Endovascular treatment of ruptured blood blister-like aneurysms with multiple (≥3) overlapping Enterprise stents and coiling

Background: Blood blister-like aneurysms (BBAs) are difficult to treat both surgically and endovascularly, and the optimal treatment remains controversial. The aim of this study was to evaluate the clinical and angiographic feasibility of multiple overlapping stents (≥3) with coiling for treating BBA. Methods: A retrospective review from four institutions identified ten patients with ruptured BBAs who were treated with multiple overlapping stents (≥3). We included both the patients who were initially treated with more than three stents and those who eventually had more than three stents as a consequence of retreatment. Angiographic results (Raymond scale), clinical outcomes (mRS) and treatment courses were evaluated. Results: Initially, seven patients were treated with triple stents and three with double stents. Immediate angiographic results revealed that six aneurysms were Raymond grade 1, three were grade 2, and one was grade 3. Complementary treatment was required in four patients. All three patients who were initially treated with double stents required complementary treatment (100 %). One patient required complementary treatment among the seven patients who were initially treated with three stents (14.3 %). The last follow-up angiography (mean, 12.2 ± 14.7 months; range, 1–44 months) revealed grade 1 in all ten patients. Clinical data (mean follow-up period, 18.2 ± 20.1 months; range, 1–62 months) revealed eight patients with a mRS score of 0–2 and two with mRS 3–5. Conclusions: Even in the era of flow diverter stents, multiple overlapping stents (≥3) with coiling could be a feasible alternative for treating ruptured BBAs. Additional experience and follow-up are needed in a larger series to state the long-term efficacy of this treatment.