Treatment of intracranial aneurysms using the new Surpass Evolve flow diverter: Safety outcomes and six-month imaging follow-up

Performance assessment of the Surpass Evolve flow diverter for the treatment of intracranial aneurysms: A systematic review and meta-analysis

BACKGROUND

The Surpass Evolve (SE) has emerged as a promising alternative treatment from the flow diverter series. The utilization of the SE has gradually increased, however, there is a scarcity of comprehensive data on the solidity of this technology in the endovascular treatment of intracranial aneurysms (IAs). This meta-analysis aimed to evaluate the safety and effectiveness of the SE flow diverter.

METHODS

A systematic literature search from inception to April 2024 was conducted across five databases for studies involving IAs treated with the SE. The primary effectiveness outcome was the proportion of complete aneurysm occlusion at the final follow-up, and the primary safety outcome comprised a composite of early and delayed complications. Subgroup analyses based on aneurysm size, anatomical location, and rupture status were also conducted.

RESULTS

Our analysis included nine studies with 645 patients and 722 IAs. Effectiveness outcomes revealed an overall complete aneurysm occlusion rate of 69% (95% confidence interval (CI) = 58%-78%; I2 = 72%) and a favorable aneurysm occlusion rate of 91% (95% CI = 82%-96%; I2 = 49%). Safety outcomes demonstrated an overall complications rate of 6% (95% CI = 3%-12%; I2 = 66%), with an early complications rate of 6% (95% CI = 4%-11%; I2 = 0%), and a delayed complications rate of 0% (95% CI = 0%-7%; I2 = 0%).

CONCLUSIONS

Our findings suggest a favorable outcome with a high rate of complete aneurysm occlusion at the last follow-up, with acceptable rates of neurological complications. Future research efforts should focus on larger, prospective studies with standardized outcome measures to further elucidate the clinical utility of the SE flow diverter in the management of IAs.

Sequential Flow Diversion After Nitinol Stent Placement for a Large, Matricidal Cavernous Internal Carotid Artery Aneurysm: Technical Video

The Surpass Evolve flow diverter is a novel 64-wire braided intravascular stent approved to treat unruptured large or giant saccular wide-neck or fusiform intracranial aneurysms of the intracranial internal carotid artery.1-3 Flow diverting stents have been used for the treatment of previously stented aneurysms, including residual aneurysms following prior flow diversion.5-8 This patient initially presented with a large symptomatic matricidal cavernous ICA aneurysm4 that was treated with stand-alone Neuroform Atlas stenting at an outside hospital. Here we present a video demonstrating the placement of sequential Surpass Evolve flow diverter stents within a Neuroform Atlas nitinol stent.

Safety and efficacy of Surpass Evolve Flow diverter for intracranial aneurysms: A study of 116 patients

BACKGROUND AND PURPOSE

Flow diverter embolization is a recognized method for treating intracranial aneurysms. This study evaluates the safety and efficacy of the Surpass Evolve flow diverter in treating intracranial aneurysm.

MATERIAL AND METHODS

From May 2019 to June 2022, our center prospectively enrolled patients presenting with both ruptured and unruptured intracranial aneurysms. We assessed aneurysm occlusion, along with the occurrence of ischemic and hemorrhagic complications, and mortality at 6-months. The 3-month occlusion rate was determined using MR angiography, while the 6-month occlusion rate employed the O'Kelly-Marotta (OKM) grading scale on DSA.

RESULTS

A total of 116 patients with 120 aneurysms received treatment with the Surpass Evolve device. The average aneurysm size was 6.6 mm (range: 2-30 mm). All patients were administered two loading doses of ticagrelor (180 mg) one day before the procedure and 2 h pre-embolization. A procedural complication occurred in one case, involving wire-related perforation of an M3 branch distant from the giant aneurysm; however, this evolved favorably. There were no reported deaths linked to the treatment. Permanent neurological deficits were observed in 3 (2.5%) patients, primarily due to early in-stent thrombosis. MR angiography results at 3 months indicated complete occlusion for 87 out of 115 (75.6%) monitored aneurysms. The 6-month DSA showed neck remnant or complete occlusion (OKM grade C or D) in 86 out of the 107 (80.4%) patients who underwent follow-up.

CONCLUSION

The Surpass Evolve stands out as a reliable and effective flow diverter for the management of intracranial aneurysms.

Ultra-Early "Fishmouth stenosis" and thrombosis of a Surpass Evolve flow diversion device following treatment of multiples right siphon aneurysms

We present a case of ultra-early symptomatic fish-mouth type stenosis (FMTS) of a Surpass Evolve flow diverter stent (SE-FDS) occurring within 24 h after deployment for the treatment of multiple unruptured right siphon aneurysms in a 44-year-old patient. The patient developed left hemiplegia and hemineglect, and was treated with mechanical thrombectomy (MT) and Tirofiban infusion. This is the first report of an ultra-early FMTS with a SE-FDS and its mechanism is discussed in the light of available data in the literature.

Comparison of arterial wall integration of different flow diverters in rabbits: The CICAFLOW study

BACKGROUND AND PURPOSE

New coated flow diverters (FDs) claim antithrombotic properties and increased arterial wall integration. The aim of this study is to compare in vivo endothelial coverage of coated and uncoated FD in the context of different antiplatelet regimens.

METHODS

Different FDs (Silk Vista - SV, Pipeline with Shield technology - PED shield and Surpass Evolve - SE) were implanted in the aorta of rabbits, all 3 in each animal with 3 different antiplatelet regimens: no antiplatelet therapy, aspirin alone, or aspirin and ticagrelor. Four weeks after FD implantation, angiography, flat-panel CT, and optical coherence tomography (OCT) were performed before harvesting the aorta. Extensive histopathology analyses were performed including environmental scanning electron microscopy (ESEM), multiphoton microscopy (MPM) and histological staining with qualitative and/or quantitative assessment of device coverage.

RESULTS

All 23 FDs that were implanted remained patent without hyperplasia. Qualitative stent coverage assessment revealed that there were no statistically significant differences between the FD groups (p = 0.19, p = 0.45, p = 0.40, and p = 0.84 for OCT, ESEM, MPM and histology, respectively). Quantitative neointimal measurement of histological sections also showed similar results in all 3 FD groups (p = 0.70). However, there were significant differences between the 3 groups of antiplatelet regimens (p = 0.07) with a higher rate in the no antiplatelet group (p = 0.05 versus aspirin alone and p = 0.03 versus aspirin and ticagrelor).

CONCLUSION

Our study provides evidence that FD integration into the arterial wall is similar with coated (PED shield) and uncoated devices (SV, SE), regardless of the antiplatelet regimen. FD integration with specific surface coverage should be promoted.

TRIAL REGISTRATION

APAFIS #2022011215518538.

Preliminary Experience of the Surpass Streamline Flow Diverter for Large and Giant Unruptured Internal Carotid Artery Aneurysms

As of January 2021, the Surpass Streamline (SS) is the most recently approved flow diverter in Japan. A total of 28 Japanese patients, including 9 clinical trial patients, with 28 large or giant unruptured internal carotid artery (ICA) aneurysms, underwent SS embolization at Juntendo University Hospital. Procedural failure occurred in two patients due to the difficulty to navigate the device in the tortuous parent artery. Therefore, 26 patients with 26 aneurysms were available for clinical and anatomical assessments. Patients' mean age was 62.6 years (range 46-86), and 24 patients (92.3%) were female. Mean aneurysm size and neck width were 15.4 mm and 7.7 mm, respectively, with 20 saccular and 6 fusiform aneurysms. Seven aneurysms were symptomatic due to the aneurysmal mass effect. Twenty patients underwent a 6-month follow-up angiography to evaluate the degree of occlusion. Anatomical outcomes were 12 (60%) complete occlusion (CO), 4 (20%) residual neck (RN), and 4 (20%) residual aneurysm. Favorable aneurysm occlusion consisted of CO, and RN was achieved in 16 (80.0%). There were no significant device stenoses. Aneurysmal mass effect improved in one and was unchanged in eight patients. There were three device-related complications, namely, delayed aneurysm rupture, minor ischemic stroke, and device occlusion (11.5%). One patient with minor ischemic stroke fully recovered before 30 days, and our series showed 7.7% risk of major ipsilateral stroke and neurological death at 30 days. The SS embolization for large and giant unruptured ICA aneurysms offers satisfactory anatomical and clinical outcomes with a low risk of device-related complications.

Surpass Evolve Flow Diverter for the Treatment of Intracranial Aneurysm: A Systematic Review

PURPOSE

This systematic review aims to summarize the evidence investigating the effectiveness and safety of the Surpass Evolve-Flow Diverter (SE-FD) to treat brain aneurysms.

METHOD

We searched MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library from January 2019 to 29 March 2022. Terms related to the "intracranial aneurysm" and "surpass evolve flow diverter" concepts were used to search the databases; Medical Subject Headings (MeSH) and reference hand search were also utilized.

RESULTS

The searches primarily identified 1586 documents. A total of five studies (four case series and one cohort) were included in this review. In the included studies, 192 (74 male and 118 females) patients with 198 aneurysms were involved. In total, 153 SE-FDs were used to treat 145 aneurysms. Complete occlusion was achieved in 69/145 (48%) cases and near-complete occlusion in 24/145 (17%) cases from aneurysms treated with SE-FD. Reported postoperative complications included stent thrombosis (n = 4 patients), hemorrhage (n = 5 patients), ischemia (n = 9 patients), and neurological complications (n = 12 patients). In total, four deaths were reported with only one related to the SE-FD procedure.

CONCLUSION

The results of this review are based on observational data, due to the absence of clinical trials. The findings of the included studies suggest that the effectiveness of the SE-FD procedure is lower than previous FDs but the safety is similar. The included studies also suggested that SE-FD has navigability and resistance to twisting, which makes the procedure an easier method to treat aneurysms that are proximal and distal to the circle of Willis deployment. This review highlights the urgency to conduct clinical trials to confirm these suggestions.

Flow diverter for the treatment of large (> 10 mm) vertebral artery dissecting aneurysms

OBJECTIVE

To evaluate the outcomes of flow-diverting device (FDD) treatment for large vertebral artery dissecting aneurysms (VADAs).

METHODS

This retrospective study evaluated 12 patients with 12 VADAs who were treated using FDD between 2013 and 2020. Clinical and radiographic data, including procedure-related complications and clinical outcomes assessed using the modified Rankin Scale (mRS) at the time of the last follow-up, were collected and reviewed.

RESULTS

All 12 patients had unruptured aneurysms. There were 3 (25%) female and 9 (75%) male patients, and the mean patient age was 54.6 years. The mean size of the aneurysm was 15.9 ± 4.8 mm. The mean follow-up duration was 15.8 months. Single FDD without additional coils was used in all patients. One patient underwent second-line treatment with FDD for recurrence of large VADA after stent-assisted coiling. Immediate follow-up angiography after placement of the FDD demonstrated intra-aneurysmal contrast stasis. There were 2 (17%) patients who had peri-procedural stroke. Angiography at the 6-month follow-up in 10 patients showed favorable occlusion (OKM grade C3 + D). A total of 11 (92%) patients had good clinical outcome (modified Rankin Scale ≤ 2) at the last follow-up. No re-treatment or delayed aneurysm rupture occurred during the follow-up period.

CONCLUSIONS

Reconstructive technique with FDD is a feasible and effective modality for the treatment of large VADAs, showing favorable occlusion rate and clinical outcome.

Treatment of Intracranial Aneurysms Using the New Silk Vista Flow Diverter: Safety Outcomes at Short-Term Follow-Up

Background: Flow diverters are widely used as the first endovascular treatment option for complex brain aneurysms due to their high percentage of occlusion and low morbi-mortality. The Silk Vista device is a new generation of flow diverters designed to facilitate full visibility, improve apposition to the vessel wall, and enhance navigability. Indeed, its greatest advantage is that it enables the easier navigation of stents between 3.5 and 4.75 mm through a 0.021 microcatheter. The objective of this study was to evaluate the safety and effectiveness of Silk Vista systems for treating cerebral aneurysms.

Methods: This prospective observational study included 25 consecutive patients with 27 wide-necked unruptured aneurysms treated with SILK Vista who were retrospectively analyzed for safety and efficacy.

Results: Endovascular treatment was successfully performed in all patients. The final morbidity and mortality rates were both 0.0%. Short-term (3–5 months) angiographic follow-up revealed 21 complete occlusions and 6 near-complete occlusions. No significant parent artery stenosis was observed.

Conclusions: This report demonstrates the efficacy of Silk Vista in treating brain aneurysms, although longer experiences should be carried out to confirm our results.