (MMAe) procedures utilising the SwiftPAC device.
Wodarg recalls that his curiosity over this fairly novel therapeutic approach was initially piqued when he first observed presentations of such procedures given by US physicians back in 2019.
“From the beginning, it seemed to be a logical approach, and an approach with low risks, so we became interested in trying it out,” he says, speaking at this year’s European Society of Minimally Invasive Neurological Therapy (ESMINT) annual congress (3–5 September, Marseille, France). “Back home, we immediately started talking to our neurosurgical colleagues. They were sceptical at first but, as it is an intervention with such a low risk profile, we were able to convince them to try it out for certain cases—and it didn’t take long for them to also see that we didn’t have any complications with these interventions.”
These positive early experiences have led to the vast majority of eligible cSDH cases now being treated via MMAe procedures at Wodarg’s centre. He notes that the specific technique they have typically favoured involves particle-based embolisation with the addition of coils.
“There are several reasons for this,” Wodarg explains. “The main reason is that it means we can treat people under local anaesthesia, which makes it much easier to perform the procedures in our daily practice. We also had no evidence on whether liquid embolics or other [materials] would be more efficient. So, we started off using particles [alongside coils] and continued to do so.”
Over time, Wodarg and his colleagues have gained a greater understanding of how best to optimise and tailor this technique to the patient. Important lessons they have learned relate to catheter sizing, and the significance of having “persistent antegrade flow” in the vessel to ensure the embolisation particles can reach more distal locations, as well as the benefits of using smaller particles.
“The data on liquid embolics are quite good, but we still don’t know how both techniques compare,” he says. “As such, and also due to a few practical reasons at our hospital regarding general anaesthesia, we’ve continued to use particles and some additional, pushable coils to create a proximal block after administering the particles.”
A “completely new” solution
However, having utilised this approach fairly consistently over the past few years, a recently introduced technology—the SwiftPAC neuroembolisation coil—has led Wodarg to reconsider his MMAe strategy, and the role coiling can play in these treatments.
“The SwiftPAC coil for this indication is something completely new,” he notes. “I hadn’t previously used detachable coils because, from my understanding, it would have made the procedure very long and very complicated. Due to the fact that there are sometimes three or more vessel branches, possibly requiring lots of coils, and because we do not know if it’s necessary to just coil distally or go all the way down, we’ve used pushable coils as an additional block in the proximal part of the MMA, but not as a standalone treatment.”
However, according to Wodarg, “that all changed” with the European debut of SwiftPAC—a recent addition to Penumbra’s Swift coil system that has been designed as a soft, space-seeking ‘liquid metal’, which has an innovative 2D sinusoidal shape and conforms to the target vessel in order to achieve dense packing. These attributes provide versatility across a variety of clinical applications, with one of these applications being the endovascular treatment of cSDH.
The SwiftPAC coil for this indication is something completely new.
“SwiftPAC is thought to be able to cover a long distance and occlude more than one branch with a single coil,” Wodarg avers. “This is an interesting idea because, with that, you’re able to start in one branch, and then come down to a bifurcation, and then treat the next branch with the same coil. And, in the end—with just one or two coils—you can often cover the whole MMA territory. Of course, a coil does not have the same deep penetration as liquid embolics or particles but, at the moment, we don’t know if that [deep penetration] is necessary. This is an important question to consider for the future.”
While the differences in efficacy between MMAe procedures utilising standalone coiling, liquid embolic agents or particles are yet to be fully elucidated via clinical research, Wodarg feels that deploying coils is likely to carry a higher safety level compared to alternative approaches.
“The safety aspect is an important point,” he explains. “If you’re unlucky or unaware of your collaterals, you can lose particles [outside the target territory]. With liquid embolics, you can lose embolic agent into smaller branches that you don’t want to embolise. This means it’s much more important to have a very good view, to have a patient who’s not moving, and to have a good understanding of where your embolic agent is going, at every moment.
“With a coil, it’s a different story. You can retrieve it at any time, if necessary. You can clearly see where it’s going after you place it, and you can correct the position if you’re not happy with it. So, in terms of the safety aspect, I would have no fear of doing any harm with a coil like this. And, while there are no [definitive] data—and we do not have a lot of complications with other embolic agents either—I would expect that it’s safer than other embolics.”
Future directions
Another “interesting question” Wodarg highlights relates to the other conditions and indications beyond cSDH within which SwiftPAC may prove to be a beneficial tool for neurointerventionists. The device has a 0.0135-inch primary diameter, deliverable through 0.0165-inch microcatheters, and is available in a range of lengths from 3cm to 60cm. These characteristics are intended to optimise embolisation across different vessel sizes and anatomies within the neurovasculature, while a SwiftPAC product expansion that saw the introduction of 20cm and 25cm coils—announced by Penumbra earlier this year—is set to help physicians meet the growing demand for the endovascular treatment of neurosurgical conditions.
“The SwiftPAC coil seems to be a good choice when you’re using small catheters but, at the same time, trying to fill a large volume,” Wodarg comments. “It’s a very long coil that can be easily used with smaller catheters, which could be useful for some aneurysms—especially when it comes to filling aneurysms with a larger volume. I can imagine that we could also use it in the embolisation of dural fistulas from the venous side, for example, or in vessel occlusions. So, when it comes to very distal locations and you have a larger volume, there are definitely options.”
The utility and potential advantages of SwiftPAC have been explored further via two recent studies, both of which were presented at the 2025 Society of NeuroInterventional Surgery (SNIS) annual meeting (14–18 July, Nashville, USA) and have also been published in the journal Interventional Neuroradiology.
The first of these publications sees Mascitelli et al report retrospective findings from 31 MMAe treatments using SwiftPAC coils as a standalone approach, with no procedural complications being observed in addition to a 93.3% rate of radiographic cSDH improvement at follow-up, leading the authors to conclude that SwiftPAC’s length and flexibility allow for distal penetration and efficient occlusion, with fewer materials, while avoiding the risks associated with liquid embolics.
In the second study, Khattar et al present a case series of 18 consecutive SwiftPAC treatments ranging from post-traumatic vessel sacrifice, preoperative tumour embolisation, and severe epistaxis, to direct CCF, aneurysm recurrence and oropharyngeal haemorrhage. All but one of these procedures were technically successful, and no major complications were observed—with the authors concluding that, as such, SwiftPAC appears to represent a safe, effective and efficient option for a variety of indications.
