[Music] uh we compared stent assisted coiling which is the old-fashioned of treating aneurysms with with flow diversion and we showed that flow diversion has more durability one once we place this flow diverter we are covering branching vessels so we had to look at those branching vessels is there a risk of occlusion of branching vessels and the most important one is the optomic artery well the risk of occluding the opthalmic artery is around 15 to 20 percent but the majority of those are not symptomatic flow diversion for bifurcating aneurysms usually flow diversion is only for sidewall aneurysms but you can use it in bifurcating andersons if you don't have any better option this is the case of an mca a fusiform aneurysm that was clipped and recurred as i said once the anisome is clipped you need to avoid going back to try to do an open surgery because of of the risk of injuring the brain with fibrosis and and adhesions and this in this case we we use the flow diverter the pipeline you see the remodeling of the vessels this is a big giant aneurysm where this the whole mca is all ballooned up this is a really big problem to have because you cannot replace the vessel what are our options here the open option is to shut down the vessel and do a bypass with the risk of having thrombosis of the bypass and major stroke and what we did is we placed the flow diverter all the way with some coals and this is the remodeling of of the vessel another distal fusiform aneurysm that we treated with pipeline you see the pipeline the stent here another pca aneurysm on a patient where what we did is we placed two pipeline and you see here completely remodeled and the aneurysm is gone a pica distal aneurysm where before that the only option here would be to shut down the vessel and do a picatu pica bypass we were able to remodel it with a flow diverter all the way here and then this is our series in in pica aneurysms and distal brain aneurysms treated with flow diversion originally when the fda approved the pipeline on label was only aneurysms of the internal carotid artery but then as i said we started using it as more this in more distant vessels and it showed that it is efficacious pipeline for ruptured aneurysms we try to avoid that why because those are ruptured aneurysms and you need to load the patient with plavix and baby aspirin which can be dangerous but in cases we showed that in cases where you don't have a better option for those aneurysms pipeline could be a an option this is a case of a ruptured aneurysm from a dissecting vertebral basilar junction dissecting aneurysm that's the dissection in this case the open option is to go in once you open it well you see that the vessel is completely damaged you don't have any other option than shutting it down with pipeline you have the option of reconstructing it by placing telescoping pipelines in this and that's what we did and reconstructed the vessel another case of an mca ruptured aneurysm you what you see here is calcification and those are the most complex and challenging one to treat because they are like a piece of rock this is not a cta this is not with contrast this is a ct head showing this hyper density it means this is calcification in this case you see that's what's the part that's filling and we decided to use a flow diverter to treat that you see the complete occlusion that's the flow diverter and you see here on regular x-ray this calcification when the anus was and you see the pipeline there another case of a pica this plastic aneurysm it's a fusiform dissecting aneurysm really nasty again we were able to place a pipeline and then reconstruct the vessel as you see here the vessel is all reconstructed you don't see the aneurysm anymore and this used to be a no-no before it's like a ruptured anisome you cannot use a flow diverter or a small vessel like this you cannot use a flow diverter but more and more we know that it is safe to do that when you have you don't have a better option this is a ruptured aneurysm from a blister mid basilar ruptured aneurysm as you see here open surgical option nearly inexistent it's really challenging with high risk what we did is we treated it with pipeline you see the complete remodeling of the vessel and the nice result so treating blister like aneurysm with pipeline is is a great option whenever you don't have a better option for that hey everyone ryan rad here from neurosurgerytraining.org if you like that video subscribe and donate to keep our content available for medical students across the world