Around-the-world technique [Neurosurgery Wiki]

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====== Around-the-world technique ======



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Establishing [[parent artery]] access for [[stent]] placement across large, [[wide-necked aneurysm]]s can be challenging. [[Around-the-world technique]], forming an intra-aneurysm [[loop]] with some form of distal [[anchoring]], has been described in several reports


The **around-the-world technique** is an **advanced endovascular maneuver** used primarily for **large, [[wide-necked intracranial aneurysm treatment]]s**, especially when **direct access to the distal [[parent artery]] is difficult or unstable**.

It consists of **looping the [[microcatheter]] *through the aneurysm sac itself*** in a circular ("around-the-world") path, **entering one side of the neck and exiting through the other**, to reach the **distal parent artery**. This allows deployment of a **stent** or other device **across the aneurysm neck** despite challenging angles.

=====  🧩 **Why it's used** =====


* Direct navigation across the neck is **not feasible** due to:

  * Sharp angles
  * Wide-neck morphology
  * Slippery catheter positioning
* Conventional anchoring is **insufficient or impossible**
* Often applied in **[[bifurcation aneurysm]]s** (e.g., basilar apex, MCA bifurcation)


===== 🔧 **Steps (Simplified) =====

1. [[Microcatheter]] enters the aneurysm via the **proximal parent artery**.

2. It is looped **within the [[aneurysm dome]]**.

3. Exits the aneurysm through the **opposite side of the neck** into the **distal parent artery**.

4. A [[stent]] (e.g., [[Neuroform]], [[LVIS]]) is deployed **across the neck** from distal to proximal.

5. [[Coil]]s may then be placed via a jailed or second catheter.


===== 🩺 **Benefits =====

* Allows treatment of otherwise **inaccessible aneurysms**.
* Stabilizes catheter trajectory using **natural anatomy**.
* Avoids the need for excessive vessel manipulation.

=====  ⚠️ **Risks & Limitations** =====

* **Intrasaccular manipulation** carries risk of **rupture or thromboembolism**.
* Requires **precise imaging and operator experience**.
* Not suitable for all aneurysm shapes or sizes.

===== Narrative reviews =====
The educational [[narrative review]] of Patel et al. 
((Patel KR, Spiotta AM, Borg N, Thorell WE, Surdell DL, Sattur MG. [[Distal anchoring]] techniques for reducing intra-aneurysmal (around-the-world) microcatheter loop prior to [[stent deployment]] across large wide-necked aneurysms- an educational review. Neuroradiology. 2025 Jun 13. doi: 10.1007/s00234-025-03675-1. Epub ahead of print. PMID: 40512377.))
is little more than a scattered anecdotal collage. It avoids any systematic approach in favor of a narrative summary based on retrospective case reports—the weakest level of clinical evidence. There is no clear methodology, no inclusion or exclusion criteria, no risk-of-bias assessment, and no attempt to contextualize these techniques within a modern framework of evidence-based interventions.

Verdict: Educational? Maybe for those still in 2005.

❌ 2. [[Cherry-picked Data]], No [[Meta-Analytic Value]]
Thirteen retrospective studies with 51 patients across varied settings are lumped together without proper stratification. The authors admit publication bias and reporting inconsistencies, but still proceed to draw reassuring conclusions about efficacy and safety.

If you admit you're standing on quicksand, don’t build a podium on it.

❌ 3. Technical Bias and Conflict of Interest by Omission
The article praises a variety of anchoring strategies (balloon, coil, vacuum, wire loop traction…) yet fails to compare them meaningfully or acknowledge the learning curve, cost implications, or long-term patency data. Nor does it disclose if any authors have financial ties to device manufacturers, despite describing device-specific techniques.

When you list tools like a product catalog but don’t show performance differences, it’s not education—it’s marketing.

❌ 4. No Clinical Relevance for Most Readers
The authors freely admit that these techniques are rarely indicated, infrequently published, and heavily dependent on individual operator preference and infrastructure availability. So why publish a “comprehensive review” of what is essentially a niche salvage maneuver?

This is less a guideline and more a [[scrapbook]] for high-volume interventionists looking to justify [[fringe practice]].

❌ 5. The “Case” Is a [[Footnote]], Not a [[Contribution]]
The illustrative technical case—the supposed “educational backbone” of the paper—is minimally detailed, lacks follow-up, and contributes nothing novel to the technique or its safety.

A case without learning points is just filler.

🧨 Conclusion:
This [[paper]] is the embodiment of what happens when low-grade data is packaged with [[authoritative language]] to sound useful. It is methodologically flimsy, clinically irrelevant for generalists, and strategically evasive in addressing [[safety]], [[cost]], and [[applicability]].

❗️Recommendation: Relegate this to technical [[newsletter]]s or [[device-sponsored workshop]]s. It doesn’t belong in a [[peer-reviewed journal]] claiming educational authority.

===== Latest PubMed Related =====
{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/105mR7PWtbWEdk_BuSyglbUGNxu4hioQaFLxbOYw891WmC3Et0/?limit=15&utm_campaign=pubmed-2&fc=20250614050452}}