Treatment of Complex Intracranial Aneurysms with a Telescoping Stent Technique

Risk factors for repeated recurrence of cerebral aneurysms treated with endovascular embolization

Purpose

To explore the risk factors of recurrence after second endovascular embolization of recurrent aneurysms and the characteristics of recurrent refractory aneurysms to help clinical decision-making.

Materials and methods

Forty-nine patients with recurrent aneurysms who underwent repeated embolization were retrospectively enrolled and divided into the recurrent and non-recurrent group. The risk factors of recurrence, complications and follow-up results of repeated embolization, and characteristics of recurrent refractory aneurysms were analyzed.

Results

Among the 49 patients with the second embolization, 5 were lost to follow-up, 9 recurred, and 35 did not. Univariate analysis showed that aneurysm size (P = 0.022), aneurysm classification (P = 0.014), and Raymond-Roy grade after the second embolization (P = 0.001) were statistically different between the two groups. Multivariate analysis demonstrated the Raymond-Roy grade as an independent risk factor for the recurrence of aneurysms after the second embolization (P = 0.042). The complication rate after the second embolization was 4%. There were five recurrent refractory aneurysms with an average aneurysm size of 23.17 ± 10.45 mm, including three giant aneurysms and two large aneurysms. To achieve complete or near-complete embolization of the recurrent refractory aneurysms, multiple treatment approaches were needed with multiple stents or flow diverting devices.

Conclusion

Aneurysm occlusion status after the second embolization is an independent risk factor for the recurrence of intracranial aneurysms. Compared with near-complete occlusion, complete occlusion can significantly reduce the risk of recurrence after second embolization. In order to achieve complete or near-complete occlusion, recurrent refractory aneurysms need multiple treatments with the use of multiple stents or flow diverting devices.

Low-profile LEO baby stents using dual stenting technique in treating complex intracranial aneurysms located in small artery: Initial and mid-term outcome

BACKGROUND

Endovascular treatment of complex intracranial aneurysms (IAs) was challenging. Our retrospective study aimed to assess the efficacy and safety of LEO Baby stents using the dual stenting technique for complex IAs.

METHODS

Clinical and angiographic data of 15 IAs located in small arteries treated by LEO Baby stents in our neurosurgical center were retrospectively collected and analyzed between April 2019 to January 2021.

RESULTS

15 patients received dual stent-assisted coiling procedures and the stent configurations include 7 cases of T- configuration, 5 cases of parallel- configuration, 2 cases of Y- configuration, and 1case of X- configuration. 11 patients received dual stents deployment with only LEO Baby stents and 4 patients received LEO Baby stent combined with LVIS stent. Immediate postprocedural results showed Raymond I in 4 patients (26.7%), Raymond II in 5 patients (33.3%), and Raymond III in 6 patients (40.0%). One patient (6.7%) was confirmed with an ischemic complication during the procedure. All 15 patients (100%) received clinical follow-up ranging between 6 and 28 months. An mRS score of 0-2 was reached in all patients. 13 patients (86.7%) received angiographic clinical follow-up ranging between 6 and 20 months. The results revealed that Raymond I was achieved in 10 patients (76.9%) and Raymond II was achieved in 3 patients (23.1%). One patient (7.7%) in 6 months after the procedure was confirmed with asymptomatic in-stent stenosis.

CONCLUSION

This preliminary study suggests that dual stents deployment of LEO Baby stents was a feasible strategy for the treatment of complex IAs located in the small arteries.

Tied Pipeline: A Case of Rare Complication

A 48-year-old female with a symptomatic giant carotid cavernous aneurysm underwent endovascular treatment with multiple Pipeline Flex embolic devices (PED). The delivery catheter had to take a complicated course of multiple turns to cross the aneurysm, and its loop was tied in the aneurysm. When the catheter was to be withdrawn, it was apparent that the tied catheter had made a tight knot that bound the tail of the previous PED together. We successfully retrieved all of the system including the tied PED, and we used telescoping stents with five PEDs in the next operation. Although this is a rare complication, it is worth noting and checking to make sure that there is no knot before deploying the stent.

Stent-assisted coiling of cerebral aneurysms: a single-center clinical and angiographic analysis

Objective

This study retrospectively compared the clinical and angiographic outcomes of treating cerebral aneurysms with Neuroform (NEU), Enterprise (EP), and Low-profile Visualized Intraluminal Support (LVIS/LVIS Jr) stents.

Materials and methods

We conducted a retrospective analysis of a procedural database. All aneurysm procedures using any of the three types of self-expanding nitinol stents (NEU, EP and LVIS/LVIS Jr) were included. Intra-procedure complications, post-procedure complications, and angiographic results (Raymond–Roy grade scale, RRGS) were analyzed retrospectively. A multivariate logistic regression analysis was conducted to identify predictors of intra-procedure and post-procedure complications.

Results

Two hundred and forty-three aneurysms in 229 patients treated with stent-assisted coiling were included (NEU group: 109 aneurysms; EP group: 61 aneurysms; LVIS/LVIS Jr: 73 aneurysms). The LVIS/LVIS Jr group was associated with the lowest rate of initial complete occlusion (RRGS I: 47.9%; 35/73). Follow-up showed the proportion of RRGS I increased for all stent groups but was greatest in the LVIS/LVIS Jr group. Overall, 17 intra-procedural complications were seen in 229 patients (7.4%) and 15 post-procedural complications were found in 198 patients at follow-up (7.6%), with no differences between stent groups. Thrombotic events were the most common complications and occurred in 13 patients (13/229, 5.7%).

Conclusions

All three types of stents used to treat cerebral aneurysms with unfavorable neck were safe and effective, providing suitable support for the coil mass. LVIS/LVIS Jr promotes better progressive aneurysm complete occlusion than the other two stents but seems to cause more common intra-procedural stent-related thrombotic events and fewer post-procedural complications.

Stent-Assisted Coiling of 501 Wide-Necked Intracranial Aneurysms: A Single-Center 8-Year Experience

BACKGROUND

Stent-assisted coiling has expanded the treatment of complex wide-necked intracranial aneurysms. We present our experience with stent-assisted coiling, with an emphasis on procedure-related neurologic complications and the incidence of angiographic recurrence.

METHODS

A total of 480 patients with 501 aneurysms who were treated with stent-assisted coiling between January 2007 and December 2014 were reviewed retrospectively. Baseline characteristics, procedure-related complications, angiographic follow-up results, and clinical outcomes were statistically analyzed.

RESULTS

Among the 480 patients, 423 (88%) were treated electively and 57 (11%) were treated in the context of subarachnoid hemorrhage. There were 22 (4.58%) overall procedure-related complications, which caused death in 4 patients (0.83%) and morbidity in 4 patients (0.83%). In a logistic regression analysis, the complications differed significantly among the patients with hypertension (odds ratio [OR], 2.85; 95% confidence interval [CI], 1.09-7.48; P = 0.03), patients with aneurysms treated with coiling before stenting (OR, 3.07; 95% CI, 1.07-8.81; P = 0.04), and patients treated with multiple stents (OR, 4.96; 95% CI, 1.02-24.07; P = 0.04). Angiographic follow-up was available for 396 patients (83.4%) for a mean of 13 months. The rates of recanalization and retreatment were 13.9% and 3.5%, respectively. In a logistic analysis, larger aneurysm size and initial incomplete aneurysm occlusion were predictors of recanalization. Clinical follow-up was available for 406 patients (85.6%) for a mean of 44.8 months, and 399 patients (98.3%) achieved a Glasgow Outcome Scale score of 5.

CONCLUSIONS

Stent-assisted coiling appears to be a safe and effective option for treating complex wide-necked aneurysms. Higher complication rates are associated with coiling before stenting, use of multiple stents, and hypertension. Stent delivery before coil deployment reduces the risk of procedural complications. Larger aneurysm size and initial incomplete occlusion are associated with aneurysm recanalization.

Complication analysis in nitinol stent-assisted embolization of 486 intracranial aneurysms

OBJECT

Stent-assisted embolization (SAE) has broadened the scope of endovascular cerebral aneurysm treatment. The risks associated with stent selection and configuration are poorly defined. In this study, the authors aimed to characterize the risk factors that contribute to complications in SAE of intracranial aneurysms.

METHODS

Over a 10-year period, a single surgeon treated 486 aneurysms with SAE in which open-cell Neuroform or closed-cell Enterprise stents were used. Single stents were used in 386 cases, overlapping stents were deployed in 80 cases, and Y-configuration stents were used in the remaining 20 cases. All neurological complications, which included transient deficits, were analyzed; disabling strokes and death were considered major complications. The chi-square test and multivariate logistic regression were used to evaluate the influence of aneurysm size and morphology, aneurysm location, stent selection, and stent configuration on complication rates.

RESULTS

There were 7 deaths (1.4%), 9 major strokes (1.9%), and 18 minor neurological complications (3.7%). For all complications, multivariate analysis revealed that large aneurysm size (10–25 mm; p = 0.01), giant aneurysm size (> 25 mm; p = 0.04), fusiform aneurysm morphology (p = 0.03), and using a Y-configuration stent (p = 0.048) were independent risk factors. For the major complications, independent risk factors included an aneurysm in the posterior circulation (p = 0.02), using an overlapping stent configuration (p = 0.03), and using a Y-configuration stent (p < 0.01).

CONCLUSIONS

In this series, SAE for cerebral aneurysm treatment carried an acceptable complication rate. With continued innovations in techniques and devices and with increased experience, the complication rates associated with SAE may be even lower in the future.

Preparedness of neurosurgery graduates for neuroendovascular fellowship: a national survey of fellowship programs

OBJECT

Endovascular interventions have become an essential part of a neurosurgeon's practice. Whether endovascular procedures have been effectively integrated into residency curricula, however, remains uncertain. The purpose of this study was to assess the preparedness of US neurosurgery graduate trainees for neuroendovascular fellowship.

METHODS

A multidomain, global assessment survey was sent to all directors/faculty of neuroendovascular fellowship programs involved in training of US neurosurgery graduates. Surveyees were asked to assess trainees as they entered fellowship.

RESULTS

The response rate was 78% (25/32). Of respondent program directors, 38% reported that new fellows did not know the history and imaging of the patient and 50% were unable to formulate an appropriate treatment plan. As many as 79% of fellows were unfamiliar with endovascular devices and 75% were unfamiliar with angiographic equipment. Furthermore, 58% of fellows were unable to perform femoral access, 54% were unable to perform femoral closure, 79% were unable to catheterize a major vessel, 86% were unable to perform a 4-vessel angiogram, and 100% were unable to catheterize an aneurysm. Additionally, program directors reported that over 50% of fellows could not recognize neurovascular anatomy and 54% could not recognize/classify vascular abnormalities. There was an overall agreement that fellows demonstrated professionalism and interest in research and had good communication/clinical skills.

CONCLUSIONS

The results of this study suggest potential gaps in the training of neurosurgery residents with regard to endovascular neurosurgery. In an era of minimally invasive therapies, changes in residency curricula may be needed to keep pace with the ever-changing field of neurosurgery.