Endovascular Treatment of Intracranial Aneurysms with the WEB Device: A Systematic Review of Clinical Outcomes

BACKGROUND AND PURPOSE:Despite the improvement in technology, endovascular treatment of bifurcation intracranial wide-neck aneurysms remains challenging, mainly due to the difficulty of maintaining coils within the aneurysm sac without compromising the patency of bifurcation arteries. The Woven EndoBridge (WEB) device is a recent intrasaccular braided device specifically dedicated to treating such aneurysms with a wide neck by disrupting the flow in the aneurysmal neck and promoting progressive aneurysmal thrombosis.MATERIALS AND METHODS:Using several health data bases, we conducted a systematic review of all published studies of WEB endovascular treatment in intracranial aneurysms from 2010 onward to evaluate its efficacy and safety profile.RESULTS:The literature search identified 6 relevant studies (7 articles) including wide-neck bifurcation aneurysms in ≥80% of cases. Clinical data supporting the efficacy and safety of the WEB are limited to noncomparative cohort studies with large heterogeneity from a methodologic standpoint. The WEB deployment was feasible with a success rate of 93%–100%. Permanent morbidity (mRS of >1 at last follow-up) and mortality were measured at 2.2%–6.7% and 0%–17%, respectively. The adequate occlusion rate (total occlusion or neck remnant) varied between 65% and 85.4% at midterm follow-up (range, 3.3–27.4 months).CONCLUSIONS:Endovascular treatment of bifurcation wide-neck aneurysms with the WEB device is feasible and allows an acceptably adequate aneurysm occlusion rate; however, the rate of neck remnants is not negligible. The WEB device needs further clinical and anatomic evaluation with long-term prospective studies, especially of the risk of WEB compression. Prospective controlled studies should be encouraged.

With the emergence of detachable coils and results of the International Subarachnoid Aneurysm Trial and Barrow Ruptured Aneurysm Trial,^1,2 endovascular coiling has become the first-line option for ruptured intracranial aneurysms. It is also a widely accepted option for unruptured aneurysms that are anatomically suitable for endovascular approaches.³ However, coiling of large and wide-neck intracranial aneurysms is associated with low initial complete obliteration, a high incidence of recanalization (up to 20% at 12 months), and a 10% rate of retreatment.⁴ Promising technologies like flow-diverter stents have the potential to overcome some of the limitations of standard coiling for sidewall aneurysms,^5–7 but the management of large wide-neck bifurcation aneurysms remains challenging. Balloon and stent-assisted techniques have widened the indications for endovascular treatment of aneurysms with a wide neck and/or unfavorable anatomy that were otherwise unsuitable for coiling.^8–10 However, endovascular treatment of such complex intracranial aneurysms requires the use of complex endovascular techniques with double-stent placement in Y and X configurations. Bartolini et al¹¹ suggested that Y and X stent-assisted coiling was associated with a high rate of complications, 10% procedure-related permanent morbidity, and 1% mortality rate.In this context, a new endovascular device, the intrasaccular flow disruptor Woven EndoBridge (WEB; Sequent Medical, Aliso Viejo, California), specifically designed to treat wide-neck bifurcation intracranial aneurysms, has emerged in the past 5 years.^12–14 There is an emerging body of literature on the use of the WEB device, but to our knowledge, no study has specifically reviewed the evidence on its use. We, therefore, performed a literature review of this technique in the management of wide-neck bifurcation intracranial aneurysms. Our specific aims were to evaluate its feasibility, safety, and effectiveness to finally discuss its place in the endovascular treatment of bifurcation intracranial aneurysms.