New Devices and Techniques
J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2019-015338 on 21 September 2019. Downloaded from http://jnis.bmj.com/ on April 19, 2023 at ESMINT. Protected by
1
Radiology Department, UH St
Ivan Rilski, Sofia, Bulgaria
2
Neurosurgery Department, UH
St Ivan Rilski, Sofia, Bulgaria
3
Department of Neurology and
Comprehensive Stroke Center,
University of California Los
Angeles David Geffen School
of Medicine, Los Angeles,
California, USA
Correspondence to
Dr Radoslav Raychev, UCLA
Department of Neurology and
Comprehensive Stroke Center,
Los Angeles, CA 90095, USA; ​
rudoray@​gmail.​com
SS and RR contributed equally.
Received 31 July 2019
Revised 27 August 2019
Accepted 2 September 2019
Published Online First
21 September 2019
© Author(s) (or their
employer(s)) 2020. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
To cite: Sirakov S, Sirakov A,
Minkin K, et al.
J NeuroIntervent Surg
2020;12:303–307.
Case series
Early clinical experience with Cascade: a novel
temporary neck bridging device for embolization of
intracranial aneurysms
Stanimir Sirakov,1 Alexander Sirakov,1 Krasimir Minkin,2 Vasil Karakostov,2
Radoslav Raychev  ‍ ‍3
Abstract during coil embolization, has recently emerged as
Background  Temporary placement of a retrievable a new and attractive alternative to placement of
neck bridging device, allowing parent vessel flow, is an occlusive balloons.6–8 Here, we describe our initial
attractive alternative to balloon remodeling for treatment experience with the recently introduced Cascade
of ruptured intracranial aneurysms. non-­occlusive neck bridging device in the treatment
Objective  To present, in a single-­center study, our of ruptured wide-­neck intracranial aneurysms.
initial experience with Cascade (Perflow, Israel) in the
treatment of ruptured intracranial aneurysms.
Methods  During a period of 1.5 months, 12 patients Materials and methods
with aneurysmal subarachnoid hemorrhage underwent Cascade is a new non-­ occlusive fully retrievable
coil embolization in conjunction with Cascade in our neck bridging device, designed to provide tempo-
rary support during coil embolization of intracra-
center. Retrospective analysis of prospectively collected
nial aneurysms. This braided device is composed
angiographic and clinical data was conducted to assess
of 42 interwoven nitinol and platinum wires,
the safety and efficacy of the device.
Results  Among all treated patients, 41.7% (5/12) forming a net-­like compliant structure with variable
were female, the median age was 55 (47–77) years, thecell porosity that persistently maintains a cell size
median aneurysm dome size was 5.75 mm (3–9.1), and of <0.3 mm2 (figure 1). The ultra-­thin wire braid
structure is produced in a specific way to allow easy
copyright.
the median neck size was 3.55 mm (2.3–7.9). Complete
adjustment of the braid through controlled expan-
obliteration (Raymond 1) was achieved in 75% (9/12) of
sion and partial resheathing, providing a working
cases, and intentional residual neck (Raymond 2) was left
length of 37 mm while the braid is fully collapsed,
in three cases (25%). None of the patients received any
and 10 mm while fully expanded. Optimal neck
oral or intravenous antiplatelet therapy perioperatively.
coverage is achieved by actively adjusting both the
No thromboembolic complications, device-­related spasm,
diameter (0.5–6 mm, controlled by handle manip-
vessel perforation, or coil entanglement were detected in
any of the treated patients. ulation) and length (by partial unsheathing or
Conclusions  In our initial experience, treatment of resheathing) of the braided net. The platinum wires
allow visibility of the device. Both ends of the device
wide-­neck ruptured intracranial aneurysms with Cascade
is safe and effective, without the need for adjuvant include radiopaque markers for its optimal visi-
bility and precise positioning. The device is deliv-
antiplatelet therapy. Long-­term follow-­up data in larger
ered in a collapsed form through a microcatheter
cohorts are needed to confirm these preliminary findings.
and subsequently expanded via a control handle.
The control handle has two modes: (1) auto-­lock
(‘ratchet’) mode for stepwise radial expansion, and
Introduction (2) continuous mode for more smooth and gradual
Effective coil embolization of ruptured wide-­ expansion that can also provide tactile feedback. A
neck intracranial aneurysms with unfavorable small radiopaque atraumatic soft tip extends from
morphology remains challenging owing to the the distal end of the device, designed for improved
limited applicability of stents and the conse- visibility, trackability, and anatomic orientation.
quent need for dual antiplatelet therapy (DAPT) Figure 2 illustrates all components of the device.
in the setting of subarachnoid hemorrhage Cascade is compatible with a 021 microcatheter
(SAH).1 Balloon-­ assisted temporal neck bridging and is available in two sizes: (1) M—recommended
during intrasaccular coil delivery has been a well-­ vessel diameter 2–4 mm; and (2) L—recommended
established technique for treatment of these lesions vessel diameter 4– 6 mm. The device received a CE
as a better choice to permanent stent implanta- mark of approval in the third quarter of 2018.
tion.2 3 However, the inevitable occlusion of the In this single-­center study, we present our initial
parent vessel associated with this technique, poses experience with this new device in the treatment of
risks of ischemic complications due to compromised ruptured intracranial aneurysms, focusing on aneu-
downstream perfusion, blockage of perforators, and rysm obliteration, parent vessel interaction, and
thrombus formation during the balloon inflation.4 5 thromboembolic complications.
The application of devices offering temporal neck We performed retrospective analysis of prospec-
bridging, while maintaining parent vessel patency tively collected data. Between May 15 and June 30,
Sirakov S, et al. J NeuroIntervent Surg 2020;12:303–307. doi:10.1136/neurintsurg-2019-015338    303
 New Devices and Techniques

J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2019-015338 on 21 September 2019. Downloaded from http://jnis.bmj.com/ on April 19, 2023 at ESMINT. Protected by
complications
†Technical

N
N
N
N
N
N
N
N
N
N
N
N
occlusion scale complications
*Clinical

N
N
N
N
N
N
N
N
N
N
N
N

†Technical complications included any intraoperative aneurysm rupture, parent vessel perforation, device-­induced dissection, device thrombosis, distal emboli, device-­induced spasm, and coil entanglement.
expansion time Raymond’s

*Clinical complications included any neurologic deterioration from the immediate postoperative period until discharge (not related to vasospasm), including signs and symptoms of rerupture, or death.
2
2
1
1
1
1
2
1
1
1
1
1
Device

Cascade model Number of coils (min)

Figure 1  Drawing of Cascade methodology: the device is expanded

7.5

6.5

10
10
10
10
across the neck of a basilar tip aneurysm to provide temporary support

9
5
7
7
9

AComA, anterior communicating artery; ICA, internal carotid artery; MCA, middle cerebral artery; PComA, posterior communicating artery; SCA, superior cerebellar artery.
during coil embolization.

2019, a total of 12 patients with aneurysmal SAH underwent

coil embolization in conjunction with Cascade in our center.

6
7
3
4
4
3
5
7
9
5
7
6
All patients were selected based on aneurysm characteristics,
which included aspect ratios  ≤1.2, and/or unfavorable aneu-
rysm morphology associated with a high risk of potentially non-­
satisfactory obliteration after primary coiling as deemed by the
primary operator. The following baseline characteristics were

M
M
M
M
M
M
M

M
L
L

L
recorded: patient age, gender, clinical presentation (Hunt and

copyright.
Hunt and Hess

Hess grade), SAH volume and extension (Fisher grade), aneu-

rysm location, aneurysm dome size, aneurysm neck size. Tech-
nical, angiographic, and clinical variables included the type of
Cascade device used, duration of time during which the device

3
1
3
3
2
1
2
1
1
3
2
3
remained expanded (device expansion time), aneurysm obliter-
ation (Raymond’s scale), clinical complications (any neurologic
Fisher grade

deterioration from the immediate postoperative period until

discharge, signs and symptoms of rerupture, or death), technical
complications (intraoperative aneurysm rupture, parent vessel
3
3
3
2
3
2
3
2
3
3
2
4

perforation, device-­induced dissection, device thrombosis, distal

Height (mm)

emboli, device-­induced spasm, coil entanglement) (table 1).

Procedural and technical details 

4.6
4.3
9.1
6.7
4.2
8.9
5.8
5.1
6.6
7.3

Written informed consent was obtained from every patient and their
6
4

relatives before each endovascular session according to local institu-

Table 1  Patient characteristics and procedural outcomes.

Dome (mm)

tional policy. The decision to perform each endovascular emboliza-

tion was based on consensus by the institutional multidisciplinary
team of interventional neuroradiologists, neurologists, and neuro-
3.2
5.5
8.4
8.9
9.1
5.1
5.1

7.9

3
7

6
5

surgeons. All procedures were performed under general anesthesia

on a biplane angiographic unit (Innova GE Healthcare 31 31 IQ
Neck (mm)

biplane). The patient’s systolic blood pressure during and after the
procedure was controlled and maintained between 90 and 120 mm
Hg in order to prevent aneurysm rerupture before satisfactory oblit-
4.8
7.9
2.3
2.9
3.2
3.3
3.3
4.9
7.4
3.1
3.8

eration. Nine of 12 (75%) lesions were accessed through distal radial

access, and right femoral access was used in three patients. After
Location

AComA
AComA
AComA

PComA
PComA
R MCA

R MCA

R MCA
ICA C6

ICA C6

R SCA
L SCA
Patient No

10
11
12

Figure 2  Cascade: schematic drawing of all device components.

9
4
5
6
7
8
1
2
3

304 Sirakov S, et al. J NeuroIntervent Surg 2020;12:303–307. doi:10.1136/neurintsurg-2019-015338


Figure 3  A 5 mm ruptured anterior communicating artery aneurysm with a small daughter sac (A and B). Cascade size M was deployed across the
aneurysm neck (C). The black arrow points to the distal tip of the device. The white arrow points to the jailed microcatheter, which is positioned in the
aneurysm sac. Final postinterventional angiogram shows complete obliteration with widely patent parent vasculature (D).
completion of diagnostic angiography, the diagnostic catheter was
exchanged over an exchange-­length wire for a 6 French Softip XF
guide catheter. In general, the guide catheter was positioned in the
pre-­petrous portion of the internal carotid artery or distal cervical
vertebral artery segment and connected to a pressurized infusion
bag of normal saline containing 10 mL of nimodipine solution and
5000 IU of heparin. A 3-­dimensional angiogram was obtained and
postprocessed at a separate station. Once the aneurysm morphology
was evaluated, a 0.021 inch microcatheter (Headway 21 or Rebar
18) was navigated into the parent vessel just distal to the aneurysm
location. Next, a 0.010 inch microcatheter (Echelon 10) was used
to catheterize the aneurysm.
Once the aneurysm was catheterized, the Cascade device was
introduced into the 0.021 inch microcatheter and deployed across
the jailed 0.010 inch microcatheter covering the aneurysm neck.
The device was deployed in its collapsed shape by completely
unsheathing the microcatheter. Next, the Cascade was inflated/
expanded using the control handle attached to the proximal shaft
of the device. Similar to other braided stents, the Cascade has vari-
able porosity, which is proportional to the device elongation and
foreshortening, and controlled via the handle. Thus, targeted over-
expansion and/or denser neck coverage was employed to achieve
the desired aneurysm obliteration in selected cases. The device was
collapsed before detachment of the initial framing coil to ensure
stable intra-­aneurysmal positioning and no parent vessel protrusion.
Once stable framing coil positioning was ensured, the device was
re-­expanded. The handle was locked once satisfactory expansion
and aneurysm neck coverage was achieved. Next, sequential coil
delivery was performed through the jailed microcatheter (figure 3).
Multiple control angiograms were obtained during the coil embo-
lization, while the device remained expanded across the aneurysm
neck. Special attention was paid to device thrombosis, distal emboli,
parent vessel dissection, and distal tip-­induced spasm. Once satis-
factory obliteration was achieved, the device was deflated/collapsed
under live fluoroscopy to assess coil mass stability. A final control
angiogram was obtained before detaching the last coil.
Results
Of the 12 treated patients, 41.7% (5/12) were female, the median
age was 55 (47–77), the median aneurysm dome size was 5.75 mm
(3–9.1), and the median neck size was 3.55 mm (2.3–7.9). Details
of the procedural results and patients’ characteristics are listed in
table 1. Complete obliteration (Raymond 1) was achieved in 75%
(9/12) of all cases. In three of the 12 cases (25%), residual neck
(Raymond 2) was left intentionally in order to avoid ischemic
Sirakov S, et al. J NeuroIntervent Surg 2020;12:303–307. doi:10.1136/neurintsurg-2019-015338
New Devices and Techniques
J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2019-015338 on 21 September 2019. Downloaded from http://jnis.bmj.com/ on April 19, 2023 at ESMINT. Protected by
complication due branch occlusion. None of the patients received
any oral or intravenous antiplatelet therapy perioperatively for the
prevention of thrombotic complications. As indicated in the proce-
dural and technical details, no additional intravenous heparin was
given beyond the standard dose used in our institution for all inter-
ventional procedures. No technical difficulties of inflation/expan-
sion and retraction/deflation associated with the control handle
occurred. No evidence of thrombus formation was seen during
device deployment as shown by multiple control angiograms. Addi-
tionally, no evidence of distal emboli on the final angiograms was
seen. No device-­related spasm, vessel perforation, or coil entan-
glement was detected. The distal tip remained straight with no
copyright.
evidence of deflection or interaction with the parent vessel during
device expansion. Overall, no technical or clinical complications
were observed.
Discussion
Many endovascular techniques for treatment of intracranial aneu-
rysms have emerged since the introduction of the revolutionary
coil embolization as a superior methodology to surgical clipping.9
From the inception of the first coiling procedure to the most
recently advanced technology, the aneurysm embolization method-
ology relies on the principle of quick intra-­aneurysmal thrombosis
with subsequent endothelialization across the neck and restoration
of normal parent vessel anatomy.10 11 This healing effect can be
achieved by intra-­aneurysmal filling and/or flow diversion through
various intrasaccular and neck covering devices.12
Coiling remains the most commonly used intrasaccular treat-
ment, with predictable clinical and angiographic outcomes and
safety, especially in cases with favorable anatomy. However,
effective coil embolization of wide-­ neck intracranial aneu-
rysms (WNAs) with low aspect ratios remains challenging
owing to a high probability of perioperative complications
and post-­treatment recurrence. This often requires adjunctive
neck  bridging devices to support the intrasaccular coils and/or
provide flow diversion effect.13–15 Despite the more durable effect
of permanent stenting, the risk of thromboembolic complica-
tions remains a considerable limitation and requires a 3–6 month
course of DAPT, which has its own independent hemorrhagic
risk.16 These limitations associated with stent-­assisted coiling and
flow diversion are particularly relevant in patients with ruptured
WNAs. SAH is independently associated with high throm-
botic risk and also limits the applicability of DAPT, especially
in the presence of a ventriculostomy drain.17 Balloon remod-
eling is a well-­established treatment of ruptured WNAs and a
305
 New Devices and Techniques
Figure 4  Cascade versus Comaneci in their expanded versions.
Cascade remains straight (thin arrow), whereas Comaneci (thick
arrow) deflects during expansion. Cascade has a visibly denser net
than Comaneci.
reasonable alternative to stenting.3 However, the parent vessel
occlusion associated with this balloon-­ assisted embolization,
poses serious risks of ischemic complications due to compromised
downstream perfusion, blockage of side-­wall perforators at the
occluded segment, and thrombus formation during the balloon
inflation.4 5 Given these serious disadvantages, other alternative
technical solutions for endovascular treatment of WNAs have
emerged in recent years. The main goal of these new techniques
is to reduce the complexity of the procedure, improve oblitera-
tion rates, and reduce the amount of metal in the parent vessel.
One such method is the placement of a temporal neck bridging
device, which allows parent vessel flow during intrasaccular
Figure 5  A 6 mm left para-­ophthalmic ruptured intracranial aneurysm
(A). Cascade L was placed across the neck and temporarily expanded
(B). Significant intra-­aneurysmal flow stagnation was noted immediately
after device expansion (C). The device was then collapsed, and the
aneurysm was catheterized (D). The device was re-­expanded, followed
by coil embolization through the jailed microcatheter (E). Complete
obliteration was achieved (F).
306 Sirakov S, et al. J NeuroIntervent Surg 2020;12:303–307. doi:10.1136/neurintsurg-2019-015338
J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2019-015338 on 21 September 2019. Downloaded from http://jnis.bmj.com/ on April 19, 2023 at ESMINT. Protected by
embolization.6 Recent clinical experience with the Comaneci
temporal neck bridging device demonstrated that this method-
ology can result in satisfactory and durable embolization.8
The Comaneci device (Rapid Medical, Israel) is similar to
Cascade. However, the two main distinguishing technical
features of Cascade as compared with Comaneci are its denser
aneurysm neck coverage and the absence of device/distal tip
deflection during expansion (figure 4). Based on our experi-
ence with over 100 patients treated with Comaneci, these tech-
nical features are important differences in performance during
embolization, including device deflection-­induced spasm, coil
entanglement, and navigability. It is important to emphasize that
these observations are based only on personal opinion and do
not represent statistically validated conclusions. As noted during
the initial experience with Comaneci, deflection of the device
(and particularly its distal tip) can produce significant nearly
occlusive spasm during expansion.8 We did not observe this
phenomenon in the present case series with the Cascade. We
also noted excellent compliance with the parent vessel geom-
etry during expansion. Another much less frequent, but also
important concern associated with Comaneci is occasional coil
entanglement, requiring careful manipulation and close observa-
tion during device expansion and retraction. Coil entanglement
was not noted in our experience with Cascade, probably owing
to the braid composition with denser net and more robust aneu-
rysm neck coverage. This unique feature of the device can also
explain the temporal intra-­aneurysmal flow stagnation observed
in one of the cases, which may promote accelerated aneurysm
thrombosis in conjunction with coiling (figure 5).
Conversely, an important advantage of Comaneci over
Cascade is its compatibility with a 0.017 inch microcatheter,
copyright.
allowing smoother navigation in tortuous anatomy. The current
version of Cascade is compatible only with 0.021 inch or larger
internal diameter microcatheters. In some patients with more
prominent tortuosity, there was notable tension on the entire
system during introduction of the device within the microcath-
eter. In those cases, placement of smaller profile device would
have been preferred for ease of navigability. Nevertheless, all
devices in our series were navigated and deployed successfully
without any technical complications.
Limitations
This is the first reported clinical experience with Cascade in
the treatment of ruptured WNAs, but our data have important
limitations. First, this was a single-­center study and the tech-
nical results are limited by the authors’ individual technique and
experience. Second, the sample size is relatively small. Third,
the clinical and angiographic outcomes are limited only to the
periprocedural period without any long-­term data for aneurysm
recanalization and rerupture.
Conclusions
In our initial experience, Cascade is a safe and effective tool
for adjunctive coil embolization of ruptured WNAs with no
evidence of periprocedural device-­ related complication and
an acceptable occlusion rate. However, larger multicenter series
with long-­term follow-­up data are needed to confirm the clinical
benefit of this new device.
Contributors  SS interpreted the data, drafted a significant portion of the
original manuscript, reviewed all suggestions provided by all coauthors, approved
the final version, and agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved. RR composed the final version
of the manuscript and assumed responsibility for final review and submission

as a corresponding author. AS, KM, VK provided a substantial contribution to
interpretation of the provided data, contributed with revisions to the original draft,
approved the final version of the manuscript, and agreed to be accountable for all
aspects of the work.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
Data sharing statement  All presented data are available upon request
ORCID iD
Radoslav Raychev http://​orcid.​org/​0000-​0001-​8463-​0664
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