First coil key during PulseRider procedures in wide-neck aneurysms


At the 2015 annual meeting of the European Society of Minimally Invasive Neurological Therapy (ESMINT; 10–12 September, Nice, France) Gyula Gal (Department of Radiology, University Hospital Odense, Denmark) reported his experience with the PulseRider aneurysm neck reconstruction device (Pulsar Vascular/Codman Neuro). 

The PulseRider is a novel neck reconstruction device that facilitates the treatment of wide-neck bifurcational aneurysms with coils. It is available in two shapes: T and Y; and for two vessel diameters: 2.7–3.5mm and 3.5–4.5mm; and the arch that supports the coils is available in sizes 8.6mm and 10.6mm. The device can be delivered through a 0.021” microcatheter.

According to Gal, the PulseRider’s arch design provides concentrated coverage at the neck—designed to allow dense coil packing; minimal coverage in the parent vessel; open architecture in the branch vessels—eliminating struts crossing through the lumen of the branch vessels vs. conventional stenting; and selected radial force in the anchor to provide stability and prevent migration.

Gal described his experience with 16 cases over a period of 15 months treating wide-neck aneurysms with coils and the PulseRider device. Of the treated aneurysms, nine were MCA, five were ACom and two were basilar artery tip aneurysms. Six of the aneurysms were ruptured and one was treated in the acute phase. One of the aneurysms was previously treated with WEB and coils, two with surgery and two with coils.

“I could successfully deploy all the devices in all of the cases and had total occlusion in all aneurysms except for one case where the device could not support the coils. There were no periprocedural complications and in the five, 6–12 month follow-up done so far, there was no recurrence. I am very happy with these results, but of course, we need further follow-up,” Gal maintained.

Giving some insight into the procedures, Gal added, “In these cases I learned that the device is very easy to work with, I can get wherever I want in the cerebral vessels and also beyond the Circle of Willis, and MCA branches are very easy to access. We should use soft coils with this device because soft coils will be easier to get in the sac supported by the arches. The first coil and the first loop is very important—you need to choose the right size and the right shape; if you get the first one right, the rest will fit in the mesh.”

NeuroNews spoke to Gal to get a more in depth picture of his experience with the PulseRider aneurysm reconstruction device.

What is the purpose of the option of T or Y shapes?

The purpose of the two shape options is to better accommodate to the different anatomical variations of the bifurcations.

How does the design of the device help to optimise the placement of coils?

The small filaments at the neck help to keep the loops of the coil in the aneurysmal sac.

Do you think the PulseRider should be used in all cases of wide-neck aneurysms?

The PulseRider is not always necessary, but it helps a lot, and some of the aneurysms are not treatable by endovascular means without it.

How do you usually make your device choice?

I try to pick the simplest possible device(s).

How did the use of the PulseRider differ in the cases of ruptured aneurysms?

The need of platelet inhibition has to carefully be balanced against the risk of rebleeding. In the only case I treated in the acute phase after the rupture, I gave IV ASA after placement of the device and some coils that slowed down the circulation in the aneurysm, kept the patient on high ACT level during the night, and loaded him with Clopidogrel the next morning.

Did you encounter any complications?

I did not, but have seen inadvertent dislocation of the device due to a pull of its delivery wire by the treating physician, while proctoring two cases. This, however, did not lead to any “real” complication.

Is there a learning curve associated with the use of the PulseRider device?

Yes, but it is not too steep.

From you experience using the PulseRider device, what are your tips and tricks?

The choice of the first coil is the most important part of the procedure. It has to be of the right size and soft enough to be able to stay in the sac. All treating physicians should be humble and patient, because the device alone cannot guarantee success.