Interventional Radiology: Indications and Best Practices

Interventional radiology employs image-guided techniques to perform minimally invasive procedures for diagnosis and treatment. Interventional radiology is often used to place central venous catheters and subcutaneous ports, with some evidence of benefit over surgical placement. Arterial embolization procedures are used to manage many types of hemorrhage and are highly effective for severe postpartum hemorrhage. Vascular interventions, such as endovascular treatment of varicosities, acute limb ischemia, and pulmonary embolism, are superior to surgical interventions. For chronic limb ischemia and deep venous thrombosis, the choice of therapy is not as clear. Inferior vena cava filters can be placed and removed endovascularly, but there is a significant risk of complications that increases over time. Vascular interventions can be effective for scrotal varicocele and uterine fibroids, although fibroid treatment is limited by high recurrence rates. Image-guided percutaneous drainage and biopsy have become standard of care. Interventional approaches are being used in oncology for local diagnosis and treatment. Percutaneous ablation and targeted delivery of chemotherapy and radiation therapy are being developed as alternatives when surgery is not practical. Vertebroplasty and kyphoplasty provide significant pain and functional improvement in patients with spinal metastases.

Usefulness of Silent MR Angiography for Intracranial Aneurysms Treated with a Flow-Diverter Device

BACKGROUND AND PURPOSE

The flow-diverter device has been established as a treatment procedure for large unruptured intracranial aneurysms. The purpose of this study was to compare the usefulness of Silent MR angiography and time-of-flight MRA to assess the parent artery and the embolization state of the aneurysm after a flow-diverter placement.

MATERIALS AND METHODS

Seventy-eight large, unruptured internal carotid aneurysms in 78 patients were the subjects of this study. After 6 months of treatment, they underwent follow-up digital subtraction angiography, Silent MRA, and TOF-MRA, performed simultaneously. All images were independently reviewed by 2 neurosurgeons and 1 radiologist and rated on a 4-point scale from 1 (not visible) to 4 (excellent) to evaluate the parent artery. The aneurysmal embolization status was assessed with 2 ratings: complete or incomplete occlusion.

RESULTS

The mean scores of Silent MRA and TOF-MRA regarding the parent artery were 3.18 ± 0.72 and 2.31 ± 0.86, respectively, showing a significantly better score with Silent MRA (P < .01). In the assessment of the embolization of aneurysms on Silent MRA and TOF-MRA compared with DSA, the percentages of agreement were 91.0% and 80.8%, respectively.

CONCLUSIONS

Silent MRA is superior for visualizing blood flow images inside flow-diverter devices compared with TOF-MRA. Furthermore, Silent MRA enables the assessment of aneurysmal embolization status. Silent MRA is useful for assessing the status of large and giant unruptured internal carotid aneurysms after flow-diverter placement.

Use of a First Large-Sized Coil Versus Conventional Coils for Embolization of Cerebral Aneurysms: Effects on Packing Density, Coil Length, and Durable Occlusion

OBJECTIVE

To investigate effects of using a large-sized coil first on embolizing cerebral aneurysms compared with conventional coils.

MATERIALS AND METHODS

Forty-six patients with 51 saccular intracranial aneurysms who underwent embolization with a large-sized coil first were enrolled as the large-sized coil group. There were 33 female and 13 male patients with a mean age of 56.9 ± 8.8 years. The treatment modality was coiling alone in 30 aneurysms and stent-assisted coiling in 21. Meanwhile, 50 patients with 53 intracranial aneurysms who were treated with conventional-sized coils were selected as the control conventional-sized coil group, including 36 female and 14 male patients with a mean age of 54.6 ± 5.8 years. The treatment modality was coiling alone in 29 aneurysms and stent-assisted coiling in 24 aneurysms. The occlusion rate, percent packing volume, total coil number and length, and follow-up occlusion rate were compared between the 2 groups.

RESULTS

Significantly (P < 0.001) decreased percent packing volume (19.54% ± 6.44% vs. 27.39% ± 5.68%), decreased coil number (2.98 ± 1.09 vs. 6.38 ± 1.65), and length (26.20 ± 26.57 vs. 44.35 ± 35.88 cm) were achieved in the large versus the conventional coil group. At angiographic follow-up of 8 months, only 1 aneurysm (2.2%) recurred in the large coil group compared with 5 aneurysms recurrent (11.1%) in the conventional coil group.

CONCLUSIONS

The use of a large-sized coil as the first one for embolizing cerebral aneurysms may be a better embolization strategy because it achieves similar initial occlusion rates, decreased packing density, decreased coil numbers and lengths, and reduced recurrence prevalence at follow-up.

The Length Versus Diameter Relationship and Radial Force Properties of the Amplatzer™ Vascular Plug Type IV: Observations for Oversizing

BACKGROUND

In palliated single ventricle patients aortopulmonary collateralization is a cause for significant loss of cardiovascular efficiency. In larger vessels, device occlusion becomes an alternative to embolization with multiple coils. The physical characteristics of the Amplatzer ™ Vascular Plug Type IV (AVPIV) are potentially conducive to oversizing the device allowing coverage of a longer portion of vessel. Despite the widespread use of the AVPIV, little published data exists describing the behavior of the device as it is constrained in different vessel sizes.

METHODS

4-8 mm AVPIV devices were measured in glass tubing in diameters ranging from 1 to 8 mm internal diameter. Radial force was measured by constraining the devices to the desire diameters from 1 to 7 mm and measuring the force the device exerted to one of the constraining walls. This force vs. diameter relationship was evaluated for each device and compared across different devices.

RESULTS

The devices range in length from 12.36 to 31.24 mm. The 4 mm device lengthened 3.44 mm from unconstrained to 1 mm diameter (12.36 to 15.80 mm), while the 8 mm AVP IV lengthened 14.74 mm from unconstrained to 1 mm diameter constraint (16.50-31.24 mm, 89% lengthening). The highest overall radial force (1.38 N), radial force at 50% compression (1.25 N), and average stiffness (0.95 N/mm) was found in the 5 mm diameter device.

CONCLUSIONS

The AVP IV device has a reliable length for diameter relationship. A counterintuitive property of the AVP IV with regards to radial force for device size was found. The 5 mm AVPIV was found to exert the highest radial force and stiffness compared to the other devices. The 7 and 8 mm AVPIV devices were consistently found to exert less radial force. This property suggests that oversizing an AVP IV could be safe and effective, potentially decreasing total devices used, cost, and overall procedure time.

Discussion on operative skills in the embolization of hydrosalpinx by hysteroscopic placement of a microcoil

This study aims to discuss the operative skills of hysteroscopic tubal embolization and reduce the occurrence of complications.Ninety-four patients were divided into group A and group B. The main surgical technique in group A: when the inner sleeve is sent to the fallopian tube and no longer accessible (but no >3 cm), remove the guide wire and put into the microcoil. But in group B, there are four major surgical techniques. First, the depth at which the guide wire enters the tube was controlled at 2 cm. Second, the inner diameter of the fallopian tube must be explored to determine the type and shape of the coils. Third, saline should be used to separate the catheter. Fourth, it is to control the release speed of the coils. The superiority of the improved operation method was confirmed by comparing the surgical failure rate, incidence of complications, and cost of surgery before and after the procedure.The reoperation rate of group A was 10% (3/30), while that of group B was 2.68% (3/112). The ectopic microcoils rate of group A was 6.67% (2/30), while that of group B was 0.89% (1/112). The microcoil damages rate of group 23.33% (7/30), while that of group B was 8.04% (9/112). All P values were <.01, and the difference was statistically significant.Hysteroscopic tubal embolization is currently a new surgical procedure to block the fallopian tubes and prevent the reverse flow of fluid in the fallopian tubes into the uterine cavity. After we improved surgical techniques, the surgical failure rate, complication rate, and operation cost of fallopian tube embolization were significantly lower than before the improved method was applied. The improved techniques led to a higher success rate.

Endovascular Management of Ruptured Middle Colic Artery Aneurysm and Review of the Literature

A ruptured aneurysm of the middle colic artery (MCA) is extremely rare, and its etiology and optimal treatment are unclear. Previously, surgical intervention was the treatment of choice for ruptured visceral artery aneurysms. However, owing to recent advances in endovascular techniques, transcatheter arterial embolization has been recommended for the management of even ruptured splanchnic aneurysms in clinically stable patients without evidence of bowel ischemia. We report a case of a ruptured MCA aneurysm in a 52-year-old previously healthy man. Coil embolization was attempted successfully. In addition, 7 previously published cases of ruptured MCA aneurysms successfully treated by endovascular embolization were reviewed.

Coil Embolization of Femoral Pseudoaneurysms in Intravenous Drug Users: An Additional Treatment Modality

BACKGROUND

This report describes our centers' experience of a new approach using coil embolization for femoral pseudoaneurysms (PSAs) in intravenous drug users (IVDUs). Current treatment options for this challenging patient group include femoral/external iliac artery ligation and excision of the PSA, with or without revascularization. Radiological thrombin injection, endoluminal stent grafting, and coil embolization have not been widely studied in this patient group and are most commonly reserved for sterile PSAs.

METHODS

A series of 6 patients who presented to the vascular surgical department with IVDU-related PSA were treated with coil embolization. We present here their clinical course and outcomes. Ethical approval was not required.

RESULTS

Coil embolization alone did not result in a satisfactory outcome. Thirty-three percent of patients required vessel ligation following their initial treatment with coil embolization. However, all patients initially managed with coil embolization, whether as a definitive treatment or temporizing measure to surgery, were discharged home, mobilizing well, with Doppler signals at the ankle. Postoperative claudication was present in 17% of patients. There were no amputations as a direct result of coil embolization. The amputation in this series resulted from triple-vessel ligation without revascularization in a patient mistaken as having a groin abscess.

CONCLUSIONS

Coil embolization is a potential, less invasive treatment option in selected cases of IVDU PSA. It offers an alternative therapeutic intervention, adding to the armamentarium available to tackle these often challenging patients.

Endovascular treatment for unruptured aneurysm associated with persistent primitive trigeminal artery: a case report and literature review

The persistent primitive trigeminal artery (PPTA) is the most common carotid-basilar anastomosis, and the incidence of cerebral aneurysms associated with the PPTA is approximately 4%. Since PPTA aneurysms often have a wide neck and other vascular anomalies, endovascular treatment using an adjunctive technique is the current first-line therapy. Here, we report a case of PPTA aneurysm treated by coil embolization with a stent-assisted technique. A detailed evaluation of the size and course of all vessels and collateral flow, including the Allcock test and balloon test occlusion, is necessary when deciding on the treatment strategy.

Efficiency and complications of Woven EndoBridge (WEB) devices for treatment of larger, complex intracranial aneurysms-a single-center experience

BACKGROUND

Several recently published multicenter studies have reported high treatment feasibility, high safety, and good 6-month to 1-year efficiency when treating smaller intracranial aneurysms (IA) with WEB deployment. The purpose of the study was to evaluate the long-term efficiency and complications related to WEB treatment of larger, complex intracranial aneurysms in a small single-center cohort.

METHODS

Patients with ruptured and unruptured IA were treated with WEB devices; data were collected prospectively and analyzed retrospectively. The study evaluates complications and clinical and radiological findings at immediate and last available follow-up.

RESULTS

The study included 16 patients with 16 aneurysms and a median follow-up time of 36 months, range 13-49 months; 9/16 were females. Median age 59 with range 39-71 years. Mean aneurysm size 11.3 ± 1.7 mm, predominant location at the basilar artery bifurcation and anterior communicating artery. Three out of sixteen IAs were ruptured. Even though 75% of the IAs were immediately occluded completely, retreatment was eventually necessary in 7/15 (46.7%). Increasing neck remnants and recurrences were mainly observed past 1-year follow-up. The WEB device showed modifications over time, with six devices showing signs of compression in the long term. There was one fatality due to aneurysm rupture after 4 years.

CONCLUSIONS

The long-term efficiency of WEB deployment in larger, complex aneurysms is low with about half of the cases needing at least one retreatment. A large fraction of WEB collapse past 1-year follow-up.

Bronchial Occlusion with Endobronchial Watanabe Spigot for Hemoptysis in a Mechanically Ventilated Patient with Extracorporeal Circulation

Bronchial occlusion with endobronchial Watanabe spigots (EWSs) can be an essential therapeutic measure for treating massive hemoptysis in intensive care patients when no other conventional options are available. A 68-year-old-man on mechanical ventilation and extracorporeal circulation after cardiovascular surgery presented massive hemoptysis. He was deemed unfit for bronchial artery embolization (BAE) and surgery while in the intensive care setting; thus, bronchial occlusion was performed using EWSs. His hemoptysis ceased, and he was successfully weaned from mechanical ventilation and extracorporeal circulation. Bronchial occlusion by EWSs may be considered an optimal, and at times, definitive treatment for obtaining hemostasis in these situations.

Comparative effectiveness analysis of Pipeline device versus coiling in unruptured aneurysms smaller than 10 mm

OBJECTIVE

Both endovascular coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for treatment of small (< 10 mm) aneurysms. The authors conducted a comparative effectiveness analysis to compare the utility of these treatment methods in terms of health benefits.

METHODS

A decision-analytical study was performed with Markov modeling methods to simulate patients with small unruptured aneurysms undergoing endovascular coiling, stent-assisted coiling (SAC), or PED placement for treatment. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses were performed to assess model and input parameter uncertainty.

RESULTS

The base case calculation for a 50-year-old man reveals PED to have a higher health benefit (17.48 quality-adjusted life years [QALYs]) than coiling (17.44 QALYs) or SAC (17.36 QALYs). PED is the better option in 6020 of the 10,000 iterations in probabilistic sensitivity analysis. When the retreatment rate of PED is lower than 9.53%, and the coiling retreatment is higher than 15.6%, PED is the better strategy. In the 2-way sensitivity analysis varying the retreatment rates from both treatment modalities, when the retreatment rate of PED is approximately 14% lower than the retreatment rate of coiling, PED is the more favorable treatment strategy. Otherwise, coiling is more effective. SAC may be better than PED when the unfavorable outcome risk of SAC is lower than 70% of its reported current value.

CONCLUSIONS

With the increasing use of PEDs for treatment of small unruptured aneurysms, the current study indicates that these devices may have higher health benefits due to lower rates of retreatment compared to both simple coiling and stent-assisted techniques. Longer follow-up studies are needed to document the rates of recurrence and retreatment after coiling and PED to assess the cost-effectiveness of these strategies.

MRI-Compatible Injection System for Magnetic Microparticle Embolization

OBJECTIVE

Dipole field navigation and magnetic resonance navigation exploit B₀ magnetic fields and imaging gradients for targeted intra-arterial therapies by using magnetic drug-eluting beads (MDEBs). The strong magnetic strength (1.5 or 3 T) of clinical magnetic resonance imaging (MRI) scanners is the main challenge preventing the formation and controlled injection of specific-sized particle aggregates. Here, an MRI-compatible injector is proposed to solve the above problem.

METHODS

The injector consists of two peristaltic pumps, an optical counter, and a magnetic trap. The magnetic property of microparticles, the magnetic compatibility of different parts within the injector, and the field distribution of the MRI system were studied to determine the optimal design and setup of the injector. The performance was investigated through 30.4-emu/g biocompatible magnetic microparticles (230 ± 35 μm in diameter) corresponding to the specifications needed for trans-arterial chemoembolization in human adults.

RESULTS

The system can form aggregates containing 20 to 60 microparticles with a precision of six particles. The corresponding aggregate lengths range from 1.6 to 3.2 mm. Based on the injections of 50 MRI-visible boluses into a phantom which mimics realistic physiological conditions, 82% of the aggregates successfully reached subbranches.

CONCLUSION AND SIGNIFICANCE

This system has the capability to operate within the strong magnetic field of a clinical 3-T MRI, to form proper particle aggregates and to automatically inject these aggregates into the MRI bore. Moreover, the versatility of the proposed injector renders it suitable for selective injections of MDEBs during MR-guided embolization procedures.

Initial and Long-Term Outcomes of Complex Bifurcation Aneurysms Treated by Y-Stent-Assisted Coiling with Low-Profile Braided Stents

BACKGROUND AND PURPOSE

Coiling complex intracranial bifurcation aneurysms often necessitates the implantation of double stents in various configurations, such as Y-stent placement. Low-profile braided stents have been introduced recently to facilitate the endovascular treatment of wide-neck aneurysms. We aimed to investigate the feasibility, safety, efficacy, and durability of Y-stent-assisted coiling with double low-profile braided stents for the treatment of complex bifurcation aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients who were treated using Y-stent-assisted coiling with low-profile braided stents. Technical success was assessed, as were initial and follow-up clinical and angiographic outcomes. Periprocedural and delayed complications were reviewed. Preprocedural and follow-up clinical statuses were assessed using the modified Rankin Scale.

RESULTS

Forty patients with 40 intracranial aneurysms were included in the study. Y-stent placement was successfully performed in all cases. Immediate postprocedural digital subtraction angiography images revealed total aneurysm occlusion in 72.5% of cases. The mean angiographic follow-up time was 24.8 months. The last follow-up angiograms showed complete occlusion in 85% of patients. During follow-up, only 1 patient showed an increase in the filling status of the aneurysm and that patient did not require retreatment. There was no mortality in this study. The overall procedure-related complication rate, including asymptomatic complications, was 17.5%. A permanent morbidity developed in 1 patient (2.5%).

CONCLUSIONS

The long-term angiographic and clinical outcomes of this retrospective study demonstrate that Y-stent-assisted coiling using low-profile braided stents is an effective, relatively safe, and durable endovascular treatment for wide-neck and complex bifurcation aneurysms.

SMART coils for intracranial aneurysm embolization: Follow-up outcomes

The SMART coil (Penumbra Inc., Alameda, CA, USA) is a new microcoil designed to enhance deliverability. Although prior studies have described its perioperative safety and efficacy, the follow-up outcomes after embolization of intracranial aneurysms using SMART coils have not been reported. Therefore, the aim of this retrospective cohort study is to assess the angiographic outcomes at interim follow-up after aneurysm embolization with SMART coils. We reviewed data from consecutive patients with intracranial aneurysms who underwent endovascular treatment using SMART coils between June 2016 and August 2017. Baseline data and follow-up angiographic outcomes using the modified Raymond-Roy classification (MRRC) were recorded. The study cohort comprised 33 patients with 34 aneurysms who underwent SMART coil embolization and had sufficient follow-up data. The mean age was 57 years, and 82% were female. The mean aneurysm maximum diameter and neck width were 6.1 ± 2.2 mm and 3.2 ± 1.2 mm, respectively, and 14.7% of aneurysms were ruptured. The overall complication rate was 12%. Initial mean coil packing density was 26%, and the initial MRRC was I, II, IIIa, and IIIb in 24%, 26%, 35%, and 15%, respectively. At last follow-up (mean duration 7.7 ± 3.2 months), the MRRC was I, II, IIIa, and IIIb in 62%, 26%, 3%, and 9%, respectively. The retreatment rate was 14.7%. The SMART coil is efficacious for the treatment of appropriately selected aneurysms, with an acceptable risk profile. The majority of residual aneurysms after the initial embolization procedure will progress to complete or near-complete occlusion at interim follow-up.

A Pial Arteriovenous Fistula in Infancy as the Presenting Manifestation of Hereditary Hemorrhagic Telangiectasia

BACKGROUND

Pial arteriovenous fistulas (PAVFs) are rare, accounting for 1.6%-4.7% of all intracranial vascular malformations. Often diagnosed in childhood, about 30% are associated with hereditary hemorrhagic telangiectasia. A case of PAVF diagnosed soon after birth and given cerebrovascular therapy 4 months after birth is reported.

CASE DESCRIPTION

The patient presented with heart failure immediately after birth. Ultrasonography of the head showed abnormal blood flow in the brain. On digital subtraction angiography performed 4 months after birth, a PAVF with a dural feeder shunt and a giant varix at the posterior temporal part was confirmed. After transarterial embolization (TAE), shunt blood flow disappeared. New shunt flow from the right posterior cerebral artery into the varix was confirmed by magnetic resonance imaging 3 months after the operation. A second TAE procedure using a liquid embolic material was performed and confirmed the complete disappearance of the shunt.

CONCLUSIONS

This report describes a case of infant PAVF with heart failure, a giant varix, hydrocephalus, and intraventricular hemorrhage treated by TAE using platinum coils and liquid embolic material.

Treatment Effect or Effective Treatment? Cardiac Compression Fraction and End-tidal Carbon Dioxide Are Higher in Patients Resuscitative Endovascular Balloon Occlusion of the Aorta Compared with Resuscitative Thoracotomy and Open-Chest Cardiac Massage

The purpose of this study is to compare end-tidal carbon dioxide (EtCO₂) during resuscitation of open-chest cardiac massage (OCCM) with aortic cross-clamp (ACC) versus receiving resuscitative endovascular balloon occlusion of the aorta (REBOA) with closed-chest compressions (CCCs). Patients who received REBOA were compared with patients receiving OCCM for traumatic arrest using continuous vital sign monitoring and videography. Thirty-three patients were enrolled in the REBOA group and 18 patients were enrolled in the OCCM group. Of the total patients, 86.3 per cent were male with a mean age of 36.2 ± 13.9 years. Ninety-four percent of patients suffered penetrating trauma in the OCCM group compared with 30.3 per cent of the REBOA group (P = <0.001). Before aortic occlusion (AO), there was no difference in initial EtCO₂ values, but mean, median, peak, and final EtCO₂ values were lower in OCCM (P < 0.005). During CPR after AO, the initial, mean, and median values were higher with REBOA (P = 0.015, 0.036, and 0.038). The rate of return of spontaneous circulation was higher in REBOA versus OCCM (20/33 [60.1%] vs 5/18 [33.3%]; P = 0.04), and REBOA patients survived to operative intervention more frequently (P = 0.038). REBOA patients had greater total cardiac compression fraction (CCF) before AO than OCCM (85.3 ± 12.7% vs 35.2 ± 18.6%, P < 0.0001) and after AO (88.3 ± 7.8% vs 71.9 ± 24.4%, P = 0.0052). REBOA patients have higher EtCO₂ and cardiac compression fraction before and after AO compared with patients who receive OCCM.

Microcatheter navigation through the clot: does size matter?

BACKGROUND

Despite high recanalization rates achieved with endovascular treatment of acute ischemic strokes, around 50% of eligible patients will not achieve a good outcome. Parameters that may determine patient outcomes include: time from puncture to recanalization, the collateral status, the anesthesia regimen, blood pressure management, and distal emboli. Characterization of distal emboli generated during mechanical thrombectomy has been performed in previous studies.

OBJECTIVE

To further investigate the risk of distal embolization associated with microcatheter navigation across the clot.

METHODS

A contrast-enhanced clot analog was used in an in vitro model that mimicked a middle cerebral artery occlusion within a complete circle of Willis vascular replica. The clot was crossed with one of the following microcatheters: Pro18, XT-27 or 3MAX. The emboli generated during the procedure were collected and measured.

RESULTS

The use of Pro18 and XT-27 resulted in a significant reduction of visible particles (size ≥500 µm) as compared with the 3MAX catheter (P<0.003). For the size range between 8 and 200 µm, there was a trend for Pro18 to generate fewer particles (-18%) than XT-27 but without statistical significance (P>0.05). In comparison with previously published data, acquired under the same conditions, it was found that the clot crossing maneuver accounts approximately for 12% of the total number of small emboli (<200 µm) induced during a stent retriever-mediated mechanical thrombectomy procedure via a balloon guide catheter.

CONCLUSIONS

The clot crossing maneuver has a significant effect on the total number of small particles induced during mechanical thrombectomy. Smaller microcatheter sizes should be favored when possible.

Risk of Branch Occlusion and Ischemic Complications with the Pipeline Embolization Device in the Treatment of Posterior Circulation Aneurysms

BACKGROUND AND PURPOSE

Flow diversion with the Pipeline Embolization Device is increasingly used for endovascular treatment of intracranial aneurysms due to high reported obliteration rates and low associated morbidity. While obliteration of covered branches in the anterior circulation is generally asymptomatic, this has not been studied within the posterior circulation. The aim of this study was to evaluate the association between branch coverage and occlusion, as well as associated ischemic events in a cohort of patients with posterior circulation aneurysms treated with the Pipeline Embolization Device.

MATERIALS AND METHODS

A retrospective review of prospectively maintained databases at 8 academic institutions from 2009 to 2016 was performed to identify patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. Branch coverage following placement was evaluated, including the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and posterior cerebral artery. If the Pipeline Embolization Device crossed the ostia of the contralateral vertebral artery, its long-term patency was assessed as well.

RESULTS

A cohort of 129 consecutive patients underwent treatment of 131 posterior circulation aneurysms with the Pipeline Embolization Device. Adjunctive coiling was used in 40 (31.0%) procedures. One or more branches were covered in 103 (79.8%) procedures. At a median follow-up of 11 months, 11% were occluded, most frequently the vertebral artery (34.8%). Branch obliteration was most common among asymptomatic aneurysms (P < .001). Ischemic complications occurred in 29 (22.5%) procedures. On multivariable analysis, there was no significant difference in ischemic complications in cases in which a branch was covered (P = .24) or occluded (P = .16).

CONCLUSIONS

There was a low occlusion incidence in end arteries following branch coverage at last follow-up. The incidence was higher in the posterior cerebral artery and vertebral artery where collateral supply is high. Branch occlusion was not associated with a significant increase in ischemic complications.

Surpass Streamline Flow-Diverter Embolization Device for Treatment of Iatrogenic and Traumatic Internal Carotid Artery Injuries

Iatrogenic and traumatic cerebral internal carotid artery injuries are uncommon but potentially lethal complications. Direct surgical repair of ICA injuries may be difficult in an acute setting. However, endovascular treatment with a flow-diverter embolization device is a feasible alternative technique that we experienced. In this clinical report, we describe demographic data, radiographic images, lesion characteristics, endovascular procedure notes, postprocedural hospital course, and follow-up digital subtraction angiography of 5 patients. At least 6-month follow-up was available in all patients without occurrence of rebleeding and other complications.

Safety and efficacy of aneurysm treatment with WEB in the cumulative population of three prospective, multicenter series

BACKGROUND

Flow disruption with the WEB is an innovative endovascular approach for treatment of wide-neck bifurcation aneurysms. Initial studies have shown a low complication rate with good efficacy.

PURPOSE

To report clinical and anatomical results of the WEB treatment in the cumulative population of three Good Clinical Practice (GCP) studies: WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm), French Observatory, and WEBCAST-2.

METHODS

WEBCAST, French Observatory, and WEBCAST-2 are single-arm, prospective, multicenter, GCP studies dedicated to the evaluation of WEB treatment. Clinical data were independently evaluated. Postoperative and 1-year aneurysm occlusion was independently evaluated using the 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant.

RESULTS

The cumulative population comprised 168 patients with 169 aneurysms, including 112 female subjects (66.7%). The patients' ages ranged between 27 and 77 years (mean 55.5±10.2 years). Aneurysm locations were middle cerebral artery in 86/169 aneurysms (50.9%), anterior communicating artery in 36/169 (21.3%), basilar artery in 30/169 (17.8%), and internal carotid artery terminus in 17/169 (10.1%). The aneurysm was ruptured in 14/169 (8.3%). There was no mortality at 1 month and procedure/device-related morbidity was 1.2% (2/168). At 1 year, complete aneurysm occlusion was observed in 81/153 aneurysms (52.9%), neck remnant in 40/153 aneurysms (26.1%), and aneurysm remnant in 32/153 aneurysms (20.9%). Re-treatment was carried out in 6.9%.

CONCLUSIONS

This series is at the moment the largest prospective, multicenter, GCP series of patients with aneurysms treated with WEB. It shows the high safety and good mid-term efficacy of this treatment.

CLINICAL TRIAL REGISTRATION

French Observatory: Unique identifier (NCT18069); WEBCAST and WEBCAST-2: Unique identifier (NCT01778322).

Re-treatment of an unruptured anterior communicating artery aneurysm using the new pCONus 2 device: Description of a case

Endovascular approach represents today the first option in treatment of ruptured and unruptured cerebral aneurysms. Nevertheless, wide-neck bifurcation aneurysms still represent a technical challenge for endovascular treatment due to the need to protect vessels arising next to the aneurysmal neck. A variety of devices have been implemented to ensure adequate assistance for coiling of these lesions. Among these devices, the new pCONus 2 represents an evolution of the well-known pCONus; compared to the previous one in fact, it allows a degree of articulation and flexibility between the shaft and the distal part (crown), making it more suitable for treatment of aneurysms presenting an angle between the longitudinal axis of the dome and parent vessel. We report our first case using pCONus 2 in the re-treatment of an unruptured anterior communicating artery aneurysm in a 57-year-old man, showing evident recanalization two years after coiling.

Pericallosal aneurysm coiling with a "hubbed" 167 cm 0.013″ headway duo via a transradial approach

Cerebral aneurysms in patients with extreme proximal tortuosity may contraindicate endovascular therapy as a result of both the approach and an inability to navigate a coil-compatible microcatheter into the aneurysm due to microcatheter length. We present a 72 year-old male with multiple medical comorbidities admitted with a grade 3, ruptured pericallosal aneurysm. Aortoiliac disease contraindicated a transfemoral approach and thus a 6 French 105 cm guide catheter was advanced through a 6 French short radial sheath into a bovine left common carotid artery. After straightening proximal access anatomy with an Amplatz wire to allow advancement of the guide catheter into the internal carotid artery, a 167 cm 0.013 in. headway duo was advanced through a 5 French Sofia through the guide catheter and "hubbed" to enter the aneurysm. The aneurysm was then successfully coil embolized with 4 Target Ultrasoft coils. This case illustrates the utility of a 167 cm microcatheter for coil embolization of a pericallosal aneurysm with significant proximal tortuosity via a transradial approach. Despite its 0.013 in. inner diameter and length, common Target coils were compatible and deployed without incident.

The New Low-Profile WEB 17 System for Treatment of Intracranial Aneurysms: First Clinical Experiences

BACKGROUND AND PURPOSE

The Woven EndoBridge (WEB) is an intrasaccular flow diverter intended to treat wide-neck aneurysms. The latest generation WEBs needed a 0.021-inch microcatheter in the small sizes. Recently, a lower profile range of WEBs compliant with a 0.017-inch microcatheter (WEB 17) has been introduced. We present the first clinical results of treatment of both ruptured and unruptured aneurysms with the WEB 17.

MATERIALS AND METHODS

Between December 2016 and September 2017, forty-six aneurysms in 40 patients were treated with the WEB 17. No supporting stents or balloons were used. Twenty-five aneurysms were ruptured (54%). There were 6 men and 34 women (mean age, 62 years; median, 63 years; range, 46-87 years). The mean aneurysm size was 4.9 mm (median, 5 mm; range, 2-7 mm).

RESULTS

There were 2 thromboembolic procedural complications without clinical sequelae and no ruptures. The overall permanent procedural complication rate was 0% (0 of 40; 97.5% CI, 0%-10.4%). Imaging follow-up at 3 months was available in 33 patients with 39 aneurysms (97.5% of 40 eligible aneurysms). In 1 aneurysm, the detached WEB was undersized and the remnant was additionally treated with coils after 1 week. This same aneurysm reopened at 3 months and was again treated with a second WEB. One other aneurysm showed persistent WEB filling at 3 months. Complete occlusion was achieved in 28 of 39 aneurysms (72%), and 9 aneurysms (23%) showed a neck remnant.

CONCLUSIONS

The WEB 17 is safe and effective for both ruptured and unruptured aneurysms. The WEB 17 is a valuable addition to the existing WEB size range, especially for very small aneurysms.