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Kusdiansah M, Benet A, Kiko K, Okada Y, Ota N, Tanikawa R. Salvage Bypass for Intraoperative Rupture of a Blood Blister-Like Aneurysm of the Internal Carotid Artery: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:360-361. [PMID: 37856766 DOI: 10.1227/ons.0000000000000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/08/2023] [Indexed: 10/21/2023] Open
Affiliation(s)
- Muhammad Kusdiansah
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo , Hokkaido , Japan
- Department of Neurosurgery, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta , Indonesia
| | - Arnau Benet
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo , Hokkaido , Japan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Katsunari Kiko
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo , Hokkaido , Japan
| | - Yasuaki Okada
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo , Hokkaido , Japan
| | - Nakao Ota
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo , Hokkaido , Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Sapporo Teishinkai Hospital, Sapporo , Hokkaido , Japan
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Shen G, Jia Z, Zhao L, Lu G, Liu S, Shi H. The safety and efficacy of a low dose of tirofiban for early complications during and after stent-assisted coiling of ruptured intracranial aneurysms: a propensity matching study. Clin Neurol Neurosurg 2022; 214:107132. [DOI: 10.1016/j.clineuro.2022.107132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/04/2022] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
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Sayin B, Karaman A, Balci S, Akmangit İ, Daglioglu E, Arat A. Dual Stenting with New-Generation Stents for Aneurysm Embolization in Acute Subarachnoid Hemorrhage. World Neurosurg 2021; 154:e102-e108. [PMID: 34229098 DOI: 10.1016/j.wneu.2021.06.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Endosaccular treatment is the backbone of endovascular treatment for acutely ruptured aneurysms. Stent-assisted coiling is a niche technique in this context. Data on X-stenting or Y-stenting (dual crossing stenting, DCS) in the acute phase after subarachnoid hemorrhage (aSAH) are scarce, and the impact of stent properties on the outcome is unknown. We retrospectively evaluated the clinical and imaging results of DCS in patients treated for aSAH. METHODS Patients with aSAH treated with DCS were evaluated retrospectively. Patient and procedural characteristics were evaluated to determine clinical outcomes, associated complications, and follow-up imaging findings. RESULTS Sixteen procedures (16 patients; 10 women, mean age 55.8) were performed within 3.2 ± 2.6 days (range 1-10 days) of aSAH. Only the latest generation of intracranial stents (dual Neuroform Atlas-12 cases, dual Leo Baby-2 cases, Neuroform Atlas with Acclino Flex, or Leo Baby-2 cases) were used. Technical success rate was 100%; however, 25% of the procedures were complicated, leading to adverse events in 3 procedures (18.8%; 2 stent thrombosis, 1aneurysm rupture). Procedure-related morbidity and mortality and overall permanent morbidity and mortality were 6.3%, none, 6.3%, and 12.5%, respectively. No additional neurologic events were noted on a mean clinical follow-up of 160 ± 156 (range: 1-540) days. CONCLUSIONS Our findings and the patient-by-patient data we extracted from the literature suggest that DCS can be performed with new-generation, low-profile stents in aSAH if a definite procedural risk is acceptable for a specific patient. New-generation open-cell stent combinations appear as a viable choice for DCS in aSAH.
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Affiliation(s)
- Bige Sayin
- Department of Interventional Radiology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Ayberk Karaman
- Department of Neurosurgery, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Sinan Balci
- Department of Interventional Radiology, Ankara Hacettepe University, Ankara, Turkey
| | - İlkay Akmangit
- Department of Interventional Radiology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Ergun Daglioglu
- Department of Neurosurgery, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Anil Arat
- Department of Interventional Radiology, Ankara Hacettepe University, Ankara, Turkey.
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Sanchez VE, Haider AS, Rowe SE, Wahood W, Sagoo NS, Ozair A, El Ahmadieh TY, Kan P, Johnson JN. Comparison of Blister Aneurysm Treatment Techniques: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 154:e82-e101. [PMID: 34224880 DOI: 10.1016/j.wneu.2021.06.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Blood blister aneurysms are small, thin-walled, rapidly growing side-wall aneurysms that have proved particularly difficult to treat, and evidence-based guidance for treatment strategies is lacking. A systematic review and meta-analysis was performed to aggregate the available data and compare the 3 primary treatment modalities. METHODS We performed a comprehensive literature search according to PRISMA guidelines followed by an indirect meta-analysis that compares the safety and efficacy of surgical, flow-diverting stents (FDS), and other endovascular approaches for the treatment of ruptured blood blister aneurysms. RESULTS A total of 102 studies were included for quantitative synthesis, with sample sizes of 687 treated surgically, 704 treated endovascularly without FDS, and 125 treated via flow diversion. Comparatively, FDS achieved significantly reduced rates of perioperative retreatment compared with both surgical (P = 0.025) and non-FDS endovascular (P < 0.001). The FDS subgroup also achieved a significantly lower incidence of perioperative rebleed (P < 0.001), perioperative hydrocephalus (P = 0.012), postoperative infarction (P = 0.002), postoperative hydrocephalus (P < 0.001), and postoperative vasospasm (P = 0.002) compared with those patients in the open surgical subgroup. Although no significant differences were found among groups on the basis of functional outcomes, angiographic outcomes detailed by rates of radiographic complete occlusion were highest for surgical (90.7%, 262/289) and FDS (89.1%, 98/110) subgroups versus the non-FDS endovascular subgroup (82.7%, 268/324). CONCLUSIONS Flow diversion seems to be an effective treatment strategy for ruptured blood blister aneurysms, with lower rates of perioperative complications compared with surgical and other endovascular techniques, but studies investigating long-term outcomes after flow diversion warrant further study.
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Affiliation(s)
- Victoria E Sanchez
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ali S Haider
- Department of Neurosurgery, Texas A&M University College of Medicine, Bryan, Texas, USA
| | - Scott E Rowe
- Department of Surgery, Nova Southeastern University College of Osteopathic Medicine, Davie, Florida, USA
| | - Waseem Wahood
- Department of Surgery, Nova Southeastern University College of Allopathic Medicine, Davie, Florida, USA
| | - Navraj S Sagoo
- Department of Orthopaedic Surgery, University of Texas Medical Branch School of Medicine, Galveston, Texas, USA
| | - Ahmad Ozair
- Department of Neurosurgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Tarek Y El Ahmadieh
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.
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Fries F, Tomori T, Schulz-Schaeffer WJ, Jones J, Yilmaz U, Kettner M, Simgen A, Reith W, Mühl-Benninghaus R. Treatment of experimental aneurysms with a GPX embolic agent prototype: preliminary angiographic and histological results. J Neurointerv Surg 2021; 14:286-290. [PMID: 33947771 PMCID: PMC8862012 DOI: 10.1136/neurintsurg-2021-017308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022]
Abstract
Background Recently, liquid embolic agents have emerged for the endovascular treatment of cerebral aneurysms. Here we describe the in vivo performance of a novel liquid embolization agent (GPX Embolic Device). Methods Elastase-induced aneurysms were embolized with a GPX prototype under balloon assistance. Digital subtraction angiography was performed pre-deployment and immediately after, and at 5, 10, and 30 min post-deployment in 10 rabbits and at 1 month in 8 rabbits. The early post-deployment intra-aneurysmal flow was graded as unchanged, moderately diminished, or completely absent. At 1 month the status of aneurysm occlusion was evaluated. Adhesion to catheter material and migration of GPX was assessed. Results The mean aneurysm neck diameter, width, and height were 3.6±1.0 mm, 3.0±0.8 mm, and 7.4±1.4 mm, respectively. The mean dome-to-neck ratio was 0.9±0.2. Complete stagnation of intra-aneurysmal flow was observed in 9 of 10 aneurysms (90%) within 30 min of device deployment. One aneurysm showed moderately diminished intra-aneurysmal flow at 30 min. At 1 month, 8 aneurysms were completely occluded. There was no evidence of GPX adhesion to the catheter material. Histologically, a leukocyte and foreign body reaction to GPX was detectable 28 days after embolization. Conclusions This is the first preclinical study reporting the performance of a protype version of the GPX Embolic Device in a wide-neck aneurysm model. GPX showed promising results by achieving and maintaining high rates of complete angiographic occlusion, but may induce an inflammatory reaction.
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Affiliation(s)
- Frederik Fries
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Toshiki Tomori
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Walter J Schulz-Schaeffer
- Department of Neuropathology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Joshua Jones
- Engeneering and Development, FLUIDX Medical Technology, Salt Lake City, Utah, USA
| | - Umut Yilmaz
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Michael Kettner
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Andreas Simgen
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Ruben Mühl-Benninghaus
- Department of Neuroradiology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
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Winkler EA, Lee A, Yue JK, Raygor KP, Rutledge WC, Rubio RR, Josephson SA, Berger MS, Raper DMS, Abla AA. Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era. Acta Neurochir (Wien) 2021; 163:1527-1540. [PMID: 33694012 PMCID: PMC8053658 DOI: 10.1007/s00701-021-04803-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/03/2021] [Indexed: 11/28/2022]
Abstract
Background Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported. Methods Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice. Results Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome. Conclusions Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Anthony Lee
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Roberto R Rubio
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - S Andrew Josephson
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.
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Aihara M, Shimizu T, Naito I, Miyamoto N, Yamaguchi R, Aishima K, Sato K, Shintoku R, Ohtani T, Okano M, Tsukada A, Yoshimoto Y. Endovascular Treatment Strategy and Clinical Outcomes for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery Using Low-Profile Visualized Intraluminal Support Stent. World Neurosurg 2021; 149:e146-e153. [PMID: 33621674 DOI: 10.1016/j.wneu.2021.02.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/13/2021] [Accepted: 02/13/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVE It is challenging to safely treat blood blister-like aneurysms (BBAs) of the internal carotid artery. Endovascular surgery has been reported, but the optimal strategy is yet to be established. We report our endovascular treatment strategy using the Low-profile Visualized Intraluminal Support (LVIS) stent. METHODS Twelve patients with ruptured BBAs including 1 patient with 2 separate aneurysmal bulges were treated from December 2017 to January 2020. Single LVIS stent-assisted coil embolization was performed as the initial treatment. If the coil could not be placed in the aneurysm, or follow-up angiography showed persistent filling or regrowth of the aneurysm, a second LVIS stent was deployed as an overlapping stent. Clinical characteristics, treatment details, and clinical outcomes were retrospectively examined. RESULTS Single stent-assisted coiling was performed in 8 patients (69%), 2 overlapping stents with coiling in 1 (8%), a single stent in 2 (15%), and 2 overlapping stents in 2 (15%). Three patients with persistent filling or regrowth of the aneurysm were re-treated with overlapping stents. Follow-up angiography confirmed complete occlusion in 12 aneurysms (92%). No re-rupture occurred. Postoperative symptomatic ischemia was confirmed in 4 patients (33%), and all 4 patients suffered severe subarachnoid hemorrhage. Modified Rankin scale was 0-2 in 8 patients (67%). CONCLUSIONS LVIS stent-assisted coil embolization is effective in preventing re-rupture of BBAs. However, the morphology of the aneurysm may change within a short period, so careful angiographic follow-up is needed. Appropriate preoperative antiplatelet administration and optimal timing of the treatment may reduce the risk of postoperative ischemic complication.
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Affiliation(s)
- Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Isao Naito
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Naoko Miyamoto
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kaoru Aishima
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Koji Sato
- Department of Neurosurgery, National Hospital Organization Takasaki General Medical Center, Takasaki, Gunma, Japan
| | - Ryosuke Shintoku
- Department of Neurosurgery, Fukaya Red Cross Hospital, Fukaya, Saitama, Japan
| | - Toshiyuki Ohtani
- Department of Neurosurgery, Fukaya Red Cross Hospital, Fukaya, Saitama, Japan
| | - Mitsuko Okano
- Department of Neurosurgery, Hokushin General Hospital Nagano Prefectural Federation of Agricultural Cooperatives for Health and Welfare, Nakano, Nagano, Japan
| | - Akihiro Tsukada
- Department of Neurosurgery, Hokushin General Hospital Nagano Prefectural Federation of Agricultural Cooperatives for Health and Welfare, Nakano, Nagano, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Telles JPM, Solla DJF, Yamaki VN, Rabelo NN, da Silva SA, Caldas JGP, Teixeira MJ, Junior JR, Figueiredo EG. Comparison of surgical and endovascular treatments for fusiform intracranial aneurysms: systematic review and individual patient data meta-analysis. Neurosurg Rev 2020; 44:2405-2414. [PMID: 33205313 DOI: 10.1007/s10143-020-01440-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/14/2020] [Accepted: 11/12/2020] [Indexed: 12/29/2022]
Abstract
Fusiform intracranial aneurysms (FIA) are associated with significant morbidity and mortality. We carried out a systematic review and meta-analysis of individual participant data with propensity score adjustment to compare the functional and angiographic outcomes between surgical and endovascular approaches to FIA. We conducted a systematic review for articles on the treatment of FIA with individual patient-level detailing. Data from patients treated for FIA in our institution from 2010 to 2018 were also collected. The primary studied outcome was morbidity, and secondary outcomes were angiographic results and retreatment. Propensity score-adjusted mixed-effects logistic regression models evaluated treatment options, stratified by anatomical location. Compiling original and published data, there were 312 cases, of which 79 (25.3%) had open surgery, and 233 (74.5%) were treated with endovascular procedures. There were no differences between treatment groups, for neither cavernous ICA (OR 1.04, 95% CI 0.05-23.6) nor supraclinoid aneurysms (OR 7.82, 95% CI 0.65-94.4). Both size (OR 1.11, 95% CI 1.03-1.19) and initial mRS (OR 2.0, 95% CI 1.2-3.3) were risk factors for morbidity, independent of location. Neither age nor rupture status influenced the odds of posterior morbidity. Unfavorable angiographic outcomes were more common in the endovascular group for supraclinoid and vertebrobasilar aneurysms (χ2, P < 0.01). There were no differences between morbidity of surgical and endovascular treatments for FIA, regardless of aneurysm location. Size and initial mRS were correlated with functional outcomes, whereas age and rupture status were not. Microsurgery seems to yield better long-term angiographic results compared to endovascular procedures.
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Affiliation(s)
- João Paulo Mota Telles
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - Davi Jorge Fontoura Solla
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Department of Interventional Neuroradiology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vitor Nagai Yamaki
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nicollas Nunes Rabelo
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Saul Almeida da Silva
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Department of Interventional Neuroradiology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - José Guilherme Pereira Caldas
- Department of Interventional Neuroradiology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jefferson Rosi Junior
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eberval Gadelha Figueiredo
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Entezami P, Holden DN, Boulos AS, Paul AR, Field NC, Nourollahzadeh E, Yamamoto J, Dalfino JC. Cangrelor dose titration using platelet function testing during cerebrovascular stent placement. Interv Neuroradiol 2020; 27:88-98. [PMID: 32611215 DOI: 10.1177/1591019920936923] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Optimal antiplatelet inhibition is vital during cerebrovascular stenting procedures, yet no standardized recommendation exists for antithrombotic therapy in these scenarios. Cangrelor is an intravenous P2Y12 inhibitor with a favorable pharmacokinetic profile for use during neuroendovascular stenting. METHODS A retrospective review of all neuroendovascular patients who underwent stenting between 1 January 2019 and 22 March 2020 and were treated with cangrelor was conducted. Thirty-seven patients met inclusion criteria. RESULTS All patients were administered a bolus of 5 mcg/kg of cangrelor followed by a maintenance infusion. Antiplatelet effects of cangrelor were monitored using platelet reactivity units (PRU). Based on the initial PRU, seven patients' doses were adjusted with subsequent PRUs in or near the goal range of 50-150. One patient experienced an acute intraprocedural occlusion likely related to a subtherapeutic PRU which subsequently resolved with cangrelor dose adjustment and intra-arterial tirofiban administration, and one patient experienced a post-procedure stent occlusion which required a thrombectomy and intra-arterial tirofiban administration. No hemorrhagic complications occurred. DISCUSSION Cangrelor utilization during neuroendovascular stenting with maintenance doses of <2 mcg/kg/min with dose adjustments based on platelet function testing has not been previously described. Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability. CONCLUSION Cangrelor is a promising alternative to currently available therapies, especially in patients with a high hemorrhagic risk.
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Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Devin N Holden
- Department of Pharmacy, Albany Medical Center, Albany, NY, USA
| | - Alan S Boulos
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Nicholas C Field
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Emad Nourollahzadeh
- Department of Neurosurgery, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Junichi Yamamoto
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - John C Dalfino
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
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Bhogal P, Wong K, Makalanda H. The Cascade device - In vitro tests to assess coil protrusion into the parent vessel. Interv Neuroradiol 2020; 26:494-500. [PMID: 32393085 DOI: 10.1177/1591019920925708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Balloon and stent-assisted coiling of aneurysms have increased the number of aneurysms available for endovascular treatment. Newer devices that allow flow within the parent vessel but coverage at the neck have recently entered the market. The Cascade is a new non-occlusive fully retrievable neck-bridging support device that has been designed to provide temporary support during coil embolisation of intracranial aneurysms. METHODS Using a silicone aneurysm model three different aneurysms were catheterised with the coiling microcatheter placed in three different positions within each aneurysm - at the neck, centrally, and looped within the aneurysm. Multiple different coils were then deployed within each aneurysm with the Cascade device deployed across the neck to provide protection. In total 480 attempted coilings were performed. Aneurysm flow was used to calculate the change in intra-aneurysmal flow with the Cascade device deployed across the neck of the aneurysm. RESULTS We did not observe a single episode of coil protrusion through the Cascade mesh nor did we observe any coil protrusion into the parent vessel when the Cascade was deployed across the neck. There was an average flow velocity reduction of 23% with the Cascade device deployed across the neck of the aneurysm. CONCLUSION The Cascade device offers robust protection of the aneurysmal neck and parent vessel as well as inducing significant intra-aneurysmal flow velocity reduction.
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Affiliation(s)
- P Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - K Wong
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Hld Makalanda
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
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