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Schüngel MS, Wohlgemuth WA, Elolf E, Rensch L, Brill R, Schob S. Review: Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms. ROFO-FORTSCHR RONTG 2024. [PMID: 38977012 DOI: 10.1055/a-2343-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
The invention of flow diverting stents (FDS) is a novel milestone in the field of endovascular aneurysm therapy, promoting physiological healing of the vessel segment contrary to prior deconstructive treatment strategies, such as coiling. The effects of FDS are based on changes in flow patterns, segmental wall stabilization, and the growth of a neointima. Although flow diversion is already well established for cerebral aneurysms in proximal segments, peripheral locations remain challenging. Especially the middle cerebral artery (MCA) with its predominance of non-collateralized perforators and functional end arteries that supply the eloquent areas of the brain is of major concern.The literature was reviewed for flow diversion of the MCA and antiplatelet therapy.Resulting from the special anatomical characteristics of the MCA, FDS implantation in this territory is completely different from the proximal vessel segments. Still, flow diversion represents an effective endovascular strategy, especially in otherwise non-accessible or sufficiently treatable lesions. However, the risk of ischemic adverse events might be increased. Special attention to the individual decision regarding device selection, antiplatelet regimen, and exact definition of the proximal and distal landing zone considering the jailed side branches is essential for a good angiographic and clinical outcome. · MCA aneurysms can be sufficiently treated by FDS.. · The anatomic and hemodynamic characteristics of the MCA result in an increased risk of thromboembolism.. · Individual device selection and antiplatelet regimen are essential for treatment success.. · Schüngel M, Wohlgemuth WA, Elolf E et al. Review: Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms. Fortschr Röntgenstr 2024; DOI 10.1055/a-2343-0046.
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Affiliation(s)
- Marie-Sophie Schüngel
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
| | - Walter A Wohlgemuth
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
| | - Erck Elolf
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
| | - Leonhard Rensch
- Clinic for Neurosurgery, University Hospital Halle (Saale), Halle, Germany
| | - Richard Brill
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
| | - Stefan Schob
- Policlinic of Radiology and Interventional Radiology, Department of Neuroradiology, University Hospital Halle, Halle (Saale), Germany
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Çay F, Arat A. Effect of the Shelving Technique on the Outcome of Embolization in Intracranial Bifurcation Aneurysms. AJNR Am J Neuroradiol 2022; 43:1152-1157. [PMID: 35902123 PMCID: PMC9575423 DOI: 10.3174/ajnr.a7583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Stent bulging technique has been introduced as a technique that improves the outcome of aneurysm coiling. Our aim was to evaluate the utility of this technique, which involves the intentional herniation of stents into the bifurcation aneurysms during coiling. MATERIALS AND METHODS Unruptured bifurcation aneurysms treated by stent-assisted coiling using a single type of low-profile braided (LEO Baby) stent between November 2012 and October 2018 were retrospectively evaluated. The clinical (age and sex) and morphologic characteristics (aneurysm size, neck size, proximal/distal diameters of the stented artery, incorporation of the origins of the side branches to the aneurysm neck, and bifurcation angle) and response to antiplatelet therapy were evaluated. RESULTS Sixty-one patients (29 men, 47.5%; mean age, 55.95 [SD, 12.33] years) with 66 aneurysms were included. There were 36 aneurysms in group A (treated with the stent bulging technique) and 30 aneurysms in group B (treated by classic stent-assisted coiling). There was no significant difference in the patient and aneurysm characteristics in the groups except for the larger size and wider neck of the aneurysms in group A (P = .02 and P = .04, respectively). At the mean follow-up of 27.30 (SD, 17.45) months, there was no significant difference in the complication rate, the occlusion status, and the early and long-term occlusion rates between the groups. The stent bulging technique did not predict total occlusion (Raymond-Roy I) at the final imaging follow-up. CONCLUSIONS The stent bulging technique enables the coiling of larger, wide-neck aneurysms; however, we did not observe an added flow-diversion effect with the stent bulging technique compared with conventional stent-assisted coiling. We, therefore, suggest that bifurcation aneurysms should be coiled as densely and as safely as possible using this technique.
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Affiliation(s)
- F Çay
- From the Department of Radiology (F.Ç., A.A.), Hacettepe University School of Medicine, Ankara, Turkey
| | - A Arat
- From the Department of Radiology (F.Ç., A.A.), Hacettepe University School of Medicine, Ankara, Turkey .,TOBB ETU Medical School Hospital (A.A.), Ankara, Turkey
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Sunohara T, Imamura H, Goto M, Fukumitsu R, Matsumoto S, Fukui N, Oomura Y, Akiyama T, Fukuda T, Go K, Kajiura S, Shigeyasu M, Asakura K, Horii R, Sakai C, Sakai N. Neck Location on the Outer Convexity is a Predictor of Incomplete Occlusion in Treatment with the Pipeline Embolization Device: Clinical and Angiographic Outcomes. AJNR Am J Neuroradiol 2021; 42:119-125. [PMID: 33184073 DOI: 10.3174/ajnr.a6859] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE With the increasing use of the Pipeline Embolization Device for the treatment of aneurysms, predictors of clinical and angiographic outcomes are needed. This study aimed to identify predictors of incomplete occlusion at last angiographic follow-up. MATERIALS AND METHODS In our retrospective, single-center cohort study, 105 ICA aneurysms in 89 subjects were treated with Pipeline Embolization Devices. Patients were followed per standardized protocol. Clinical and angiographic outcomes were analyzed. We introduced a new morphologic classification based on the included angle of the parent artery against the neck location: outer convexity type (included angle, <160°), inner convexity type (included angle, >200°), and lateral wall type (160° ≤ included angle ≤200°). This classification reflects the metal coverage rate and flow dynamics. RESULTS Imaging data were acquired in 95.3% of aneurysms persistent at 6 months. Complete occlusion was achieved in 70.5%, and incomplete occlusion, in 29.5% at last follow-up. Multivariable regression analysis revealed that 60 years of age or older (OR, 5.70; P = .001), aneurysms with the branching artery from the dome (OR, 10.56; P = .002), fusiform aneurysms (OR, 10.2; P = .009), and outer convexity-type saccular aneurysms (versus inner convexity type: OR, 30.3; P < .001; versus lateral wall type: OR, 9.71; P = .001) were independently associated with a higher rate of incomplete occlusion at the last follow-up. No permanent neurologic deficits or rupture were observed in the follow-up period. CONCLUSIONS The aneurysm neck located on the outer convexity is a new, incomplete occlusion predictor, joining older age, fusiform aneurysms, and aneurysms with the branching artery from the dome. No permanent neurologic deficits or rupture was observed in the follow-up, even with incomplete occlusion.
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Affiliation(s)
- T Sunohara
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan.
| | - H Imamura
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - M Goto
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - R Fukumitsu
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - S Matsumoto
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - N Fukui
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Y Oomura
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - T Akiyama
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - T Fukuda
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - K Go
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - S Kajiura
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - M Shigeyasu
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - K Asakura
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - R Horii
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - C Sakai
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - N Sakai
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
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Panchendrabose K, Muram S, Mitha AP. Promoting endothelialization of flow-diverting stents: a review. J Neurointerv Surg 2020; 13:86-90. [PMID: 32487770 DOI: 10.1136/neurintsurg-2020-015874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/27/2022]
Abstract
Intracranial flow-diverting (FD) stents have revolutionized the treatment of intracranial aneurysms in recent years, but complications resulting from failed endothelialization can still occur. Approaches to promote endothelialization are understudied, but hold promise in mitigating both short- and long-term complications associated with FD stent insertion. The aim of this review is to highlight the various features of and modifications that have been made to FD stents in order to expedite endothelialization. More specifically, we focus on how endothelialization can be influenced by the stent design, wall apposition, surface modifications, and the inclusion of biological agents.
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Affiliation(s)
| | - Sandeep Muram
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Alim P Mitha
- Biomedical Engineering, University of Calgary, Calgary, Alberta, Canada .,Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada
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A Virtual Comparison of the eCLIPs Device and Conventional Flow-Diverters as Treatment for Cerebral Bifurcation Aneurysms. Cardiovasc Eng Technol 2019; 10:508-519. [PMID: 31286438 PMCID: PMC6715664 DOI: 10.1007/s13239-019-00424-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Effective, consistent, and complication-free treatment of cerebral bifurcation aneurysms remains elusive despite a pressing need, with the majority of lesions presenting in such locations. Current treatment options focus either on aneurysm coil retention, supported by a stent-like device positioned in the parent vessel lumen, or intrasaccular devices that disrupt flow within the aneurysm dome. A third alternative, i.e., the use of conventional (intraluminal) flow-diverters to treat such bifurcation aneurysms raises the problem that at least one daughter vessel needs to be jailed in such a deployment. The eCLIPs is a stent-like device that offers the possibility of flow-diversion at the aneurysm neck, without the drawbacks of daughter vessel occlusion or those of intrasaccular deployment. METHODS In this study the eCLIPs device was virtually deployed in five cerebral bifurcation aneurysms and compared with a conventional tubular flow-diverter device. Computational fluid dynamics (CFD) simulations of the aneurysm haemodynamic environment pre- and post-implantation were conducted, and focussed on metrics associated with successful aneurysm occlusion. Absolute and relative reductions in aneurysm inflow rate (Q) and time-averaged wall shear stress (TAWSS) were recorded. RESULTS The eCLIPs device was found to perform in a similar qualitative fashion to tubular flow-diverters, with overall reduction of metrics being somewhat more modest however, when compared to such devices. Aneurysm inflow reduction and TAWSS reduction were typically 10-20% lower for the eCLIPs, when compared to a generic flow diverter (FDBRAIDED) similar to devices currently in clinical use. The eCLIPs was less effective at diffusing inflow jets and at reducing the overall velocity of the flow, when compared to these devices. This result is likely due to the larger device pore size in the eCLIPs. Notably, it was found that the eCLIPs provided approximately equal resistance to flow entering and exiting the aneurysm, which was not true for the FDBRAIDED device, where high-speed concentrations of outflow were seen at the aneurysm neck along with local TAWSS elevation. The clinical implications of such behaviour are not examined in detail here but could be significant. CONCLUSIONS Our findings indicate that the eCLIPs device acts as a flow-diverter for bifurcation aneurysms, with somewhat diminished occlusion properties comparing to tubular flow diverters but without the jailing and diminished flow evident in a daughter vessel associated with use of conventional devices.
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Flow diversion: what can clinicians learn from animal models? Neuroradiology 2017; 59:255-261. [DOI: 10.1007/s00234-016-1781-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
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Fahed R, Darsaut TE, Salazkin I, Gentric JC, Mazighi M, Raymond J. Testing Stenting and Flow Diversion Using a Surgical Elastase-Induced Complex Fusiform Aneurysm Model. AJNR Am J Neuroradiol 2016; 38:317-322. [PMID: 27884881 DOI: 10.3174/ajnr.a5018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/29/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Rabbit elastase-induced saccular aneurysms have been commonly used for preclinical testing of endovascular devices, including flow diverters. However, all tested devices have been shown to be capable of aneurysm occlusion with this model. We aimed to create a more challenging model to test and discriminate among neurovascular devices of varying efficacies. MATERIALS AND METHODS With a surgical approach that included elastase infusion and balloon dilation, we attempted the creation of complex fusiform aneurysms in 16 rabbits, with standard saccular carotid aneurysms created in 15 other animals. Aneurysms were randomly allocated to one of the following treatments: flow diversion (n = 8), high-porosity stent (n = 6), double high-porosity stent (n = 5), and control (n = 6). Angiographic assessment and pathologic analyses were performed at 3 months. RESULTS Creation of complex fusiform and standard saccular aneurysms was successful in 12/16 and 13/15 attempts, respectively. All saccular (n = 4) or complex fusiform (n = 4) aneurysms treated with flow diverters were successfully occluded. Three of 3 saccular compared with 0/2 complex fusiform aneurysms were occluded by double high-porosity stents. One of 3 saccular and 0/3 complex fusiform aneurysms were occluded by a single high-porosity stent. Both aneurysm types shared the same pathologic findings when untreated: The aneurysm wall lacked an elastic layer and smooth muscle cells, while the lumen was lined with neointima of varying thickness. Neointimal coverage of the devices was complete when aneurysms were occluded, while leaks were always associated with aneurysm remnants. CONCLUSIONS Challenging fusiform aneurysms can be created in rabbits by using a surgical modification of the elastase method.
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Affiliation(s)
- R Fahed
- From the Centre Hospitalier de l'Université de Montréal (R.F., I.S., J.R.), Interventional Neuroradiology Research Laboratory, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - T E Darsaut
- Department of Surgery (T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - I Salazkin
- From the Centre Hospitalier de l'Université de Montréal (R.F., I.S., J.R.), Interventional Neuroradiology Research Laboratory, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - J-C Gentric
- Department of Radiology (J.-C.G.), Division of Neuroradiology, Centre Hospitalo-Universitaire Cavale Blanche, Brest, France
| | - M Mazighi
- Department of Interventional Neuroradiology (M.M.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - J Raymond
- From the Centre Hospitalier de l'Université de Montréal (R.F., I.S., J.R.), Interventional Neuroradiology Research Laboratory, Notre-Dame Hospital, Montreal, Quebec, Canada
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Topcuoglu OM, Akgul E, Daglioglu E, Topcuoglu ED, Peker A, Akmangit I, Belen D, Arat A. Flow Diversion in Middle Cerebral Artery Aneurysms: Is It Really an All-Purpose Treatment? World Neurosurg 2016; 87:317-27. [DOI: 10.1016/j.wneu.2015.11.073] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/24/2015] [Indexed: 11/16/2022]
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Peach TW, Spranger K, Ventikos Y. Towards Predicting Patient-Specific Flow-Diverter Treatment Outcomes for Bifurcation Aneurysms: From Implantation Rehearsal to Virtual Angiograms. Ann Biomed Eng 2015; 44:99-111. [PMID: 26240061 PMCID: PMC4690836 DOI: 10.1007/s10439-015-1395-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 07/15/2015] [Indexed: 12/14/2022]
Abstract
Despite accounting for the majority of all cerebral aneurysm cases, bifurcation aneurysms present many challenges to standard endovascular treatment techniques. This study examines the treatment of bifurcation aneurysms endovascularly with flow-diverting stents and presents an integrative computational modeling suite allowing for rehearsing all aspects of the treatment. Six bifurcation aneurysms are virtually treated with 70% porosity flow-diverters. Substantial reduction (>50%) in aneurysm inflow due to device deployment is predicted in addition to reductions in peak and average aneurysm wall shear stress to values considered physiologically normal. The subsequent impact of flow-diverter deployment on daughter vessels that are jailed by the device is investigated further, with a number of simulations conducted with increased outlet pressure conditions at jailed vessels. Increased outlet pressures at jailed daughter vessels are found to have little effect on device-induced aneurysm inflow reduction, but large variation (13–86%) is seen in the resulting reduction in daughter vessel flow rate. Finally, we propose a potentially powerful approach for validation of such models, by introducing an angiographic contrast model, with contrast transport modeled both before and after virtual treatment. Virtual angiograms and contrast residence curves are created, which offer unique clinical relevance and the potential for future in vivo verification of simulated results.
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Affiliation(s)
- T W Peach
- Department of Mechanical Engineering, University College London, London, UK.,Department of Engineering Science, University of Oxford, Oxford, UK
| | - K Spranger
- Department of Mechanical Engineering, University College London, London, UK
| | - Y Ventikos
- Department of Mechanical Engineering, University College London, London, UK.
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Darsaut TE, Gentric JC, McDougall CM, Gevry G, Roy D, Weill A, Raymond J. Uncertainty and agreement regarding the role of flow diversion in the management of difficult aneurysms. AJNR Am J Neuroradiol 2015; 36:930-6. [PMID: 25593206 DOI: 10.3174/ajnr.a4201] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 11/06/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The role of flow diversion in the management of aneurysms remains unknown. We sought to evaluate the community agreement regarding indications for flow diversion. MATERIALS AND METHODS A portfolio of 35 difficult aneurysm cases was sent to 40 clinicians with varying backgrounds and experience. Responders were asked whether they considered flow diversion a treatment option, whether other options were possible, whether recruitment in a randomized trial would be considered, and to select their final choice. Agreement was studied by using κ statistics. RESULTS Decisions for flow diversion were more frequent (n = 300, 39%) than decisions to coil (n = 163, 21.2%), to observe (n = 121, 15.7%), to occlude the parent vessel (n = 102, 13.2%), or to clip (n = 66, 8.6%). Sidewall aneurysm morphology was associated with flow diversion as the final choice (P = .001). Interjudge agreement was fair at best (κ <0.3) for all cases and all judges, despite high certainty levels (range, 7.2-8.9 ± 2.0 on a 0-10 scale). Agreement was no better within specialties or with more experience. All patients were judged to have other treatment options. Judges were willing to offer trial participation in 417 of 741 (56.3%) scenarios, more frequently when the aneurysm was sidewall (P = .001) or in the anterior circulation (P = .028). CONCLUSIONS Individuals did not agree regarding the indications for flow diversion. There is sufficient uncertainty to justify trials designed to protect patients from the potential risks of premature adoption of an innovation.
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Affiliation(s)
- T E Darsaut
- From the Division of Neurosurgery (T.E.D., C.M.M.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J-C Gentric
- Department of Radiology (J.-C.G., D.R., A.W., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - C M McDougall
- From the Division of Neurosurgery (T.E.D., C.M.M.), Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - G Gevry
- Laboratory of Interventional Neuroradiology (G.G., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada
| | - D Roy
- Department of Radiology (J.-C.G., D.R., A.W., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - A Weill
- Department of Radiology (J.-C.G., D.R., A.W., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - J Raymond
- Department of Radiology (J.-C.G., D.R., A.W., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada Laboratory of Interventional Neuroradiology (G.G., J.R.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital Research Centre, Montreal, Quebec, Canada.
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Wakhloo AK, Lylyk P, de Vries J, Taschner C, Lundquist J, Biondi A, Hartmann M, Szikora I, Pierot L, Sakai N, Imamura H, Sourour N, Rennie I, Skalej M, Beuing O, Bonafé A, Mery F, Turjman F, Brouwer P, Boccardi E, Valvassori L, Derakhshani S, Litzenberg MW, Gounis MJ. Surpass flow diverter in the treatment of intracranial aneurysms: a prospective multicenter study. AJNR Am J Neuroradiol 2014; 36:98-107. [PMID: 25125666 DOI: 10.3174/ajnr.a4078] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Incomplete occlusion and recanalization of large and wide-neck brain aneurysms treated by endovascular therapy remains a challenge. We present preliminary clinical and angiographic results of an experimentally optimized Surpass flow diverter for treatment of intracranial aneurysms in a prospective, multicenter, nonrandomized, single-arm study. MATERIALS AND METHODS At 24 centers, 165 patients with 190 intracranial aneurysms of the anterior and posterior circulations were enrolled. The primary efficacy end point was the percentage of intracranial aneurysms with 100% occlusion on 6-month DSA. The primary safety end point was neurologic death and any stroke through a minimum follow-up of 6 months. RESULTS Successful flow-diverter delivery was achieved in 161 patients with 186 aneurysms (98%); the mean number of devices used per aneurysm was 1.05. Clinical follow-up (median, 6 months) of 150 patients (93.2%), showed that the primary safety end point occurred in 18 subjects. Permanent neurologic morbidity and mortality were 6% and 2.7%, respectively. Morbidity occurred in 4% and 7.4% of patients treated for aneurysms of the anterior and posterior circulation, respectively. Neurologic death during follow-up was observed in 1.6% and 7.4% of patients with treated intracranial aneurysms of the anterior and posterior circulation, respectively. Ischemic stroke at ≤30 days, SAH at ≤7 days, and intraparenchymal hemorrhage at ≤7 days were encountered in 3.7%, 2.5%, and 2.5% of subjects, respectively. No disabling ischemic strokes at >30 days or SAH at >7 days occurred. New or worsening cranial nerve deficit was observed in 2.7%. Follow-up angiography available in 158 (86.8%) intracranial aneurysms showed 100% occlusion in 75%. CONCLUSIONS Clinical outcomes of the Surpass flow diverter in the treatment of intracranial aneurysms show a safety profile that is comparable with that of stent-assisted coil embolization. Angiographic results showed a high rate of intracranial aneurysm occlusion.
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Affiliation(s)
- A K Wakhloo
- From the Division of Neuroimaging and Intervention (A.K.W.), Departments of Radiology, Neurology, and Neurosurgery
| | - P Lylyk
- Department of Neurosurgery (P.L., J.L.), ENERI, Buenos Aires, Argentina
| | - J de Vries
- Department of Neurosurgery (J.d.V.), Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - C Taschner
- Department of Neuroradiology (C.T.), University of Freiburg, Freiburg, Germany
| | - J Lundquist
- Department of Neurosurgery (P.L., J.L.), ENERI, Buenos Aires, Argentina
| | - A Biondi
- Department of Neuroradiology and Endovascular Therapy (A. Biondi), University of Besançon, Besançon, France
| | - M Hartmann
- Department of Neuroradiology (M.H.), Helios Hospital, Berlin, Germany
| | - I Szikora
- National Institute of Neurosciences (I.S.), Budapest, Hungary
| | - L Pierot
- Department of Neuroradiology (L.P.), Hôpital Maison Blanche, University Hospital of Reims, Reims, France
| | - N Sakai
- Department of Neurosurgery (N. Sakai, H.I.), Kobe City Medical Center General Hospital, Kobe, Japan
| | - H Imamura
- Department of Neurosurgery (N. Sakai, H.I.), Kobe City Medical Center General Hospital, Kobe, Japan
| | - N Sourour
- Department of Neuroradiology (N. Sourour), Hôpital Pitié-Salpetrière, Paris, France
| | - I Rennie
- Department of Neuroradiology (I.R.), The Royal Hospitals, Belfast, Ireland
| | - M Skalej
- Department of Neuroradiology (M.S., O.B.), Universitātsklinikum Magdeburg, Magdeburg, Germany
| | - O Beuing
- Department of Neuroradiology (M.S., O.B.), Universitātsklinikum Magdeburg, Magdeburg, Germany
| | - A Bonafé
- Department of Neuroradiology (A. Bonafé), Hôpital Guy de Chauillac, Montpellier, France
| | - F Mery
- Department of Neurosurgery (F.M.), Pontificia Universidad Católica de Chile, Santiago, Chile
| | - F Turjman
- Department of Neuroradiology (F.T.), Hôpital Neurologique, Lyon, France
| | - P Brouwer
- Department of Neuroradiology (P.B.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - E Boccardi
- Department of Neuroradiology (E.B., L.V.), Niguarda Ca' Granda Hospital, Milan, Italy
| | - L Valvassori
- Department of Neuroradiology (E.B., L.V.), Niguarda Ca' Granda Hospital, Milan, Italy
| | - S Derakhshani
- Department of Neuroradiology (S.D.), Essex Center for Neurological Sciences, Queen's University Hospital, London, United Kingdom
| | | | - M J Gounis
- New England Center for Stroke Research (M.J.G.), University of Massachusetts Medical School, Worcester, Massachusetts
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Wakhloo AK, Gounis MJ. Revolution in Aneurysm Treatment: Flow Diversion to Cure Aneurysms: A Paradigm Shift. Neurosurgery 2014; 61 Suppl 1:111-20. [DOI: 10.1227/neu.0000000000000392] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ajay K. Wakhloo
- Division Neuroimaging and Intervention and New England Center for Stroke Research Departments of Radiology, Neurology and Neurosurgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Matthew J. Gounis
- Division Neuroimaging and Intervention and New England Center for Stroke Research Departments of Radiology, Neurology and Neurosurgery, University of Massachusetts Medical School, Worcester, Massachusetts
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Flow diverters for intracranial aneurysms. Stroke Res Treat 2014; 2014:415653. [PMID: 24967131 PMCID: PMC4054970 DOI: 10.1155/2014/415653] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 04/29/2014] [Indexed: 12/03/2022] Open
Abstract
Flow diverters (pipeline embolization device, Silk flow diverter, and Surpass flow diverter) have been developed to treat intracranial aneurysms. These endovascular devices are placed within the parent artery rather than the aneurysm sac. They take advantage of altering hemodynamics at the aneurysm/parent vessel interface, resulting in gradual thrombosis of the aneurysm occurring over time. Subsequent inflammatory response, healing, and endothelial growth shrink the aneurysm and reconstruct the parent artery lumen while preserving perforators and side branches in most cases. Flow diverters have already allowed treatment of previously untreatable wide neck and giant aneurysms. There are risks with flow diverters including in-stent thrombosis, perianeurysmal edema, distant and delayed hemorrhages, and perforator occlusions. Comparative efficacy and safety against other therapies are being studied in ongoing trials. Antiplatelet therapy is mandatory with flow diverters, which has highlighted the need for better evidence for monitoring and tailoring antiplatelet therapy. In this paper we review the devices, their uses, associated complications, evidence base, and ongoing studies.
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