A scanning electron microscopic study of arterial endothelial repair under turbulent flow conditions

Combined microsurgical and endovascular management of complex intracranial aneurysms

OBJECTIVE

The disciplines of microneurosurgery and cranial base surgery have reached maturity, and technical advances in the surgical management of aneurysms are limited. Although most aneurysms can be clipped microsurgically or coiled endovascularly, a subset of patients may require a combined approach. A consecutive series of patients with aneurysms in one surgeon's cerebrovascular practice was reviewed retrospectively to analyze strategies for integrating microsurgical and endovascular techniques in the management of complex aneurysms.

METHODS

Between 1997 and 2001, 596 aneurysms in 491 patients were treated microsurgically by the senior author (MTL) at the University of California, San Francisco, and 77 of these patients (96 aneurysms) were managed with a multimodality approach comprising a total of eight different combinations: selective revascularization and aneurysm occlusion (n = 23), endovascular and surgical trapping (n = 1), clipping of the aneurysm after attempted or incomplete coiling (n = 22), coiling after attempted or incomplete clipping (n = 5), clipping of recurrent aneurysm after coiling (n = 6), coiling of recurrent aneurysm after clipping (n = 1), clipping and coiling of multiple remote aneurysms (n = 13), and coiling after previous surgery (n = 6).

RESULTS

A total of 96 aneurysms were treated with combined therapy, of which 43% were large or giant in size and 34% had fusiform or dolichoectatic morphology. Complete angiographic obliteration was achieved in 91 aneurysms (95%). Overall, 66 patients (86%) had good outcomes (Glasgow Outcome Scale score of 4 or 5; mean follow-up, 9 mo). The treatment mortality rate was 9.1% (seven patients), and permanent treatment-associated neurological morbidity rate was 5.2% (four patients).

CONCLUSION

Evolving endovascular technologies need to be integrated into the microsurgical management of aneurysms. Multimodality approaches are best used with complex aneurysms in which conventional therapy with a single modality has failed. Revascularization remains a unique surgical contribution to the overall management of aneurysms with which current endovascular techniques cannot be used. Multimodality management should be considered an elegant addition to the therapeutic armamentarium that, through simplification and increased safety, improves the treatment of complex aneurysms beyond what is achievable by performing clipping or coiling alone.

Influence of stent edge angle on endothelialization in an in vitro model

PURPOSE

To investigate the influence of topographic features in the path of migrating endothelial cells, specifically the effect of edge angle of intravascular metallic material on endothelialization.

MATERIALS AND METHODS

Flat 1-cm x 1-cm 316-L pieces of stainless steel were placed on confluent monolayers of human aortic endothelial cells. The thickness of each metal piece was ground to achieve an edge angle of 35 degrees, 70 degrees, 90 degrees, or 140 degrees (n = 6 each) in relation to the endothelial surface. Migration distance and density of endothelial cell coverage on the metal pieces were measured in groups of six each under static conditions at 4, 7, and 11 days and flow conditions (16 dynes/cm(2)) at 4 days.

RESULTS

Endothelial cell migration distance along the surface of the pieces with edge angles of 35 degrees was significantly greater than that with those with larger angles (P < .05) under static and flow conditions. The migration distances on the 35 degrees piece were 87.5%, 47.3%, 57.1%, and 66.1% greater than those on the 90 degrees piece at the upstream, downstream, right, and left edges, respectively. There were no significant differences in cell density among different angle groups under flow or static conditions.

CONCLUSION

The edge angle of intravascular metallic material has an influence on the rate of endothelialization. A smaller edge angle facilitates endothelialization over metallic material when compared to a larger angle. These results demonstrate the importance of metallic stent profile on endothelialization rate.

Structural fragility and inflammatory response of ruptured cerebral aneurysms. A comparative study between ruptured and unruptured cerebral aneurysms

BACKGROUND AND PURPOSE

Despite technical advances in endovascular and microsurgical treatment, patients with aneurysmal subarachnoid hemorrhage still have a high mortality and morbidity rate. To improve the treatment results in patients with aneurysms, we must better understand the pathophysiology of cerebral aneurysms and the mechanisms leading to their rupture. Therefore, we studied the pathological differences between unruptured and ruptured aneurysms.

METHODS

Ruptured (n=44) and unruptured (n=27) aneurysms were obtained at surgery. The aneurysmal endothelium was scored from 0 (normal) to 5 (complete disruption) by using a scanning electron microscope. The aneurysmal wall was evaluated by immunohistochemical methods. The wall structure was scored from 1 (dense collagen and rich, smooth muscle cells) to 5 (hyaline-like structure). The degree of inflammatory cell invasion into the wall was also scored from 0 (very few cells) to 3 (many cells).

RESULTS

Ruptured aneurysms manifested significant endothelial damage (score of 3.7 versus 0.8; Mann-Whitney U test, P<10(-3)), significant structural changes of the wall (3.7 versus 1.7, P<10(-5)), and significant inflammatory cell invasion (2.2 versus 0.8, P<10(-4)) compared with unruptured aneurysms. There was a significant correlation between the score for wall structure and the score for inflammatory cell invasion (Rs=0. 63; Spearman rank correlation test, P<10(-5)). The pathophysiology of several symptomatic unruptured aneurysms was similar to that of ruptured aneurysms.

CONCLUSIONS

We conclude that the pathophysiology of unruptured, asymptomatic and ruptured aneurysms is different. The wall of ruptured aneurysms was found to be fragile, possibly because macrophage infiltration into the aneurysmal wall resulted in loss of smooth muscle cells and in degradation of matrix proteins.

Experimental creation of fusiform carotid artery aneurysms using vein grafts in rats

OBJECTIVE

We developed an in vivo model of growing fusiform aneurysms, using vein grafts to the rat carotid artery. This aneurysm model might demonstrate the pathological features of the development and growth of aneurysms to become giant aneurysms.

METHODS

Placement of an interposed femoral vein graft to restore carotid artery flow was performed in Wistar rats. On Day 21, 75% of the grafts (mean diameter, 1.6 mm) were found to be dilated to resemble fusiform aneurysms (mean diameter, 5.82 mm), and 53% of these were giant. Quantitative analysis of the histological findings was performed using image-analyzing software.

RESULTS

Histological findings were similar to those for human intracranial giant aneurysms. The average length of the initial grafts in the aneurysm group was 9.1+/-1.9 mm, and grafts were significantly longer and more tortuous than in the normal graft group (6.4+/-0.8 mm) (P = 0.01). Cross-sectional areas of the aneurysms (mean, 18.9 mm2) were significantly correlated with the following: 1) the area of intra-aneurysmal thrombosis (mean, 11.1 mm2) (P < 0.0001); 2) the number of intrathrombotic vascular channels (P = 0.005); and 3) the area of dissection, with hemorrhage, between the thrombus and the wall of the aneurysm (mean, 0.72 mm2) (P = 0.0013). Scanning electron microscopic examination showed evidence of endothelial damage associated with growth of the aneurysms.

CONCLUSION

Recurrent hemorrhaging from intrathrombotic vascular channels caused dissection between the thrombus and the aneurysm wall, which led to growth of the experimental aneurysms to giant aneurysms. With this model, we demonstrated the growth mechanism of giant fusiform aneurysms.