A292 When flow disruption fails: lessons from suboptimal intrasaccular treatment of wide-neck bifurcation aneurysms

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Background/Introduction Wide-neck bifurcation aneurysms remain among the most challenging lesions in endovascular neurointervention. Intrasaccular flow disruptors (ISDs), including WEB, Contour, and Artisse, have expanded treatment options by enabling aneurysm occlusion without routine parent-vessel reconstruction. Since 2014, our center has treated approximately 400 aneurysms using ISDs, predominantly WEB, followed by Contour and Artisse. Despite excellent overall results, suboptimal occlusion, recurrence, or the need for retreatment may occur. Objective/Purpose To analyze the main technical causes of unsatisfactory ISD outcomes and to present practical strategies for prevention and staged correction, including the SAFE TEDDY BEAR technique. Methods/Case Description Based on our long-term single-center experience, we reviewed cases with incomplete occlusion, device instability, protrusion, or early recurrence after ISD treatment. Particular attention was paid to aneurysm morphology, bifurcation anatomy, device sizing, microcatheter selection, and bailout strategies. Technical errors were categorized as undersizing, oversizing, inaccurate aneurysm measurement, inappropriate device-to-sac matching, excessive procedural routine, and use of overly large or unstable microcatheter systems within the aneurysm sac. Results/Findings The most frequent cause of poor ISD performance was incorrect device sizing. Undersizing may lead to inadequate wall apposition, device compression, persistent inflow, and recanalization. Oversizing may cause device protrusion into the parent artery or branch compromise. Inaccurate preprocedural measurements and overreliance on routine device selection were important contributing factors. The SAFE TEDDY BEAR technique, based on placing a second microcatheter in the parent artery before ISD deployment, may facilitate immediate rescue stenting in cases of protrusion. Importantly, even when the initial ISD result is suboptimal, the implanted device may serve as a scaffold for planned retreatment with coils and stent-assisted reconstruction. Discussion/Conclusions/Learning Points Flow disruptors are powerful tools, but their success depends on meticulous sizing, morphology analysis, and procedural flexibility. Failure of the first-stage ISD treatment should not always be considered definitive failure, but rather a potential foundation for staged, multimodal aneurysm reconstruction.

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