Challenging the limits of angioplasty: Comaneci device for distal vasospasm following subarachnoid hemorrhage

Abstract

Introduction

Aneurysmal subarachnoid hemorrhage (aSAH) is often complicated by delayed cerebral vasospasm (DCV), a major cause of morbidity and mortality. Balloon angioplasty is standard for refractory cases but carries a high risk in distal vessels. This study reports preliminary single-center experience with the Comaneci device for DCV, emphasizing distal segments beyond the circle of Willis, where evidence remains limited.

Methods

We retrospectively analyzed patients with aSAH and symptomatic DCV refractory to medical therapy treated with Comaneci-assisted angioplasty (CAA). Demographic, procedural, clinical, and angiographic data were collected from electronic records. Angiographic response was graded using a vasospasm severity scale.

Results

CAA was performed in 94 vessels across 14 patients (median age 63 years; 85.7% female). Severe-to-critical vasospasm was present in 88.6%. Most interventions involved the anterior circulation (79.1%), with distal segments (M2 and A2–A4) comprising 54.1%. The M2 segment was most frequently treated (36.4%). Patients underwent a median of three interventions (range 2–6). Angioplasty resulted in significant resolution of vasospasm in 92.7% of vessels, with retreatment required in 8.3%. At 6 months, a favorable outcome (mRS 0–2) was observed in 51.5% of patients, while 90-day mortality was 21.4%. No vessel perforations or long-term complications occurred; one transient occlusion was successfully managed with aspiration.

Conclusions

CAA appears feasible and safe for DCV, particularly in the distal vasculature where balloon angioplasty is rarely used. These findings suggest the device may provide a valuable alternative to conventional therapy. Larger prospective studies are required to confirm safety, efficacy, and long-term clinical impact.