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Uysal A, Cay F, Balcı S, Arat A. Initial Experience with the Derivo 2Heal Flow Diverter under Standard or Reduced-Dose Single Antiplatelet Therapy. AJNR Am J Neuroradiol 2024:ajnr.A8292. [PMID: 39025640 DOI: 10.3174/ajnr.a8292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/09/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND AND PURPOSE Flow diverters with surface modifications or coatings have been recently introduced to clinical practice with the expectation that they can reduce the rate of thromboembolic complications and residual aneurysms. The purpose of this study is to evaluate the utility of the Derivo 2Heal (D2H) device, a new fibrin and heparin-coated flow diverter. MATERIALS AND METHODS Patients treated by a single operator by using the D2H were retrospectively evaluated for demographic data, aneurysm characteristics, procedural variables, and follow-up data. All patients were treated by using a single D2H, monitored by platelet function testing and kept under single antiplatelet therapy with regular or half-dose clopidogrel or prasugrel after the procedure. RESULTS Twenty patients with 26 aneurysms were treated. Three presented acutely with subarachnoid hemorrhage. Adjunctive devices were used in 6 patients. There were no technical failures and 2 periprocedural self-limited nonthrombotic minor adverse events. During follow-up, 1 of the acutely ruptured aneurysms reruptured, and 1 patient had a visual TIA. All patients were doing well clinically (19 with mRS of 0 and 1 with 1) at the last follow-up after discharge. The rates of total occlusion on very early angiographic (MRA/CTA or DSA, mean: 2.4 months), DSA (mean: 5.8 months), and midterm angiographic (mean: 14.5 months) follow-up for all versus uncoiled aneurysms were 68% versus 70%, 77.8% versus 90.0%, and 91.7% versus 90.1%, respectively. CONCLUSIONS The absence of permanent neurologic deficits in the periprocedural period and favorable occlusion rates in this preliminary study suggest that the novel coating comprising fibrin and heparin may have the potential to increase the safety and efficacy of flow diversion and needs to be further studied by comparing the D2H device with its bare counterpart and other coated or surface-modified flow diverters.
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Affiliation(s)
- Aycan Uysal
- From the Hacettepe University Faculty of Medicine (A.U., F.C., S.B, A.A.), Ankara, Turkey
| | - Ferdi Cay
- From the Hacettepe University Faculty of Medicine (A.U., F.C., S.B, A.A.), Ankara, Turkey
| | - Sinan Balcı
- From the Hacettepe University Faculty of Medicine (A.U., F.C., S.B, A.A.), Ankara, Turkey
| | - Anıl Arat
- From the Hacettepe University Faculty of Medicine (A.U., F.C., S.B, A.A.), Ankara, Turkey
- Department of Neurosurgery (A.A.), Yale University, New Haven, Connecticut
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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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King RM, Peker A, Epshtein M, Arends JM, Brochu AB, Raskett CM, Slazas KJ, Puri AS, Arthur AS, Fiorella D, Gounis MJ, Anagnostakou V. Active drug-coated flow diverter in a preclinical model of intracranial stenting. J Neurointerv Surg 2024; 16:731-736. [PMID: 37399337 DOI: 10.1136/jnis-2023-020391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/18/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Flow diverters carry the risk of thromboembolic complications (TEC). We tested a coating with covalently bound heparin that activates antithrombin to address TEC by locally downregulating the coagulation cascade. We hypothesized that the neuroimaging evidence of TEC would be reduced by the coating. METHODS 16 dogs were implanted with overlapping flow diverters in the basilar artery, separated into two groups: heparin-coated (n=9) and uncoated (n=7). Following implantation, high-frequency optical coherence tomography (HF-OCT) was acquired to quantify acute thrombus (AT) formation on the flow diverters. MRI was performed postoperatively and repeated at 1, 2, 3, 4, and 8 weeks, consisting of T1-weighted imaging, time-0f-flight (ToF), diffusion weighted imaging (DWI), susceptibility weighted imaging (SWI), and fluid attenuated inversion recovery (FLAIR) sequences. Neurological examinations were performed throughout the 8-week duration of the study. RESULTS The mean AT volume on coated devices was lower than uncoated (0.014 vs 0.018 mm3); however, this was not significant (P=0.3). The mean number of foci of magnetic susceptibility artifacts (MSAs) on SWI was significantly different between the uncoated and coated groups at the 1-week follow-up (P<0.02), and remained statistically different throughout the duration of the study. The AT volume showed a direct linear correlation with the MSA count and 80% of the variance in the MSA could be explained by the AT volume (P<0.001). Pathological analysis showed evidence of ischemic injury at locations of MSA. CONCLUSIONS Heparin-coated flow diverters significantly reduced the number of new MSAs after 1 week follow-up, showing the potential to reduce TEC.
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Affiliation(s)
- Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ahmet Peker
- Radiology, Koç University Hospital, Istanbul, Turkey
| | - Mark Epshtein
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | | | - Alice B Brochu
- Research and Development, Stryker Neurovascular, Fremont, California, USA
| | - Christopher M Raskett
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Kimiko J Slazas
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Vania Anagnostakou
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Bilgin C, Senol YC, Kobeissi H, Orscelik A, Ghozy S, Oliver AA, Kadirvel R, Brinjikji W, Kallmes DF. Phenox HPC and Phenox flow modulation devices for the endovascular treatment of intracranial aneurysms: a systematic review and meta-analysis. J Neurointerv Surg 2024; 16:706-714. [PMID: 37536930 DOI: 10.1136/jnis-2023-020514] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/12/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Surface-modified flow diverters are increasingly used in clinical settings. However, their safety profiles and additional benefits over non-coated devices still need to be explored. In this meta-analysis, we aimed to investigate and compare the clinical outcomes of the uncoated Phenox and coated Phenox HPC flow diverters. METHODS A systematic literature review was performed using PubMed, Scopus, Embase, and Web of Science databases. Collected data were pooled and corresponding 95% confidence intervals (CI) were calculated. Outcomes of interest included aneurysm occlusion (>6 months) and complication rates. Additionally, the safety outcomes of prophylactic single (SAPT) and dual antiplatelet treatment (DAPT) approaches were compared for patients treated with coated Phenox HPC flow diverters. RESULTS We included 17 studies with 1238 patients. The overall complete occlusion rates were 80% (95% CI 74.01% to 86.56%) for Phenox HPC and 71.3% (95% CI 59.71% to 85.20%) for non-coated Phenox flow diverters (p=0.24). Ischemic complication rates were 7.3% (95% CI 4.6% to 11.39%) with the Phenox HPC and 5.3% (95% CI 4.07% to 6.91%) with the Phenox (p=0.24). For patients treated with Phenox HPC, the SAPT (5.5%; 95% CI 2.83% to 10.85%) and DAPT (7.1%; 95% CI 1.23% to 41.45%) approaches resulted in comparable ischemic complication rates (p=0.79). The DAPT group (4.8%; 95% CI 1.46% to 16.24%) had higher hemorrhagic complication rates than the SAPT group (1.7%; 95% CI 0.52% to 6.09%), but the difference was not statistically significant for patients treated with Phenox HPC (p=0.25). CONCLUSIONS Our findings indicate that Phenox HPC is equally as safe and effective as non-coated Phenox devices. Additionally, our results suggest that prasugrel monotherapy might effectively prevent ischemic complications in patients treated with Phenox HPC flow diverters.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Atakan Orscelik
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Pielenz D, Klisch J, Fiorella D, Gawlitza M, Steinbrecher A, Leinisch E, Lobsien E, Hoffmann KT, Lobsien D. The pEGASUS-HPC stent system for intracranial arterial stenosis: a single-center case series. J Neurointerv Surg 2024:jnis-2024-021737. [PMID: 38760166 DOI: 10.1136/jnis-2024-021737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Intracranial arterial stenting is a technique for the treatment of symptomatic stenosis. In this single-center retrospective case series we evaluated a novel low profile laser-cut stent with an antithrombogenic hydrophilic polymer coating (pEGASUS-HPC, Phenox GmbH, Bochum, Germany) for the treatment of intracranial stenosis in the setting of acute ischemic stroke and elective cases. METHODS All patients treated with pEGASUS-HPC for one or more intracranial arterial stenoses at our institution were retrospectively included. Clinical, imaging and procedural parameters as well as clinical and imaging follow-up data were collected. RESULTS We performed 43 interventions in 41 patients with 42 stenoses in our neurovascular center between August 2021 and February 2024. Twenty-one patients (51.2%) were female and the mean±SD age was 71±10.8 years. Thirty-seven (86.1%) procedures were performed in the setting of endovascular acute ischemic stroke treatment. Technical or procedural complications occurred in seven patients (16.3%), six in the thrombectomy group and one in the elective group. One stent-related hemorrhagic complication (subarachnoid hemorrhage) occurred in emergency cases and symptomatic intracerebral hemorrhage occurred in one patient treated in an elective setting. Overall stenosis reduction following pEGASUS-HPC stent implantation was 53.0±18.0%. On follow-up imaging, which was available for 16 patients (37.2%) after an average of 32±58.6 days, 62.5% of the stents were patent. CONCLUSION Our single-center case series demonstrates the feasibility of using the pEGASUS-HPC stent system, especially in emergency situations when thrombectomy fails.
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Affiliation(s)
- Daniel Pielenz
- Department of Neuroradiology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Joachim Klisch
- Department of Neuroradiology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
- Department of Neuroradiology, Helios Vogtland Hospital Plauen, Plauen, Sachsen, Germany
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - Matthias Gawlitza
- University Hospital Leipzig Institute for Neuroradiology, Leipzig, Sachsen, Germany
| | | | - Elke Leinisch
- Department of Neurology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Elmar Lobsien
- Department of Neurology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Karl-Titus Hoffmann
- University Hospital Leipzig Institute for Neuroradiology, Leipzig, Sachsen, Germany
| | - Donald Lobsien
- Department of Neuroradiology, Helios Hospital Erfurt, Erfurt, Thüringen, Germany
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6
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Hohenstatt S, Saatci I, Jesser J, Çekirge HS, Koçer N, Islak C, Lücking H, DuPlessis J, Rautio R, Bendszus M, Vollherbst DF, Möhlenbruch MA. Prasugrel Single Antiplatelet Therapy versus Aspirin and Clopidogrel Dual Antiplatelet Therapy for Flow Diverter Treatment for Cerebral Aneurysms: A Retrospective Multicenter Study. AJNR Am J Neuroradiol 2024; 45:592-598. [PMID: 38453414 DOI: 10.3174/ajnr.a8163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/07/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE The optimal antiplatelet regimen after flow diverter treatment of cerebral aneurysms is still a matter of debate. A single antiplatelet therapy might be advantageous in determined clinical scenarios. This study evaluated the efficacy and safety of prasugrel single antiplatelet therapy versus aspirin and clopidogrel dual antiplatelet therapy. MATERIALS AND METHODS We performed a post hoc analysis of 4 retrospective multicenter studies including ruptured and unruptured aneurysms treated with flow diversion using either prasugrel single antiplatelet therapy or dual antiplatelet therapy. Primary end points were the occurrence of any kind of procedure- or device-related thromboembolic complications and complete aneurysm occlusion at the latest radiologic follow-up (mean, 18 months). Dichotomized comparisons of outcomes were performed between single antiplatelet therapy and dual antiplatelet therapy. Additionally, the influence of various patient- and aneurysm-related variables on the occurrence of thromboembolic complications was investigated using multivariable backward logistic regression. RESULTS A total of 222 patients with 251 aneurysms were included, 90 (40.5%) in the single antiplatelet therapy and 132 (59.5%) in the dual antiplatelet therapy group. The primary outcome-procedure- or device-related thromboembolic complications-occurred in 6 patients (6.6%) of the single antiplatelet therapy and in 12 patients (9.0%) of the dual antiplatelet therapy group (P = .62; OR, 0.712; 95% CI, 0.260-1.930). The primary treatment efficacy end point was reached in 82 patients (80.4%) of the single antiplatelet therapy and in 115 patients (78.2%) of the dual antiplatelet therapy group (P = .752; OR, 1.141; 95% CI, 0.599-2.101). Logistic regression showed that non-surface-modified flow diverters (P = .014) and fusiform aneurysm morphology (P = .004) significantly increased the probability of thromboembolic complications. CONCLUSIONS Prasugrel single antiplatelet therapy after flow diverter treatment may be as safe and effective as dual antiplatelet therapy and could, therefore, be a valid alternative in selected patients. Further prospective comparative studies are required to validate our findings.
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Affiliation(s)
- Sophia Hohenstatt
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - Işıl Saatci
- Interventional Neuroradiology Section (I.S., H.S.C.), Koru and Bayindir Private Hospitals, Ankara, Turkey
| | - Jessica Jesser
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - H Saruhan Çekirge
- Interventional Neuroradiology Section (I.S., H.S.C.), Koru and Bayindir Private Hospitals, Ankara, Turkey
| | - Naci Koçer
- Department of Neuroradiology (N.K., CI.), Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Civan Islak
- Department of Neuroradiology (N.K., CI.), Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Hannes Lücking
- Department of Neuroradiology (H.L.), University of Erlangen-Nuremberg, Erlangen, Germany
| | - Johannes DuPlessis
- Department of Clinical Neurosciences (J.D.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Riitta Rautio
- Department of Interventional Radiology (R.R.), Turku University Hospital, Turku, Finland
| | - Martin Bendszus
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - Dominik F Vollherbst
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
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Ma L, Hoz SS, Al-Bayati AR, Nogueira RG, Lang MJ, Gross BA. Flow Diverters with Surface Modification in Patients with Intracranial Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 185:320-326.e17. [PMID: 38160909 DOI: 10.1016/j.wneu.2023.12.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/24/2023] [Accepted: 12/25/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Flow diverters with surface modification (FDSM) are increasingly being used in the treatment of intracranial aneurysms (ANs). We aimed to evaluate the effectiveness and safety across different devices and antiplatelet therapies using a systematic review and meta-analysis. METHODS A systematic review was performed to identify original studies of ≥10 patients with intracranial ANs treated with FDSM from database inception through August 2023. Primary effectiveness outcome was the rate of complete AN occlusion at follow-up ≥6 months. Safety outcomes included ischemic stroke, hemorrhage, and in-stent thrombosis, and were stratified by FDSM devices and antiplatelet therapies. Certainty of evidence was evaluated following the Grading of Recommendations, Assessment, Development, and Evaluations approach. RESULTS Twenty-seven studies were included, yielding 2161 patients with 2373 ANs. A total of 70.5% of the ANs were located on the internal carotid artery (ICA). Total 10.3% were acutely ruptured. The complete AN occlusion rate was 72.3% at follow-up ≥6 months. Sensitivity analysis in the ICA AN cohort yielded comparable occlusion rates between Pipeline Flex Embolization Device-Shield (80.4%) and Phenox-hydrophilic polymer-coated (77.5%, P = 0.54), but a lower 66.2% rate for Flow Redirection Endoluminal Device-X (P = 0.02). The rate of in-stent thrombosis and stenosis tended to be higher in Phenox-hydrophilic polymer-coated (3.4%) and Flow Redirection Endoluminal Device-X (4.3%) versus Pipeline Flex Embolization Device-Shield (0.8%, P = 0.05). CONCLUSIONS FDSM were safe with satisfactory effectiveness for intracranial ANs. More specific investigations are warranted to explore their performance in ANs beyond the ICA and optimal antiplatelet therapy.
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Affiliation(s)
- Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samer S Hoz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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8
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Enomoto Y, Matsubara H, Ishihara T, Shoda K, Mizutani D, Egashira Y, Ishii A, Sakamoto M, Sumita K, Nakagawa I, Higashi T, Yoshimura S. Optimal duration of dual antiplatelet therapy for stent-assisted coiling or flow diverter placement. J Neurointerv Surg 2024; 16:491-497. [PMID: 37344176 PMCID: PMC11041548 DOI: 10.1136/jnis-2023-020285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/04/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is necessary to prevent thromboembolic complications after stent-assisted coiling (SAC) or flow-diversion (FD) for cerebral aneurysms, but the optimal antiplatelet regimen remains unclear. OBJECTIVE To determine the optimal DAPT duration in patients with SAC/FD. METHODS This multicenter cohort study enrolled patients who received SAC/FD for cerebral aneurysms at seven Japanese institutions between January 2010 and December 2020. The primary outcome was the time from procedure to the occurrence of a composite of target vessel-related thromboembolic events, procedure-unrelated major bleeding events, or death. The cumulative event-free survival rates were analyzed using a Kaplan-Meier curve, and the differences in each outcome between the groups dichotomized by the duration of DAPT were analyzed using the log-rank test. RESULTS Of 632 patients (median observational period, 646 days), primary outcome occurred in 63 patients (10.0%), most frequently within 30 days after the procedure. The cumulative event-free survival rates at 30 days, 1 year, and 2 years after the procedure were 93.3% (91.4 to 95.3%), 91.5% (89.3 to 93.7%), and 89.5% (87.0 to 92.0%), respectively. The cumulative event-free survival rates after switching to monotherapy were similar for the >91 and <90 days DAPT groups in the population limited to patients who were switched from DAPT to monotherapy without major clinical events. CONCLUSIONS Thromboembolic events rarely occurred beyond 30 days after SAC/FD. The duration of DAPT may be shortened if patients have a periprocedural period without events. Further prospective studies are warranted to determine the optimal duration of antiplatelet therapy. TRIAL REGISTRATION NUMBER UMIN000044122 :https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000050384.
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Affiliation(s)
- Yukiko Enomoto
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | | | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Kenji Shoda
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | - Daisuke Mizutani
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | - Yusuke Egashira
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | - Akira Ishii
- Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Makoto Sakamoto
- Division of Neurosurgery, Department of Neurological Sciences, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Kazutaka Sumita
- Endovascular surgery, Tokyo Medical and Dental University, Bunkyo-ku, Japan
| | - Ichiro Nakagawa
- Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Toshio Higashi
- Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
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Goertz L, Hohenstatt S, Vollherbst DF, Weyland CS, Nikoubashman O, Styczen H, Gronemann C, Weiss D, Kaschner M, Pflaeging M, Siebert E, Zopfs D, Kottlors J, Pennig L, Schlamann M, Bohner G, Liebig T, Turowski B, Dorn F, Deuschl C, Wiesmann M, Möhlenbruch MA, Kabbasch C. Safety and efficacy of coated flow diverters in the treatment of ruptured intracranial aneurysms: a retrospective multicenter study. J Neurointerv Surg 2024:jnis-2024-021516. [PMID: 38569886 DOI: 10.1136/jnis-2024-021516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/07/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND This multicenter study evaluated the safety and efficacy of coated flow diverters (cFDs) for the treatment of ruptured intracranial aneurysms. METHODS Consecutive patients treated with different cFDs for ruptured aneurysms under tirofiban at eight neurovascular centers between 2016 and 2023 were retrospectively analyzed. The majority of patients were loaded with dual antiplatelet therapy after the treatment. Aneurysm occlusion was determined using the O'Kelly-Marotta (OKM) grading scale. Primary outcome measures were major procedural complications and aneurysmal rebleeding during hospitalization. RESULTS The study included 60 aneurysms (posterior circulation: 28 (47%)) with a mean size of 5.8±4.7 mm. Aneurysm morphology was saccular in 28 (47%), blister-like in 12 (20%), dissecting in 13 (22%), and fusiform in 7 (12%). Technical success was 100% with a mean of 1.1 cFDs implanted per aneurysm. Adjunctive coiling was performed in 11 (18%) aneurysms. Immediate contrast retention was observed in 45 (75%) aneurysms. There was 1 (2%) major procedural complication (a major stroke, eventually leading to death) and no aneurysmal rebleeding. A good outcome (modified Rankin Scale 0-2) was achieved in 40 (67%) patients. At a mean follow-up of 6 months, 27/34 (79%) aneurysms were completely occluded (OKM D), 3/34 (9%) had an entry remnant (OKM C), and 4/34 (12%) had residual filling (OKM A or B). There was 1 (3%) severe in-stent stenosis during follow-up that was treated with balloon angioplasty. CONCLUSIONS Treatment of ruptured aneurysms with cFDs was reasonably safe and efficient and thus represents a valid treatment option, especially for complex cases.
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Affiliation(s)
- Lukas Goertz
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Sophia Hohenstatt
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | | | - Daniel Weiss
- Department of Neuroradiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marius Kaschner
- Department of Neuroradiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Muriel Pflaeging
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, University Hospital Berlin (Charité), Berlin, Germany
| | - David Zopfs
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Jonathan Kottlors
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Lenhard Pennig
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Marc Schlamann
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Georg Bohner
- Department of Neuroradiology, University Hospital Berlin (Charité), Berlin, Germany
| | - Thomas Liebig
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Bernd Turowski
- Department of Neuroradiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Kabbasch
- Department of Radiology and Neuroradiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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10
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Khanafer A, Henkes H, Cohen J, Albiña-Palmarola P, Gomori JM, Forsting M, von Gottberg P. Endovascular treatment of distal anterior cerebral artery aneurysms using flow modulation devices: mid- and long-term results from a two-center study. Front Neurol 2024; 15:1368612. [PMID: 38529030 PMCID: PMC10962386 DOI: 10.3389/fneur.2024.1368612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/28/2024] [Indexed: 03/27/2024] Open
Abstract
Purpose Flow-diverter (FD) stents have become an established treatment for intracranial aneurysms in recent years, but their use for aneurysms in distal cerebral vessels with small carrier vessel diameters remains controversial. This study describes the method and mid- and long-term outcomes of FD treatment of distal anterior cerebral artery aneurysms (DACAAs) at two neurointerventional centers, to elucidate this topic and provide more in-depth data. Methods Data for all patients at two neurointerventional centers who were treated with FDs for DACAAs in the pericallosal and supracallosal segment of the anterior cerebral artery were retrospectively analyzed. Data on periprocedural complications, and short-, mid- and long-term follow-up findings were recorded. Results Forty-one patients were eligible for inclusion in the study. Three FD models were used, one of which had an anti-thrombotic coating. Two periprocedural complications (5%) occurred but did not cause a change in the mRS. In the long-term follow-up, at 29 months and beyond, 83% of assessable patients showed complete occlusion of the aneurysms without new neurological deficits. Conclusion FDs are a safe and effective treatment approach for DACAAs. This study indicated a low risk of complications, and high closure rates in short-, mid- and long-term follow-up.
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Affiliation(s)
- Ali Khanafer
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
| | - Jose Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Pablo Albiña-Palmarola
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
| | - John Moshe Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michael Forsting
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
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11
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Suyama K, Nakahara I, Matsumoto S, Morioka J, Tanabe J, Hasebe A, Watanabe S. Efficacy and Safety of Dual Antiplatelet Therapy with the Routine Use of Prasugrel for Flow Diversion of Cerebral Unruptured Aneurysms. Clin Neuroradiol 2024; 34:201-208. [PMID: 37847296 PMCID: PMC10881594 DOI: 10.1007/s00062-023-01355-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/26/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE Prasugrel is not approved for patients treated with flow diverters, which have a high metal coverage ratio. However, robust antiplatelet therapy with prasugrel may prevent thromboembolic complications. We administered prasugrel and aspirin to all patients treated with flow diverters and reported the safety of the antiplatelet therapy regimen. METHODS This retrospective, single-center study evaluated the angiographic and clinical data of consecutive patients treated with flow diverters for cerebral unruptured aneurysms between June 2020 and May 2022. All patients received dual antiplatelet therapy, including prasugrel and aspirin. The administration of prasugrel ended 3 or 6 months after the procedure, whereas aspirin use continued for at least 12 months. Periprocedural complications (< 30 days post-procedure) and delayed complications (> 30 days post-procedure) were recorded. RESULTS During the study period, 120 unruptured aneurysms were treated with flow diverters in 110 patients. All patients, except one, survived longer than 12 months after the procedure. The rate of thromboembolic complications was 6.4%, and more than half of the patients had transient symptoms; one (0.9%) had a major ischemic stroke. One patient (0.9%) each had an asymptomatic, small subarachnoid hemorrhage and significant hemorrhagic complications with melena. The rate of permanent neurological deficits was 1.8%, and the mortality rate was 0.9%. CONCLUSIONS Dual antiplatelet therapy comprising routine use of prasugrel and aspirin for flow diverter-implanted patients possibly contributed to a low rate of thromboembolic complications and low risk of hemorrhagic complications.
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Affiliation(s)
- Kenichiro Suyama
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan.
| | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Shoji Matsumoto
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Jun Morioka
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Jun Tanabe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Akiko Hasebe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Sadayoshi Watanabe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
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12
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Ernst M, Jamous A, Bartl M, Riedel CH, Holtmannspötter M, Voit-Höhne H, Grieb D, Schlunz-Hendann M, Fiebig T, Fiorella D, Klisch J, Lobsien D. Multicenter study of the safety and effectiveness of intracranial aneurysm treatment with the p64MW-HPC flow modulation device. Interv Neuroradiol 2023:15910199231220964. [PMID: 38105527 DOI: 10.1177/15910199231220964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND AND PURPOSE The new p64 flow diverter with hydrophilic polymer coating (HPC) was designed to reduce thrombogenicity. To date, it is unclear how antithrombogenic surface modifications affect neoendothelialization and thrombus formation in patients with unruptured intracranial aneurysms. The purpose of this study was to evaluate the safety and effectiveness of the p64MW-HPC in the treatment of unruptured aneurysms of small to giant size and of both the anterior and posterior circulation. MATERIALS AND METHODS Between March 2020 and October 2022 all patients with unruptured intracranial aneurysms treated with the p64MW-HPC were included at five neurovascular centers. Demographic data, aneurysm characteristics, antiplatelet therapy, procedural complications, and clinical and angiographic outcomes were recorded. RESULTS A total of 100 patients with 100 unruptured intracranial aneurysms met the inclusion criteria. Eighty-three aneurysms were classified as saccular, 12 aneurysms were fusiform, 4 aneurysms dissecting, and 1 aneurysm was blister-like. Dual antiplatelet therapy with Clopidogrel and Aspirin was given in 68 cases, and with Ticagrelor and Aspirin in 24 cases. Technical issues with deployment were encountered in 14 cases (torsion (n = 3), foreshortening (n = 8), and incomplete opening (n = 3)). Ischemic stroke occurred in a total of seven cases. In one patient a wire perforation and subsequent severe ICH occurred. Complete aneurysm occlusion at angiographic follow-up (mean time = 7 months) was seen in 73% and adequate occlusion in 93%. CONCLUSION This study is the largest multicenter study to date documenting the safety and effectiveness of the new antithrombogenic p64MW-HPC in the treatment of unruptured intracranial aneurysms of the anterior and posterior circulation.
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Affiliation(s)
- M Ernst
- Institute of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - A Jamous
- Institute of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - M Bartl
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - C H Riedel
- Institute of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - M Holtmannspötter
- Institute of Radiology und Neuroradiology, Paracelsus Medical University, Nuremberg, Germany
| | - H Voit-Höhne
- Institute of Radiology und Neuroradiology, Paracelsus Medical University, Nuremberg, Germany
| | - D Grieb
- Department of Radiology and Neuroradiology, Klinikum Duisburg-Sana Kliniken, Duisburg, Germany
- Department of Diagnostic and Interventional Neuroradiology, Medical School Hannover, Hannover, Germany
| | - M Schlunz-Hendann
- Department of Radiology and Neuroradiology, Klinikum Duisburg-Sana Kliniken, Duisburg, Germany
| | - T Fiebig
- Department of Radiology, Helios Klinikum Meiningen, Meiningen, Germany
| | - D Fiorella
- Cerebovascular Center, Stony Brook University, Stony Brook, NY, USA
| | - J Klisch
- Institute of Diagnostic and Interventional Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - D Lobsien
- Institute of Diagnostic and Interventional Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
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13
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White TG, Santhumayor BA, Turpin J, Shah K, Toscano D, Teron I, Link T, Patsalides A, Woo HH. Flow diverter surface modifications for aneurysm treatment: A review of the mechanisms and data behind existing technologies. Interv Neuroradiol 2023:15910199231207550. [PMID: 37899636 DOI: 10.1177/15910199231207550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023] Open
Abstract
Flow diversion (FD) has become a mainstay treatment for large wide-necked aneurysms. Despite excellent safety and efficacy, the risk of thromboembolic complications necessitates the use of dual antiplatelet therapy (DAPT). The use of DAPT makes hemorrhagic complications of stenting carry high morbidity and mortality. Additionally, DAPT usage carries a risk of "nuisance" complications that do not directly impact intracranial circulation but need to be managed nonetheless. To circumvent this issue, the most recent generation of flow diverters have undergone surface modification with various compounds to confer blood compatibility to limit clotting and thrombosis. While these newer generation flow diverters are marketed to enhance ease of deployment, the goal is to eventually facilitate single antiplatelet use with flow diverter treatment. This generation of FDs have potential to expand indications beyond unruptured wide-necked aneurysms to include ruptured intracranial aneurysms without the necessity of DAPT. Currently, no comprehensive review details the molecular mechanisms and pre-clinical and clinical data on these modifications. We seek to fill this gap in the literature by consolidating information on the coating technology for four major FDs currently in clinical use-PipelineTM Flex and Vantage Shield TechnologyTM, FREDTMX, p48/64 hydrophilic coating, and Acandis Dervio® 2heal-to serve as a reference guide in neurointerventional aneurysm treatment. Although the Balt silkTM was one of the first FDs, it is uncoated, thus we will not cover this device in our review. A literature review was performed to obtain information on each coating technology for the major flow diverters currently on the market using international databases (PUBMED, Embase, Medline, Google Scholar). The search criteria used the keywords for each coating technology of interest "phosphorylcholine," "poly 2-methoxyethyl acrylate," "hydrophilic polymer coating," and "fibrin-heparin" Keywords related to the device names "Pipeline Shield," "Pipeline Shield with Flex Technology," "FRED," "FREDX," "p64," "p64-HPC," "Derivo 2heal" were also used. Studies that detailed the mechanism of action of the coating, any pre-clinical studies with surface-modified intravascular devices, and any clinical retrospective series, prospective series, or randomized clinical trials with surface-modified devices for aneurysm treatment were included.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Brandon A Santhumayor
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Kevin Shah
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Daniel Toscano
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Ina Teron
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Thomas Link
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Athos Patsalides
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
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14
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Zoppo CT, Mocco J, Manning NW, Bogdanov AA, Gounis MJ. Surface modification of neurovascular stents: from bench to patient. J Neurointerv Surg 2023:jnis-2023-020620. [PMID: 37793794 DOI: 10.1136/jnis-2023-020620] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
Flow-diverting stents (FDs) for the treatment of cerebrovascular aneurysms are revolutionary. However, these devices require systemic dual antiplatelet therapy (DAPT) to reduce thromboembolic complications. Given the risk of ischemic complications as well as morbidity and contraindications associated with DAPT, demonstrating safety and efficacy for FDs either without DAPT or reducing the duration of DAPT is a priority. The former may be achieved by surface modifications that decrease device thrombogenicity, and the latter by using coatings that expedite endothelial growth. Biomimetics, commonly achieved by grafting hydrophilic and non-interacting polymers to surfaces, can mask the device surface with nature-derived coatings from circulating factors that normally activate coagulation and inflammation. One strategy is to mimic the surfaces of innocuous circulatory system components. Phosphorylcholine and glycan coatings are naturally inspired and present on the surface of all eukaryotic cell membranes. Another strategy involves linking synthetic biocompatible polymer brushes to the surface of a device that disrupts normal interaction with circulating proteins and cells. Finally, drug immobilization can also impart antithrombotic effects that counteract normal foreign body reactions in the circulatory system without systemic effects. Heparin coatings have been explored since the 1960s and used on a variety of blood contacting surfaces. This concept is now being explored for neurovascular devices. Coatings that improve endothelialization are not as clinically mature as anti-thrombogenic coatings. Coronary stents have used an anti-CD34 antibody coating to capture circulating endothelial progenitor cells on the surface, potentially accelerating endothelial integration. Similarly, coatings with CD31 analogs are being explored for neurovascular implants.
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Affiliation(s)
- Christopher T Zoppo
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - J Mocco
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathan W Manning
- The MIRI Centre, Ingham Institute for Applied Medical Science, Sydney, New South Wales, Australia
- Department of Interventional Radiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Alexei A Bogdanov
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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15
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Goertz L, Zopfs D, Schönfeld M, Zaeske C, Pennig L, Brinker G, Schlamann M, Kabbasch C. First clinical experience with the Derivo 2heal embolization device for the treatment of intracranial aneurysms. Interv Neuroradiol 2023:15910199231193577. [PMID: 37574801 DOI: 10.1177/15910199231193577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
OBJECTIVE The development of new flow-diverting devices with antithrombotic coatings may result in an improved safety profile, particularly a reduction in ischaemic stroke rates. The aim of this study was to evaluate our initial experience with the recently introduced coated Derivo® 2heal® Embolization Device (Acandis, Pforzheim, Germany). METHODS This is a retrospective, single-centre analysis of patients with intracranial aneurysms undergoing Derivo® 2heal® Embolization Device treatment. Patient and aneurysm characteristics, procedural parameters, complications, and degree of initial and short-term aneurysm occlusion were evaluated on an intention-to-treat basis. RESULTS A total of 16 unruptured aneurysms in 9 patients were treated with the Derivo® 2heal® Embolization Device in 10 treatment sessions. In one case the Derivo® 2heal® Embolization Device could not be deployed due to severe friction in the microcatheter. In all successful cases, one Derivo® 2heal® Embolization Device was sufficient to treat the target aneurysm and no additional coiling was performed. In-stent balloon angioplasty was performed in one procedure (10%) to improve vessel wall apposition. Twelve arterial side branches were covered in 9 procedures and all were patent at the end of the procedure. There were no clinical complications and no thromboembolic events during treatment. At the end of the procedure, contrast retention was observed in 13/16 (81%) aneurysms and at short-term follow-up, 6/9 (67%) were completely occluded. CONCLUSIONS The preliminary results of the new Derivo® 2heal® Embolization Device appear promising and warrant further evaluation by multicentre studies with long-term follow-up.
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Affiliation(s)
- Lukas Goertz
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Strasse 62, Cologne, Germany
| | - David Zopfs
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Strasse 62, Cologne, Germany
| | - Michael Schönfeld
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Strasse 62, Cologne, Germany
| | - Charlotte Zaeske
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Strasse 62, Cologne, Germany
| | - Lenhard Pennig
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Strasse 62, Cologne, Germany
| | - Gerrit Brinker
- Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Kerpener Strasse 62, Cologne, Germany
| | - Marc Schlamann
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Strasse 62, Cologne, Germany
| | - Christoph Kabbasch
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Strasse 62, Cologne, Germany
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16
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Sirakova K, Sirakov A, Ninov K, Minkin K, Sirakov S. Comaneci stent-angioplasty for the optimization of inadequately deployed flow diverter stents. Interv Neuroradiol 2023:15910199231184520. [PMID: 37402394 DOI: 10.1177/15910199231184520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND AND PURPOSE In endovascular procedures, inadequate deployment of a flow diverter stent is a highly concerning technical complication that can lead to acute parent vessel occlusion and ischaemic events. This study aimed to assess the off-label use of the Comaneci device in managing technical difficulties associated with flow diversion. MATERIALS AND METHODS We conducted an analysis of all flow diverter procedures documented in our prospectively collected database. Our objective was to identify patients with inadequately deployed implants who underwent Comaneci stent-angioplasty. Both Comaneci 17 and Comaneci 21 devices were utilized to address and remediate technical complications related to stent deployment. We reviewed anatomical features, technical details, intraprocedural complications, as well as clinical and angiographic outcomes. RESULTS Thirty-one Comaneci devices were employed to remediate 31 inadequately deployed flow diverter stents. Successful resolution of technical complications associated with flow diverter placement was achieved in all attempted cases. No clinically significant complications were attributed to the technique, and no mortality was observed during the study. CONCLUSION Technical issues arising from flow diverter stent deployment are formidable complications. Familiarity with appropriate corrective manoeuvres is essential to achieve successful outcomes. The Comaneci device can be safely and effectively incorporated into the range of techniques used to rectify inadequately deployed stents.
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Affiliation(s)
| | | | - Kristian Ninov
- Neurosurgery Department, UH St Ivan Rilski, Sofia, Bulgaria
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17
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Ma Y, Madjidyar J, Schubert T, Thurner P, Barnaure I, Kulcsar Z. Single antiplatelet regimen in flow diverter treatment of cerebral aneurysms: The drug matters. A systematic review and meta-analysis. Interv Neuroradiol 2023:15910199231177745. [PMID: 37221854 DOI: 10.1177/15910199231177745] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Hemorrhagic and thromboembolic complications (TECs) are the main concerns in the endovascular treatment of intracranial aneurysms using flow diverter devices (FDs). The clinical demand for single antiplatelet therapy (SAPT) is increasing especially with the development of devices with lower thrombogenicity profile. However, the safety of SAPT is not well established. OBJECTIVE To analyze the safety and efficacy of SAPT in terms of ischemic and hemorrhagic complications in patients undergoing FDs treatment for cerebral aneurysms. METHODS A systematic literature search and meta-analysis were conducted in PubMed, Ovid MEDLINE, Ovid Embase, and Web of Science from January 2010 until October 2022. Twelve articles which reported SAPT and data on hemorrhagic, TECs, and mortality following FDs treatment were included. RESULTS Overall, the 12 studies involved 237 patients with 295 aneurysms. Five investigated the safety and efficacy of SAPT in 202 unruptured aneurysms. Six studies focused on 57 ruptured aneurysms. One study included both ruptured and unruptured aneurysms. Among the 237 patients, prasugrel was most often used as SAPT in 168 cases (70.9%), followed by aspirin in 42 (17.7%) patients, and by ticagrelor in 27 (11.4%). Overall, the hemorrhagic complication rate was 0.1% (95% CI 0% to 1.8%). The TEC rate was 7.6% (95% CI 1.7% to 16.1%). In the subgroup analysis, the TEC rates of prasugrel monotherapy of 2.4% (95% CI 0% to 9.3%) and ticagrelor monotherapy of 4.2% (95% CI 0.1% to 21.1%) were lower than of aspirin monotherapy 20.2% (95% CI 5.9% to 38.6%). The overall mortality rate was 1.3% (95% CI 0% to 6.1%). CONCLUSION According to the available data, SAPT regimen in patients undergoing FDs treatment for cerebral aneurysms has an acceptable safety profile, especially with the use of ADP-receptor antagonists.
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Affiliation(s)
- Yihui Ma
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jawid Madjidyar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Isabelle Barnaure
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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18
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Pierot L. Coated Flow Diverters and Single Antiplatelet Treatment: Where are We? Cardiovasc Intervent Radiol 2022; 45:1375-1376. [PMID: 35817931 PMCID: PMC9458681 DOI: 10.1007/s00270-022-03185-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Laurent Pierot
- Department of Neuroradiology, CHU Reims, University Reims Champagne Ardenne, 45 rue Cognacq-Jay, 51100, Reims, France.
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