UNASSIGNED: Currently, endovascular treatment of intracranial aneurysms (ICAs) is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded the applicability of endovascular therapy; however, the superiority of novel embolic devices over the traditional Guglielmi detachable coils (GDCs) is still debated. We performed a systematic review of literature that reported Raymond-Roy occlusion classification (RROC) rates of modern endovascular devices to determine their immediate and follow-up occlusion effectiveness for the treatment of unruptured saccular ICAs.
UNASSIGNED: A search was conducted using electronic databases (PUBMED, Cochrane, ClinicalTrials.gov, Web of Science). We retrieved studies published between 2000-2022 reporting immediate and follow-up RROC rates of subjects treated with different endovascular ICA therapies. We extracted demographic information of the treated patients and their reported angiographic RROC rates.
UNASSIGNED: A total of 80 studies from 15 countries were included for data extraction. RROC rates determined from angiogram were obtained for 21,331 patients (72.5% females, pooled mean age: 58.2 (95% CI: 56.8-59.6), harboring 22,791 aneurysms. The most frequent aneurysm locations were the internal carotid artery (46.4%, 95% CI: 41.9%-50.9%), the anterior communicating artery (26.4%, 95% CI: 22.5%-30.8%), the middle cerebral artery (24.5%, 95% CI:19.2%-30.8%) and the basilar tip (14.4%, 95% CI:11.3%-18.3%). The complete occlusion probability (RROC-I) was analyzed for GDCs, the Woven EndoBridge (WEB), and flow diverters. The RROC-I rate was the highest in balloon-assisted coiling (73.9%, 95% CI: 65.0%-81.2%) and the lowest in the WEB (27.8%, 95% CI:13.2%-49.2%). The follow-up RROC-I probability was homogenous in all analyzed devices.
UNASSIGNED: We observed that the coil-based endovascular therapy provides acceptable rates of complete occlusion, and these rates are improved in balloon-assisted coils. Out of the analyzed devices, the WEB exhibited the shortest time to achieve >90% probability of follow-up complete occlusion (~18 months). Overall, the GDCs remain the gold standard for endovascular treatment of unruptured saccular aneurysms.

OBJECTIVE: The recent introduction of the Woven EndoBridge (WEB) has presented an alternative treatment modality for intracranial bifurcation and wide-neck aneurysms with a growing body of literature evaluating its efficacy. However, no previous systematic review has focused on comparing WEB with previously using endovascular approaches, specifically primary coiling (PC) and stent-assisted coiling (SAC). Herein, the authors present the first systematic review summarizing available literature to reach a consensus regarding the safety and effectiveness of WEB.
METHODS: A systematic review of articles identified through a search of PubMed, Embase, Scopus, and Web of Science was conducted. Studies were included if they compared WEB with PC or SAC from any aspect for intracranial aneurysms. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies-of Interventions tool. Meta-analyses of the outcomes based on stent use and rupture status were performed.
RESULTS: A total of 16 studies were included. The three endovascular approaches were comparable in terms of baseline characteristics except for older age and smaller aneurysm neck in the PC group (p < 0.05). Moreover, the follow-up duration was shorter in the WEB group (p < 0.05). Although the WEB group demonstrated lower complete and adequate immediate occlusion rates (p < 0.01), the rates at follow-up evaluations were comparable with SAC and PC (p = 0.61 and p = 0.27, respectively). The WEB group experienced significantly fewer unfavorable neurological outcomes than the SAC group (p = 0.04), while comparable to the PC group (p = 0.36). Retreatment rates were comparable between WEB and coiling (p = 0.92). The WEB group had fewer hemorrhagic and thromboembolic complications (p < 0.01 and p = 0.01, respectively), with similar neurological and procedure-related complications compared with combined PC and SAC groups. Lastly, mortality was comparable among the different endovascular approaches.
CONCLUSIONS: This study provides evidence on the noninferiority of WEB compared with PC and SAC in terms of angiographic outcomes. Meanwhile, our findings on lower complication rates, cost, and improved operative aspects associated with WEB establish this novel endovascular treatment as a safe and effective alternative for the treatment of bifurcation and wide-neck aneurysms.

BACKGROUND: The Woven EndoBridge (WEB) device is a minimally invasive endovascular treatment option for patients with cerebral aneurysms. Transradial access (TRA) is a technique that involves accessing the arterial system through the radial artery in the wrist rather than the femoral artery in the groin. Several studies have investigated the use of TRA for WEB device deployment in treating intracranial aneurysms.
METHODS: A systematic review was conducted to evaluate the TRA for WEB device deployment in treating intracranial aneurysms. The databases PubMed, Cochrane, Embase, Scopus, and Web of Science were searched. To reduce the risk of bias, this systematic review only included studies reporting on using TRA in WEB device deployment for intracranial aneurysm treatment with a minimum of four patients.
RESULTS: In this systematic review, 186 patients were included across five studies, with TRA used in 183 cases analyzed. The study population had a higher proportion of females (n = 118%-69%) than males, with a mean age of 62 years old. Among the aneurysms treated, 46 were ruptured, and 119 were located at bifurcation sites, with a mean maximum diameter/width of 6.6 mm and mean height of 5.9 mm. Adjunctive coiling was used in three cases, and adjunctive stenting was used in nine cases. In two cases, conversion to a femoral artery access was necessary.
CONCLUSIONS: The available results suggest TRA with the WEB device is a safe and effective alternative. However, using TRA versus TFA should be individualized based on patient factors and operator experience.

The invested effort and collaboration of clinicians and medical device companies to improve occlusion rates and clinical outcomes for patients with intracranial aneurysms treated via less invasive endovascular means led to the development of the concept of intrasaccular devices. Intrasaccular devices were introduced to offer simple treatment options, offering easier navigation through difficult anatomy, simpler and quicker deployment into large and wide-neck aneurysms. Additionally, they offer easier sizing, whilst offering a wide range of options suitable for aneurysms of different sizes. The concept of most intrasaccular devices is to occupy the aneurysm neck, however offering better stability than simple coiling, therefore increasing the chance of long-term aneurysm occlusion. This is achieved without a sizable metal content within the parent vessel, contrary to flow diverters, theoretically reducing the risk of thromboembolic events. This review aims to discuss the history and latest developments of intrasaccular intracranial devices, which offer an exciting and potentially successful option for treatment of complex intracranial aneurysms.

The Woven EndoBridge (WEB) device is designed for intrasaccular flow disruption for embolization of intracranial aneurysms. In limited experience so far, the rate of rupture after adequate occlusion by embolization has been low.
A 58-year-old man initially had an incidental, unruptured 10.4-mm anterior communicating artery aneurysm treated with WEB embolization. Although his 6 months follow-up angiogram showed adequate occlusion of the aneurysm, he presented to our facility with aneurysmal recurrence caused by WEB compaction and rupture. This condition was treated with surgical clipping of the aneurysm. The literature was systematically reviewed for cases of delayed rupture after WEB embolization. Statistical analyses included studies with at least 20 patients and follow-up of 3 months.
We identified 36 studies, which were primarily retrospective observational studies. The rate of complete occlusion ranged from 33% to 89%, and the rate of re-treatment ranged from 1.5% to 27%. Across 4 studies, the rate of recanalization ranged from 8.7% to 13%. Two cases of delayed rupture were reported; an additional 4 cases were found in case reports and case series. In only 1 previous case, the aneurysm was reported as previously untreated.
Early retrospective data have begun to define the history of WEB-treated aneurysms. Rupture of a previously unruptured, WEB-treated aneurysm with adequate initial occlusion is rare. We describe such a case with techniques for management, showing that aneurysm recurrence and delayed rupture are possible despite good interim angiographic results. This report raises questions about follow-up for WEB-treated aneurysms.

The Woven EndoBridge (WEB) device is a barrel-shaped nitinol mesh deployed within the aneurysmal sac. The absence of metallic mesh in the aneurysm\'s parent vessel lumen obviates the need for potent antiplatelet therapy, making this device appealing for acutely ruptured aneurysms not amenable to clipping or coiling. To assess the literature regarding WEB treatment of these aneurysms, we performed a comprehensive systematic search of PubMed, MEDLINE, and EMBASE databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Keywords were combined with Boolean operators to increase search sensitivity and specificity (\'woven endobridge device\' AND \'ruptured\'). Nine studies comprising 377 acutely ruptured aneurysms were included. Overall, 82.7% were wide-necked, 85.9% were located in the anterior circulation, and 26.9% of patients presented with poor subarachnoid hemorrhage grade. Intraprocedure and postprocedure complications occurred in 8.4% (95% CI 3.6% to 13.3%) and 1% (95% CI 0% to 2%), respectively. The post-treatment rebleeding rate was 0%. Rates of adequate occlusion (complete occlusion to neck remnant) and retreatment at last follow-up were 84.8% (95% CI 73% to 96.6%) and 4.5% (95% CI 2.2% to 6.8%), respectively. The favorable outcome rate (modified Rankin Scale score 0-2) was 62.2% (95% CI 53% to 71.4%); mortality was 13.6% (95% CI 9.7% to 17.6%). WEB treatment of acutely ruptured aneurysms results in high adequate occlusion rates, low perioperative complication rates, no rebleeding, and low recurrence requiring retreatment. This device is promising for acutely ruptured aneurysms not amenable to clipping or coiling, considering the lower need for antiplatelet regimens during the procedure or follow-up.

OBJECTIVE: The clinical outcome and angiographic outcome data of Woven EndoBridge (WEB) device for the treatment of ruptured intracranial aneurysms (IAs) are limited. We conducted a meta-analysis of the latest literature on the WEB device in the treatment of ruptured IAs.
METHODS: A comprehensive literature search of 4 databases (PubMed, Web of Science, Cochrane library, and Embase) was conducted for studies published from January 1, 2010 to December 31, 2020. Two reviewers independently extracted variables (aneurysm and patient characteristics) using a prespecified data-collection sheet. Outcomes studied included initial and latest follow-up angiographic outcomes, technical success rate, perioperative mortality, retreated rate, perioperative re-bleeding, complication, intraoperative rupture, favorable neurologic outcome at discharge. We used random-effects model to pool the data.
RESULTS: We finally presented the results of 7 articles including 276 patients with 283 aneurysms. Initial complete and adequate occlusion rate were 38% (95% CI, 25%-50%) and 98% (95% CI, 95%-100%), respectively. Latest follow-up complete and adequate occlusion rate were 61% (95% CI, 46%-75%) and 91% (95% CI, 84%-98%), respectively.Technical success rate was 99% (95% CI, 98%-100%). Perioperative mortality rates and perioperative re-bleeding rate were 9% (95% CI, 3%-15%) and 1% (95% CI, 0%-2%), respectively. Retreated rate was 6% (95% CI, 3%-10%). Overall and WEB treatment-related thromboembolic complication was 10% (95% CI, 6%-13%) and 7% (95% CI, 2%-12%), respectively. Intraoperative rupture rate was 3% (95% CI, 0%-6%).
CONCLUSIONS: Endovascular treatment of ruptured IAs with the WEB device has a good safety profile and an acceptable aneurysm occlusion rate.

OBJECTIVE: The Woven EndoBridge is an intrasaccular device for the treatment of intracranial aneurysms. The first generation consisted of a high-profile double-layer braid. This review aims to evaluate the outcomes of the new generation low-profile Woven EndoBridge single layer device for intracranial aneurysm treatment.
METHODS: A systematic review was conducted with Medline, Embase, and Web of Science Conference Proceedings databases. The search strategy provided 589 articles, 15 articles were included.
RESULTS: Fifteen articles were identified reporting the use of Woven EndoBridge single-layer devices in 963 aneurysms, mostly wide-necked bifurcation aneurysms. Procedural aneurysm rupture was reported in 8 of 963 patients (0.83%; 95%CI 0.39-1.66%) and thromboembolic events in 54 of 963 patients (5.61%, 95CI 4.31-7.26%). Cumulative morbidity was 2.85% (27/949, 95%CI 1.95-4.12%) and mortality 0.93% (9/963, 95%CI 0.46-1.80%). The overall rate of adequate aneurysm occlusion at last follow-up was 83.3% (613/736; 95%CI 80.4-85.8%). Retreatment was reported in 38 aneurysms in eight studies with 450 aneurysms with follow-up (38/450; 8.4%, 95CI 6.2-11.4%). In 12 studies comprising 644 aneurysms with follow-up, rebleeds occurred in three patients in three studies with mean follow-up between 3.3 and 14.4 months (0.47%, 95%CI 0.09-1.43%).
CONCLUSIONS: Woven EndoBridge single-layer is a promising new low-profile device especially for wide-neck bifurcation aneurysms, both ruptured and unruptured. No antiplatelet medication is needed which is a great advantage, especially in ruptured aneurysms. Efficacy and safety compare favorably with (stent-assisted) coiling. However, no direct comparison with other treatments is available as yet.

OBJECTIVE: To assess the current efficacy, safety, and risk factors of the Woven EndoBridge (WEB) in treating wide-neck intracranial aneurysms.
METHODS: We searched the PubMed, Ovid MEDLINE, and Embase databases between December 1, 2012 and June 30, 2018. Studies were included if they featured ≥5 patients undergoing WEB for wide-neck intracranial aneurysms, reported an angiographic or clinical outcome and risk factors, and were published after December 1, 2012. Major outcomes included initial or short-term complete and adequate occlusion. Secondary outcomes included treatment failure, recanalization, mortality, morbidity, and complication rates. A random-effect model was used to pool the data. To assess risk factors for short-term angiographic outcomes and the most common complications, we conducted subgroup analyses.
RESULTS: We included 36 studies (1759 patients with 1749 aneurysms). The initial complete and adequate occlusion rates were 35% and 77%, respectively. The short-term (mean follow-up, 9.34 months) complete and adequate occlusion rates were 53% and 80%, respectively. Thromboembolism and recanalization had the highest occurrence (both 9%), followed by mortality (7%), morbidity (6%), failure (5%) and intraoperative rupture (3%). The following factors were related to higher short-term obliteration rates: unruptured status, in the anterior circulation, a medium neck (4-9.9 mm), newer-generation WEB, and treatment without additional devices. Ruptured status, anterior circulation, preoperative antiplatelet therapy, and newer-generation WEB were not significantly related to thromboembolism.
CONCLUSIONS: WEB is safe and shows promising efficacy in treating wide-neck intracranial aneurysms. We preliminarily identified several risk factors for short-term angiographic outcomes.

OBJECTIVE: The Woven EndoBridge (WEB) device is an innovative tool for endovascular treatment of wide-necked bifurcation aneurysms. Numerous studies of primary aneurysm treatment with the WEB device have been reported. We analyzed the safety and efficacy of WEB embolization for recurrent and residual aneurysms.
METHODS: We performed a retrospective observational study of consecutive patients with initially endovascularly or surgically treated aneurysms and an aneurysm recurrence or remnant retreated with the WEB device at 3 German high-volume neurovascular centers from May 2011 to February 2018. The technical success, complications, and angiographic outcomes were evaluated.
RESULTS: Eleven patients (median age, 65 years; 5 women) with 11 aneurysms (median size, 6.8 mm) were identified. The aneurysms were located at the anterior communicating artery in 4, basilar tip in 4, internal carotid artery in 1, middle cerebral artery in 1, and posterior communicating artery in 1 patient. Three aneurysms had been previously clipped and 8 had undergone endovascular therapy. WEB embolization was feasible in 10 patients. Ancillary devices were used for 4 aneurysms. Perforation occurred in 1 aneurysm, which resolved without sequelae. Of the 9 patients available for angiographic follow-up (median follow-up, 6 months), complete and near-complete aneurysm occlusion was achieved in 3 (33%) and 7 patients (78%), respectively. Three patients underwent repeat treatment (33%).
CONCLUSIONS: The results of the present study have indicated that WEB embolization of previously treated aneurysms is reasonably safe. However, careful aneurysm selection could be necessary to achieve adequate mid-term occlusion rates.