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Ghaith AK, Greco E, Rios-Zermeno J, El-Hajj VG, Perez-Vega C, Ghanem M, Kashyap S, Fox WC, Huynh TJ, Sandhu SS, Ohlsson M, Elmi-Terander A, Bendok BR, Bydon M, Tawk RG. Safety and efficacy of the pipeline embolization device for treatment of small vs. large aneurysms: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:284. [PMID: 37882896 DOI: 10.1007/s10143-023-02192-0] [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: 09/06/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
Flow diversion with the pipeline embolization device (PED) is increasingly used to treat intracranial aneurysms with high obliteration rates and low morbidity. However, long-term (≥ 1 year) angiographic and clinical outcomes still require further investigation. The aim of this study was to compare the occlusion and complication rates for small (< 10 mm) versus large (10-25 mm) aneurysms at long-term following treatment with PED. A systematic review and meta-analysis were performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We conducted a comprehensive search of English language databases including Ovid MEDLINE and Epub Ahead of Print, In-Process, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Our studies included a minimum of 10 patients treated with PED for small vs. large aneurysms and with at least 12 months of follow-up. The primary safety endpoint was the rate of clinical complications measured by the occurrence of symptomatic stroke (confirmed clinically and radiographically), intracranial hemorrhage, or aneurysmal rupture. The primary efficacy endpoint was the complete aneurysm occlusion rate. Our analysis included 19 studies with 1277 patients and 1493 aneurysms. Of those, 1378 aneurysms met our inclusion criteria. The mean age was 53.9 years, and most aneurysms were small (89.75%; N = 1340) in women (79.1%; N = 1010). The long-term occlusion rate was 73% (95%, CI 65 to 80%) in small compared to 84% (95%, CI 76 to 90%) in large aneurysms (p < 0.01). The symptomatic thromboembolic complication rate was 5% (95%, CI 3 to 9%) in small compared to 7% (95%, CI 4 to 13%) in large aneurysms (p = 0.01). The rupture rate was 2% vs. 4% (p = 0.92), and the rate of intracranial hemorrhage was 2% vs. 4% (p = 0.96) for small vs. large aneurysms, respectively; however, these differences were not statistically significant. The long-term occlusion rate after PED treatment is higher in large vs. small aneurysms. Symptomatic thromboembolic rates with stroke are also higher in large vs. small aneurysms. The difference in the rates of aneurysm rupture and intracranial hemorrhage was insignificant. Although the PED seems a safe and effective treatment for small and large aneurysms, further studies are required to clarify how occlusion rate and morbidity are affected by aneurysm size.
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Affiliation(s)
- Abdul Karim Ghaith
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Elena Greco
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Victor Gabriel El-Hajj
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Carlos Perez-Vega
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Marc Ghanem
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Samir Kashyap
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - W Christopher Fox
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Thien J Huynh
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Marcus Ohlsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
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Vranic JE, Harker P, Stapleton CJ, Regenhardt RW, Dmytriw AA, Doron OM, Alotaibi NM, Leslie-Mazwi TM, Gupta R, Berglar IK, Tan CO, Koch MJ, Raymond SB, Mascitelli JR, Patterson TT, Seinfeld J, White A, Case D, Roark C, Gandhi CD, Al-Mufti F, Cooper J, Matouk C, Sujijantarat N, Devia DA, Ocampo-Navia MI, Villamizar-Torres DE, Puentes JC, Patel AB. The Impact of Dual Antiplatelet Therapy Duration on Unruptured Aneurysm Occlusion After Flow Diversion: A Multicenter Study. J Comput Assist Tomogr 2023; 47:753-758. [PMID: 37707405 DOI: 10.1097/rct.0000000000001457] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
OBJECTIVE Endoluminal flow diversion reduces blood flow into intracranial aneurysms, promoting thrombosis. Postprocedural dual antiplatelet therapy (DAPT) is necessary for the prevention of thromboembolic complications. The purpose of this study is to therefore assess the impact that the type and duration of DAPT has on aneurysm occlusion rates and iatrogenic complications after flow diversion. METHODS A retrospective review of a multicenter aneurysm database was performed from 2012 to 2020 to identify unruptured intracranial aneurysms treated with single device flow diversion and ≥12-month follow-up. Clinical and radiologic data were analyzed with aneurysm occlusion as a function of DAPT duration serving as a primary outcome measure. RESULTS Two hundred five patients underwent flow diversion with a single pipeline embolization device with 12.7% of treated aneurysms remaining nonoccluded during the study period. There were no significant differences in aneurysm morphology or type of DAPT used between occluded and nonoccluded groups. Nonoccluded aneurysms received a longer mean duration of DAPT (9.4 vs 7.1 months, P = 0.016) with a significant effect of DAPT duration on the observed aneurysm occlusion rate (F(2, 202) = 4.2, P = 0.016). There was no significant difference in the rate of complications, including delayed ischemic strokes, observed between patients receiving short (≤6 months) and prolonged duration (>6 months) DAPT (7.9% vs 9.3%, P = 0.76). CONCLUSIONS After flow diversion, an abbreviated duration of DAPT lasting 6 months may be most appropriate before transitioning to low-dose aspirin monotherapy to promote timely aneurysm occlusion while minimizing thromboembolic complications.
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Affiliation(s)
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Omer M Doron
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Naif M Alotaibi
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | | | | | | | - Matthew J Koch
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Scott B Raymond
- Department of Radiology, University of Vermont Medical Center, Burlington, VT
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - T Tyler Patterson
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Joshua Seinfeld
- Department of Neurosurgery, University of Colorado, Denver, CO
| | - Andrew White
- Department of Neurosurgery, University of Colorado, Denver, CO
| | - David Case
- Department of Neurosurgery, University of Colorado, Denver, CO
| | | | | | | | | | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT
| | | | - Diego A Devia
- Department of Neurosurgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana School of Medicine
| | - Maria I Ocampo-Navia
- Department of Neurosurgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana School of Medicine
| | - Daniel E Villamizar-Torres
- Department of Neurosurgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana School of Medicine
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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3
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Hanel RA, Cortez GM, Lopes DK, Nelson PK, Siddiqui AH, Jabbour P, Mendes Pereira V, István IS, Zaidat OO, Bettegowda C, Colby GP, Mokin M, Schirmer CM, Hellinger FR, Given C, Krings T, Taussky P, Toth G, Fraser JF, Chen M, Priest R, Kan P, Fiorella D, Frei D, Aagaard-Kienitz B, Diaz O, Malek AM, Cawley CM, Puri AS, Kallmes DF. Prospective study on embolization of intracranial aneurysms with the pipeline device (PREMIER study): 3-year results with the application of a flow diverter specific occlusion classification. J Neurointerv Surg 2023; 15:248-254. [PMID: 35292570 PMCID: PMC9985759 DOI: 10.1136/neurintsurg-2021-018501] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/06/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The pipeline embolization device (PED; Medtronic) has presented as a safe and efficacious treatment for small- and medium-sized intracranial aneurysms. Independently adjudicated long-term results of the device in treating these lesions are still indeterminate. We present 3-year results, with additional application of a flow diverter specific occlusion scale. METHODS PREMIER (prospective study on embolization of intracranial aneurysms with pipeline embolization device) is a prospective, single-arm trial. Inclusion criteria were patients with unruptured wide-necked intracranial aneurysms ≤12 mm. Primary effectiveness (complete aneurysm occlusion) and safety (major neurologic event) endpoints were independently monitored and adjudicated. RESULTS As per the protocol, of 141 patients treated with a PED, 25 (17.7%) required angiographic follow-up after the first year due to incomplete aneurysm occlusion. According to the Core Radiology Laboratory review, three (12%) of these patients progressed to complete occlusion, with an overall rate of complete aneurysm occlusion at 3 years of 83.3% (115/138). Further angiographic evaluation using the modified Cekirge-Saatci classification demonstrated that complete occlusion, neck residual, or aneurysm size reduction occurred in 97.1%. The overall combined safety endpoint at 3 years was 2.8% (4/141), with only one non-debilitating major event occurring after the first year. There was one case of aneurysm recurrence but no cases of delayed rupture in this series. CONCLUSIONS The PED device presents as a safe and effective modality in treating small- and medium-sized intracranial aneurysms. The application of a flow diverter specific occlusion classification attested the long-term durability with higher rate of successful aneurysm occlusion and no documented aneurysm rupture. TRIAL REGISTRATION NCT02186561.
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Affiliation(s)
- Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | | | - Peter Kim Nelson
- Interventional Radiology, NYU Langone Medical Center, New York, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Istvan Szikora István
- Department of Neuroradiology, National Institute of Neurosciences, Budapest, Hungary
| | - Osama O Zaidat
- Neuroscience Institute, Mercy Health Saint Vincent Medical Center, Toledo, Ohio, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geoffrey P Colby
- Department Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
| | - Frank R Hellinger
- Department of Radiology, Florida Hospital Neuroscience Institute, Winter Park, Florida, USA
| | - Curtis Given
- Department of Radiology, Baptist Health Lexington, Lexington, Kentucky, USA
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Justin F Fraser
- Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Michael Chen
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ryan Priest
- Charles T Dotter Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Fiorella
- Department of Neurosurgery, Cerebrovascular Center, Stony Brook University, Stony Brook, New York, USA
| | - Donald Frei
- Department of Neuroradiology, Swedish Medical Center, Englewood, Colorado, USA
| | - Beverly Aagaard-Kienitz
- Department of Neurological Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Orlando Diaz
- Cerebrovascular Center, Houston Methodist Research Institute, Houston, Texas, USA
| | - Adel M Malek
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - C Michael Cawley
- Department of Neurointerventional Radiology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Guo H, Liu JF, Li CH, Wang JW, Li H, Gao BL. Effects of stent-assisted coiling in comparison with flow diversion on intracranial aneurysms. Front Neurol 2022; 13:937536. [PMID: 36425805 PMCID: PMC9679156 DOI: 10.3389/fneur.2022.937536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
Objective The aim of this study was to investigate the efficacy and complications of stent-assisted coiling in comparison with flow diversion for wide-necked intracranial aneurysms. Methods Patients with wide-necked intracranial aneurysms who were treated with stent-assisted coiling or flow diversion were respectively, enrolled into the stent-assisted coiling or flow diversion treatment group. The clinical and angiographic data were analyzed. Results A total of 61 patients with intracranial aneurysms underwent stent-assisted coiling, including 35 (57.4%) female and 26 (42.6%) male patients with 21 (34.4%) ruptured and 40 (65.6%) unruptured aneurysms. Also, 53 patients underwent deployment of flow-diverting devices, including 30 (56.6%) female and 23 (43.4%) male patients with 25 (47.2%) ruptured and 28 (52.8%) unruptured aneurysms. Stent-assisted coiling was performed successfully in 60 patients with 63 stents deployed, and immediate aneurysm occlusion was complete occlusion in 38 (62.3%) aneurysms, residual neck in 12 (19.7%), and residual aneurysm in 10 (16.4%). Procedure-related complications included in-stent thrombosis in three (4.9%) patients, coil protrusion in three (4.9%), and re-rupture of one (1.6%) aneurysm, with a total complication rate of 11.5%. In the flow diversion group, a pipeline embolization device alone was deployed in each of the 24 (45.3%) patients, adjunctive coiling combined with a pipeline device in 29 (54.7%), and double pipeline devices in each of the 6 (11.3%) patients. Immediately after treatment, complete occlusion was achieved in 3 (5.7%) patients with adjunctive coiling, residual neck in 3 (5.7%), and residual aneurysm in 47 (88.7%). Procedure-related complications included aneurysm rebleeding in one patient (1.9%). Clinical and angiographic follow-up was performed 13–49 months (median 29) after the procedure for 49 (80.3%) patients with stent-assisted coiling, with complete aneurysm occlusion in 27 (55.1%) aneurysms, residual neck in 3 (6.1%), residual aneurysm in 5 (10.2%), and recurrence in 14 (28.6%). Follow-up was performed for 14–37 (median 25) months in 45 (84.9%) patients with flow diversion treatment, with complete occlusion in 39 (86.7%) patients, residual neck in 5 (11.1%), residual aneurysm in 1 (2.2%), and no aneurysm recurrence. Conclusions Stent-assisted coiling comes with more complications but fewer permanent aneurysm occlusions than flow diverters, and flow diverters are superior to stent-assisted coiling in the treatment of wide-necked intracranial aneurysms, especially in the long-term effect.
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Li W, Xiao Z, Zhao K, Yang S, Zhang Y, Li B, Zhou Y, Ma Y, Chai E. Efficacy of pipeline embolization device vs. traditional coils in embolization of intracranial aneurysms: A systematic review and meta-analysis. Front Neurol 2022; 13:978602. [PMID: 36247783 PMCID: PMC9558282 DOI: 10.3389/fneur.2022.978602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionIn recent years, the Pipeline embolization device (PED) has been widely used in the embolization of intracranial aneurysms, but there are some inconsistent findings on whether its efficacy and safety are superior to those of traditional coils embolization (coils alone, stent-assisted coils and balloon-assisted coils). The purpose of this meta-analysis was to evaluate the safety and efficacy of PED in intracranial aneurysm embolization by comparing with traditional coils.MethodsWe systematically searched PubMed, Embase, Web of Science, and The Cochrane Library databases for randomized controlled trials and observational studies (case-control studies and cohort studies) comparing the efficacy of PED with traditional coils in intracranial aneurysm embolization published before April 1, 2022. The endpoints observed in this meta-analysis were procedure-related intracranial hemorrhage, procedure-related intracranial ischemia, other procedure-related complications (e.g., aneurysm rupture, neurological impairment, etc.), retreatment rate, complete occlusion (100%) of the aneurysm at the last follow-up, and favorable functional outcome (MRS ≤ 2).ResultsA total of 10 studies with a total of 1,400 patients (PED group: 576 and Traditional coils: 824) were included in this meta-analysis. A comprehensive analysis of the included literature showed that the PED group had a higher rate of complete aneurysm occlusion [OR = 2.62, 95% Cl (1.94, 3.55), p < 0.00001] and Lower re-treatment rate [OR = 0.20, 95% Cl (0.12, 0.34 p < 0.00001)] compared with the traditional coil embolization group at the last follow-up. In terms of procedure-related intracranial hemorrhage [OR = 3.04, 95% Cl (1.08, 8.57), p = 0.04] and other procedure-related complications [OR = 2.91, 95% Cl (1.48, 5.57), p = 0.002], the incidence of PED was higher than that of the traditional coil embolization group. Moreover, in terms of favorable functional outcome [OR = 0.4, 95% Cl (0.22, 0.71), p = 0.002] of patients at the last follow-up, the PED group was lower than the traditional coil embolization group. There was no statistically significant between the two groups in terms of surgery-related intracranial ischemia complications [OR = 0.88, 95% Cl (0.47, 1.64), p = 0.68].ConclusionPED had higher rates of complete aneurysm occlusion and lower rates of aneurysm retreatment compared with traditional coils, but traditional coils was superior to the PED group in terms of procedure-related intracranial hemorrhage complication and other procedure-related complications (aneurysm rupture, neurological impairment), and favorable functional outcome (mRS ≤ 2). This result still needs to be further confirmed by additional large-sample, multicenter, prospective randomized controlled trials.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022325673.
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Affiliation(s)
- Wei Li
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Zaixing Xiao
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Kaixuan Zhao
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Shijie Yang
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Yichuan Zhang
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Bin Li
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Yu Zhou
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Yong Ma
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Erqing Chai
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
- *Correspondence: Erqing Chai
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Li S, Zeng C, Tao W, Huang Z, Yan L, Tian X, Chen F. The Safety and Efficacy of Flow Diversion versus Conventional Endovascular Treatment for Intracranial Aneurysms: A Meta-analysis of Real-world Cohort Studies from the Past 10 Years. AJNR Am J Neuroradiol 2022; 43:1004-1011. [PMID: 35710123 DOI: 10.3174/ajnr.a7539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/16/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although the flow diverter has advantages in the treatment of intracranial aneurysms, pooled studies that directly compare it with conventional endovascular treatments are rare. PURPOSE Our aim was to compare the safety and efficacy of flow-diverter and conventional endovascular treatments in intracranial aneurysms. DATA SOURCES We performed a comprehensive search of the literature using PubMed, EMBASE, and the Cochrane Database. STUDY SELECTION We included only studies that directly compared the angiographic and clinical outcomes of flow-diverter and conventional endovascular treatments. DATA ANALYSIS Random effects or fixed effects meta-analysis was used to pool the cumulative rate of short- and long-term angiographic and clinical outcomes. DATA SYNTHESIS Eighteen studies with 1001 patients with flow diverters and 1133 patients with conventional endovascular treatments were included; 1015 and 1201 aneurysm procedures were performed, respectively. The flow-diverter group had aneurysms of a larger size (standard mean difference, 0.22; 95% CI, 0.03-0.41; P = .026). There was a higher risk of complications in the flow-diverter group compared with the conventional endovascular group (OR, 1.4; 95% CI, 1.01-1.96; P = .045) during procedures. The follow-up angiographic results of flow-diverter treatment indicated a higher rate of complete occlusion (OR, 2.55; 95% CI, 1.70-3.83; P < .001) and lower rates of recurrence (OR, 0.24; 95% CI, 0.12-0.46; P < .001) and retreatment (OR, 0.31; 95% CI, 0.21-0.47; P < .001). LIMITATIONS Limitations include a retrospective, observational design in some studies, high heterogeneity, and selection bias. CONCLUSIONS Compared with the conventional endovascular treatments, the placement of a flow diverter may lead to more procedure-related complications, but there is no difference in safety, and it is more effective in the long term.
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Affiliation(s)
- S Li
- From the Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - C Zeng
- From the Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - W Tao
- From the Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Z Huang
- From the Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - L Yan
- From the Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - X Tian
- From the Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - F Chen
- From the Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
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Liu J, Li W, Zhang Y, Wang K, Yang X, Zhang Y. Hemodynamic analysis for endovascular treatment in small unruptured intracranial aneurysms: a matched comparison study of flow diverter versus LVIS. Chin Neurosurg J 2021; 7:49. [PMID: 34852851 PMCID: PMC8638548 DOI: 10.1186/s41016-021-00266-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 11/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We compared the treatment of small unruptured intracranial aneurysms (UIAs) with flow diverter and LVIS-assisted coiling to determine the effects of hemodynamic changes caused by different stent and coil packing in endovascular treatment. METHODS Fifty-one UIAs in 51 patients treated with pipeline embolization device (PED) were included in this study and defined as the PED group. We matched controls 1:1 and enrolled 51 UIAs who were treated with LVIS stent, which were defined as the LVIS group. Computational fluid dynamics were performed to assess hemodynamic alterations between PED and LVIS. Clinical analysis was also performed between these two groups after the match. RESULTS There was no difference in procedural complications between the two groups (P = 0.558). At the first angiographic follow-up, the complete occlusion rate was significantly higher in the LVIS group compared with that in the PED group (98.0% vs. 82.4%, P = 0.027). However, during the further angiographic follow-up, the complete occlusion rate in the PED group achieved 100%, which was higher than that in the LVIS group (98.0%). Compared with the LVIS group after treatment, cases in the PED group showed a higher value of velocity in the aneurysm (0.03 ± 0.09 vs. 0.01 ± 0.01, P = 0.037) and WSS on the aneurysm (2.32 ± 5.40 vs. 0.33 ± 0.47, P = 0.011). Consequently, the reduction ratios of these two parameters also showed statistical differences. These parameters in the LVIS group showed much higher reduction ratios. However, the reduction ratio of the velocity on the neck plane was comparable between two groups. CONCLUSIONS Both LVIS and PED were safe and effective for the treatment of small UIAs. However, LVIS-assisted coiling produced greater hemodynamic alterations in the aneurysm sac compared with PED. The hemodynamics in the aneurysm neck may be a key factor for aneurysm outcome.
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Affiliation(s)
- Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, China
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, China.
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, China.
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Suzuki R, Takigawa T, Nariai Y, Hyodo A, Suzuki K. Comparison of Pipeline Embolization and Coil Embolization for the Treatment of Large Unruptured Paraclinoid Aneurysms. Neurol Med Chir (Tokyo) 2021; 62:97-104. [PMID: 34759071 PMCID: PMC8841233 DOI: 10.2176/nmc.oa.2021-0242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The efficacy of flow diversion (FD) in the treatment of paraclinoid aneurysms has been established. The pipeline embolization device (PED) is one of the most commonly used FD devices. Coil embolization is also useful for treating paraclinoid aneurysms. This study aimed to compare the efficacy and safety of PED treatment and coil embolization for large unruptured paraclinoid aneurysms. This was a single-center, retrospective study of large unruptured paraclinoid aneurysms treated endovascularly between 2009 and 2019 (coil embolization between 2009 and 2015, and PED between 2015 and 2019). Cases with a follow-up period of less than 1 year and recurrence after coil embolization were excluded. The treatment outcomes between coil embolization and PED were compared. We investigated 45 patients with 45 large unruptured paraclinoid aneurysms treated by endovascular surgery in our institution. Twenty-four patients were treated with coil embolization and 21 with PED. In the PED group, the device cost was significantly lower (2,770.4 ± 699.5 vs. 1941.2 ± 552.8 [1000 yen], P = 0.03), procedure duration was significantly shorter (155.4 ± 66.7 vs. 95.1 ± 35.4 min, P <0.01), and the numbers of re-treatments were lower than those in the coil embolization group (41.7 vs. 14.3%, P = 0.05). Both PED and coil embolization were effective and safe for large unruptured paraclinoid aneurysms, and their treatment results were similar. The PED is more beneficial because of its lower cost, shorter procedure duration, and fewer retreatments, and is therefore more useful for the treatment of large unruptured paraclinoid aneurysms.
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Affiliation(s)
- Ryotaro Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
| | - Yasuhiko Nariai
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
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9
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Vranic JE, Harker P, Stapleton CJ, Regenhardt RW, Dmytriw AA, Alotaibi NM, Gupta R, Leslie-Mazwi TM, Koch MJ, Raymond SB, Mascitelli JR, Patterson TT, Seinfeld J, White A, Case D, Roark C, Gandhi CD, Al-Mufti F, Cooper J, Patel AB. Determinants of intracranial aneurysm retreatment following embolization with a single flow-diverting stent. Neuroradiol J 2021; 35:461-467. [PMID: 34747246 PMCID: PMC9437496 DOI: 10.1177/19714009211049086] [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: 11/15/2022] Open
Abstract
PURPOSE Flow diverting stents have revolutionized the treatment of intracranial aneurysms through endoluminal reconstruction of the parent vessel. Despite this, certain aneurysms require retreatment. The purpose of this study was to identify clinical and radiologic determinants of aneurysm retreatment following flow diversion. METHODS A multicenter flow diversion database was evaluated to identify patients presenting with an unruptured, previously untreated aneurysm with a minimum of 12 months' clinical and angiographic follow-up. Univariate and multivariate logistic regression modeling was performed to identify determinants of retreatment. RESULTS We identified 189 aneurysms treated in 189 patients with a single flow-diverting stent. Mean age was 54 years, and 89% were female. Complete occlusion was achieved in 70.3% and 83.6% of patients at six and 12 months, respectively. Aneurysm retreatment with additional flow-diverting stents occurred in 5.8% of cases. Univariate analysis revealed that dome diameter ≥10 mm (p = 0.012), pre-clinoid internal carotid artery location (p = 0.012), distal > proximal parent vessel diameter (p = 0.042), and later dual antiplatelet therapy (DAPT) discontinuation (p < 0.001) were predictive of retreatment. Multivariate analysis identified discontinuation of DAPT >12 months (p = 0.003) as a strong determinant of retreatment with dome diameter ≥10 mm trending toward statistical significance (p = 0.064). Large aneurysm neck diameter, presence of aneurysm branch vessels, patient age, smoking history, and hypertension were not determinant of retreatment on multivariate analysis. CONCLUSIONS Prolonged DAPT is the most important determinant of aneurysm retreatment following single-device flow diversion. Abbreviating DAPT duration to only six months should be a consideration in this population, especially for patients with a large aneurysm dome diameter.
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Affiliation(s)
- Justin E Vranic
- Department of Radiology, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA.,Department of Neurosurgery, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA
| | - Pablo Harker
- Department of Neurosurgery, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA
| | - Robert W Regenhardt
- Department of Neurosurgery, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA
| | - Adam A Dmytriw
- Department of Neurosurgery, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA
| | - Naif M Alotaibi
- Department of Neurosurgery, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA
| | - Rajiv Gupta
- Department of Radiology, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurosurgery, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Matthew J Koch
- Department of Neurosurgery, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA
| | - Scott B Raymond
- Department of Radiology, 2090University of Vermont Medical Center, University of Vermont Medical Center, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Long School of Medicine, USA
| | - T Tyler Patterson
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Long School of Medicine, USA
| | | | - Andrew White
- Department of Neurosurgery, University of Colorado, USA
| | - David Case
- Department of Neurosurgery, University of Colorado, USA
| | | | - Chirag D Gandhi
- Department of Neurosurgery, 8138Westchester Medical Center, 8138Westchester Medical Center, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, 8138Westchester Medical Center, 8138Westchester Medical Center, USA.,Department of Neurology, 8138Westchester Medical Center, 8138Westchester Medical Center, USA
| | - Jared Cooper
- Department of Neurosurgery, 8138Westchester Medical Center, 8138Westchester Medical Center, USA
| | - Aman B Patel
- Department of Neurosurgery, 2348Massachusetts General Hospital, Massachusetts General Hospital, Harvard Medical School, USA
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10
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Tian Z, Liu J, Kumar J, Li W, Zhang Y, Zhang Y, Wang K, Wang S, Ren Z, Yang X. Significant flow velocity reduction at the intracranial aneurysm neck after endovascular treatment leads to favourable angiographic outcome: a prospective study. Stroke Vasc Neurol 2021; 6:366-375. [PMID: 33526635 PMCID: PMC8485238 DOI: 10.1136/svn-2020-000413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/16/2020] [Accepted: 12/01/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND With widely usage of flow diverter in intracranial aneurysm treatment, some previously used predictors may not be effective in evaluating the recurrence risk. We aimed to comprehensively re-evaluate the predictors of intracranial aneurysm outcome with various endovascular treatment methods and devices. METHODS This is a prospective registered study. We analysed 6-month and 18-month follow-up angiographic data from the prospective study. Data on patient demographics, aneurysm morphology and type of treatment were recorded. Patient-specific haemodynamic simulations were performed. An unfavourable angiographic outcome was defined as recurrence of aneurysm in cases with coiling or stent-assisted coiling, patency of aneurysm in cases with flow diverters or retreatment during follow-up. RESULTS In total, 165 patients (177 intracranial aneurysms) with at least one angiographic follow-up data were analysed. For the short-term (6-month) results, after univariate analysis, the demographic, morphological and treatment-related factors did not achieve significantly statistical differences. The reduction ratio (RR) of velocity at aneurysm neck after embolisation was significantly lower in the unfavourable angiographic group than the favourable angiographic outcome group (p=0.002). After the Cox regression analysis, the RR of velocity at aneurysm neck was the only independent factor associated with favourable angiographic outcome (OR 0.028; p=0.001) and had an acceptable area under the curve (0.714) with a clear cut-off value (46.14%). Similarly, for the analysis of midterm (18-month) results, the RR of velocity at the aneurysm neck was the only independent significant factor for the unfavourable angiographic outcome (OR 0.050; p=0.017). The area under the curve was 0.754 and the cut-off value was 48.20%. CONCLUSIONS The haemodynamics showed an independent effect on angiographic follow-up results and may provide helpful suggestions for clinical practice in the future.
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Affiliation(s)
- Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Jay Kumar
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Shengzhang Wang
- Department of Mechanics and Engineering Science, Fudan University, Shanghai, China
| | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
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11
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Su T, Reymond P, Brina O, Bouillot P, Machi P, Delattre BMA, Jin L, Lövblad KO, Vargas MI. Large Neck and Strong Ostium Inflow as the Potential Causes for Delayed Occlusion of Unruptured Sidewall Intracranial Aneurysms Treated by Flow Diverter. AJNR Am J Neuroradiol 2020; 41:488-494. [PMID: 32054620 DOI: 10.3174/ajnr.a6413] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 12/23/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diverter-induced hemodynamic change plays an important role in the mechanism of intracranial aneurysm occlusion. Our aim was to explore the relationship between aneurysm features and flow-diverter treatment of unruptured sidewall intracranial aneurysms. MATERIALS AND METHODS MR imaging, 4D phase-contrast, was prospectively performed before flow diverter implantation in each patient with unruptured intracranial aneurysm. Two postprocedure follow-ups were scheduled at 6 and 12 months. Responses were grouped according to whether the aneurysms were occluded or remnant. Preprocedural aneurysm geometries and ostium hemodynamics in 38 patients were compared between the 2 groups at 6 and 12 months. Receiver operating characteristic curve analyses were performed for significant geometric and hemodynamic continuous parameters. RESULTS After the 6-month assessment, 21 of 41 intracranial aneurysms were occluded, and 9 additional aneurysms were occluded at 12 months. Geometrically, the ostium maximum diameter was significantly larger in the remnant group at 6 and 12 months (both P < .001). Hemodynamically, the proximal inflow zone was more frequently observed in the remnant group at 6 months. Several preprocedural ostium hemodynamic parameters were significantly higher in the remnant group. As a prediction for occlusion, the areas under the curve of the ostium maximum diameter (for 6 and 12 months), systolic inflow rate ratio (for 6 months), and systolic inflow area (for 12 months) reached 0.843, 0.883, 0.855, and 0.860, respectively. CONCLUSIONS Intracranial aneurysms with a large ostium and strong ostium inflow may need a longer time for occlusion. Preprocedural 4D flow MR imaging can well illustrate ostium hemodynamics and characterize aneurysm treatment responses.
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Affiliation(s)
- T Su
- From the Department of Interventional Radiology (T.S., L.J.), Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - P Reymond
- Division of Neuroradiology and Neuro-Interventional Radiology (P.R., O.B., P.M., K.O.L., M.I.V.)
| | - O Brina
- Division of Neuroradiology and Neuro-Interventional Radiology (P.R., O.B., P.M., K.O.L., M.I.V.)
| | - P Bouillot
- and Division of Radiology (B.M.A.D.), University Hospitals of Geneva, Geneva, Switzerland
| | - P Machi
- Division of Neuroradiology and Neuro-Interventional Radiology (P.R., O.B., P.M., K.O.L., M.I.V.)
| | - B M A Delattre
- Department of Quantum Matter Physics (P.B.), University of Geneva, Geneva, Switzerland
| | - L Jin
- From the Department of Interventional Radiology (T.S., L.J.), Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - K O Lövblad
- Division of Neuroradiology and Neuro-Interventional Radiology (P.R., O.B., P.M., K.O.L., M.I.V.)
| | - M I Vargas
- Division of Neuroradiology and Neuro-Interventional Radiology (P.R., O.B., P.M., K.O.L., M.I.V.)
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12
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Chiu AHY, Phillips TJ. Future Directions of Flow Diverter Therapy. Neurosurgery 2020; 86:S106-S116. [PMID: 31838531 PMCID: PMC6911736 DOI: 10.1093/neuros/nyz343] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/26/2019] [Indexed: 12/20/2022] Open
Abstract
The treatment of intracranial aneurysms has undergone a few very significant paradigm shifts in its history. Needless to say, microsurgery and surgical clipping served as the initial basis for successful treatment of these lesions. The pursuit of endovascular therapy subsequently arose from the desire to reduce the invasiveness of therapy. While the first breakthrough arose with Guido Guglielmi's invention of the detachable platinum coil, commercialized flow diverter therapy represents a disruptive therapy with a completely different paradigm for aneurysmal obliteration. This has not only altered the distribution of aneurysmal management strategies, but also opened the gateway to the treatment of previously inoperable lesions. With the basic flow diverter stent technology now considered an integral part of the neurointerventional armamentarium, we now consider what may lay in the future - including potential directions for research with regards to case selection; the location and type of aneurysms which may become routinely treatable; and modifications to the flow diverter, which may increase its utility and safety in terms of size, structural design, and surface modifications.
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Affiliation(s)
- Albert Ho Yuen Chiu
- Neurological Intervention & Imaging Service of Western Australia, Sir Charles Gairdner, Fiona Stanley and Royal Perth Hospitals, WA Health, Perth, Australia
- Division of Medicine, University of Western Australia, Perth, Australia
| | - Timothy John Phillips
- Neurological Intervention & Imaging Service of Western Australia, Sir Charles Gairdner, Fiona Stanley and Royal Perth Hospitals, WA Health, Perth, Australia
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13
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Daou BJ, Linzey JR, Pandey AS. Commentary: Flow Diversion for Intracranial Aneurysm Treatment: Trials Involving Flow Diverters and Long-Term Outcomes. Neurosurgery 2020; 86:E87-E90. [PMID: 31838539 DOI: 10.1093/neuros/nyz437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/18/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Badih J Daou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Joseph R Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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14
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Hanel RA, Kallmes DF, Lopes DK, Nelson PK, Siddiqui A, Jabbour P, Pereira VM, Szikora István I, Zaidat OO, Bettegowda C, Colby GP, Mokin M, Schirmer C, Hellinger FR, Given Ii C, Krings T, Taussky P, Toth G, Fraser JF, Chen M, Priest R, Kan P, Fiorella D, Frei D, Aagaard-Kienitz B, Diaz O, Malek AM, Cawley CM, Puri AS. Prospective study on embolization of intracranial aneurysms with the pipeline device: the PREMIER study 1 year results. J Neurointerv Surg 2019; 12:62-66. [PMID: 31308197 PMCID: PMC6996098 DOI: 10.1136/neurintsurg-2019-015091] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 11/25/2022]
Abstract
Background Preliminary clinical studies on the safety and efficacy of the pipeline embolization device (PED) for the treatment of small/medium aneurysms have demonstrated high occlusion rates with low complications. Objective To evaluate the safety and effectiveness of the PED for treatment of wide necked small and medium intracranial aneurysms. Methods PREMIER is a prospective, multicenter, single arm trial. Patients were treated with the PED for unruptured wide necked aneurysms, measuring ≤12 mm along the internal carotid artery or vertebral artery, between July 2014 and November 2015. At 1 year post-procedure, the primary effectiveness endpoint was complete occlusion (Raymond grade 1) without major parent vessel stenosis (≤50%) or retreatment, and the primary safety endpoint was major stroke in the territory supplied by the treated artery or neurologic death. Results A total of 141 patients were treated with PEDs (mean age 54.6±11.3 years, 87.9% (124/141) women). Mean aneurysm size was 5.0±1.92 mm, and 84.4% (119/141) measured <7 mm. PED placement was successful in 99.3% (140/141) of patients. Mean number of PEDs implanted per patient was 1.1±0.26; a single PED was used in 92.9% (131/141) of patients. At 1 year, 97.9% (138/141) of patients underwent follow-up angiography with 76.8% (106/138) of patients having met the study’s primary effectiveness endpoint. The combined major morbidity and mortality rate was 2.1% (3/140). Conclusions Treatment of wide necked small/medium aneurysms with the PED results in high rates of complete occlusion without significant parent vessel stenosis and low rates of permanent neurologic complications. Trial registration NCT02186561.
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Affiliation(s)
- Ricardo A Hanel
- Baptist Neurological Institute, Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - David F Kallmes
- Departments of Neurosurgery and Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Peter Kim Nelson
- Interventional Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Adnan Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Vitor M Pereira
- Departments of Medical Imaging and Surgery, Division of Neuroradiology and Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Istvan Szikora István
- Department of Neuroradiology, National Institute of Neurosciences, Budapest, Hungary
| | - Osama O Zaidat
- Neuroscience Institute, St Vincent Mercy Hospital, Toledo, Ohio, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Clemens Schirmer
- Department of Neurological Surgery, Geisinger Clinic, Danville, Pennsylvania, USA
| | - Frank R Hellinger
- Department of Radiology, Florida Hospital Neuroscience Institute, Winter Park, Florida, USA
| | - Curtis Given Ii
- Department of Radiology, Baptist Health Lexington, Lexington, Kentucky, USA
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Justin F Fraser
- Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Michael Chen
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ryan Priest
- Charles T Dotter Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Fiorella
- Department of Neurosurgery, Cerebrovascular Center, Stony Brook University, Stony Brook, New York, USA
| | - Don Frei
- Department of Neuroradiology, Swedish Medical Center, Denver, Colorado, USA
| | - Beverly Aagaard-Kienitz
- Department of Neurological Surgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Orlando Diaz
- Division of Interventional Neuroradiology, Houston Methodist Research Institute, Houston, Texas, USA
| | - Adel M Malek
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - C Michael Cawley
- Departments of Neurointerventional Radiology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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15
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Xin WQ, Xin QQ, Yuan Y, Chen S, Gao XL, Zhao Y, Zhang H, Li WK, Yang XY. Comparison of Flow Diversion and Coiling for the Treatment of Unruptured Intracranial Aneurysms. World Neurosurg 2019; 128:464-472. [PMID: 31132489 DOI: 10.1016/j.wneu.2019.05.149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND To systematically assess the efficacy and safety between flow diversion and coiling for patients with unruptured intracranial aneurysms. METHODS Potential academic articles were identified from Cochrane Library, Medline, PubMed, EMBASE, ScienceDirect, and other databases. The time range we retrieved from was the inception of electronic databases to February 2019. Gray studies were identified from the references of included literature reports. STATA version 11.0 was used to analyze the pooled data. RESULTS A total of 11 articles (10 retrospective studies and 1 prospective study) were involved in our study. The overall participants of the coiling group were 611, whereas 576 were in the flow diversion group. Our meta-analysis showed that flow diversion was preferable for unruptured intracranial aneurysms as its lower value of total cost per case (weighted mean difference, 5705.906; 95% confidence interval [CI], [4938.536, 6473236]; P < 0.001), fluoroscopy time per case (weighted mean difference, 25.786; 95% CI, 17.169-34.377; P < 0.001), and retreatment rates (odds ratio [OR], 7.127; 95% CI, [3.525, 14.410]; P < 0.001), at the same time, a higher rate of immediate completed occlusion (OR, 0.390; 95% CI, [0.224, 0.680]; P = 0.001) and follow-up completed occlusion (OR, 0.173; 95% CI, [0.080, 0.375]; P < 0.001) was demonstrated in the flow diversion group. There was no difference on intraoperative complication rates (P = 0.070), procedure-related mortality (P = 0.609) and rupture rates (P = 0.408), modified Rankin Scale (mRS) 0-2 at discharge (P = 0.077), and mRS 0-2 at follow-up (P = 0.484). CONCLUSIONS The use of flow diversion for the treatment of unruptured intracranial aneurysms may reduce total cost per case, fluoroscopy time per case, retreatment rates, and increases immediate completed occlusion and follow-up completed occlusion rates without affecting the results of mRS and intraoperative complication.
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Affiliation(s)
- Wen-Qiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Qi-Qiang Xin
- Department of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, People's Republic of China
| | - Yan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Shi Chen
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Xiang-Liang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Yan Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Hao Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Wen-Kui Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Xin-Yu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, People's Republic of China.
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16
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Raper DMS, Chen CJ, Kumar J, Kalani MY, Park MS. Predicting Outcomes for Cerebral Aneurysms Treated with Flow Diversion: A Comparison Between 4 Grading Scales. World Neurosurg 2019; 128:e209-e216. [PMID: 31004852 DOI: 10.1016/j.wneu.2019.04.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Despite the development of 4 grading scales of angiographic outcome after flow diversion for cerebral aneurysms, none have been widely adopted in the neurosurgical literature, nor have any been validated in an independent dataset. We evaluated the reported grading scales for their ability to predict aneurysm occlusion at follow-up. METHODS Four reported grading scales were applied in a retrospective analysis of our prospectively maintained institutional database of patients with intracranial aneurysms treated with flow-diverting stents. Analysis of patient factors, aneurysm factors, and outcomes was made to compare the grading scales' ability to predict aneurysm occlusion. RESULTS Ninety-nine aneurysms in 90 patients treated at our institution between 2011 and 2018 were included in the analysis. Lower Flow-Diverting Stent Score (FDSS) scores were associated with higher rates of aneurysm occlusion at final follow-up (P=0.004). The OKM, Kamran-Byrne, and SMART scales scores were not associated with aneurysm occlusion at final follow-up even after adjustments for baseline differences. Area under the receiver operating characteristic curve for the FDSS was 0.675 (0.534-0.816). CONCLUSIONS Although the FDSS was the only reported grading scale that was significantly associated with occlusion at follow-up, its ability to predict occlusion fell below the typical level for widespread clinical utility. The high rate of eventual occlusion of most aneurysms after flow diversion likely limits the clinical utility of a grading score for this application.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jeyan Kumar
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - M Yashar Kalani
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
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Malhotra A, Wu X, Miller T, Matouk CC, Sanelli P, Gandhi D. Comparative effectiveness analysis of Pipeline device versus coiling in unruptured aneurysms smaller than 10 mm. J Neurosurg 2019; 132:42-50. [PMID: 30641830 DOI: 10.3171/2018.8.jns181080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/24/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Both endovascular coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for treatment of small (< 10 mm) aneurysms. The authors conducted a comparative effectiveness analysis to compare the utility of these treatment methods in terms of health benefits. METHODS A decision-analytical study was performed with Markov modeling methods to simulate patients with small unruptured aneurysms undergoing endovascular coiling, stent-assisted coiling (SAC), or PED placement for treatment. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses were performed to assess model and input parameter uncertainty. RESULTS The base case calculation for a 50-year-old man reveals PED to have a higher health benefit (17.48 quality-adjusted life years [QALYs]) than coiling (17.44 QALYs) or SAC (17.36 QALYs). PED is the better option in 6020 of the 10,000 iterations in probabilistic sensitivity analysis. When the retreatment rate of PED is lower than 9.53%, and the coiling retreatment is higher than 15.6%, PED is the better strategy. In the 2-way sensitivity analysis varying the retreatment rates from both treatment modalities, when the retreatment rate of PED is approximately 14% lower than the retreatment rate of coiling, PED is the more favorable treatment strategy. Otherwise, coiling is more effective. SAC may be better than PED when the unfavorable outcome risk of SAC is lower than 70% of its reported current value. CONCLUSIONS With the increasing use of PEDs for treatment of small unruptured aneurysms, the current study indicates that these devices may have higher health benefits due to lower rates of retreatment compared to both simple coiling and stent-assisted techniques. Longer follow-up studies are needed to document the rates of recurrence and retreatment after coiling and PED to assess the cost-effectiveness of these strategies.
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Affiliation(s)
- Ajay Malhotra
- 1Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Wu
- 1Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Timothy Miller
- 2Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles C Matouk
- 1Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
- 3Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Pina Sanelli
- 4Department of Radiology, Northwell Health, Manhasset, New York; and
| | - Dheeraj Gandhi
- 5Division of Interventional Neuroradiology, Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
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18
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Chalouhi N, Patel PD, Atallah E, Starke RM, Chitale A, Lang M, Tjoumakaris S, Hasan D, Zarzour H, Smith MJ, Rosenwasser R, Jabbour P. Low Yield of Cerebral Angiography in Adequately Occluded Aneurysms After Flow Diversion. Neurosurgery 2018. [PMID: 29518235 DOI: 10.1093/neuros/nyx625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Flow diversion has emerged as a highly effective treatment for intracranial aneurysms. OBJECTIVE To assess the yield of further angiographic follow-up in aneurysms that have achieved adequate occlusion after treatment with the Pipeline Embolization Device (PED; Medtronic Inc, Dublin, Ireland). METHODS This is a single-institution, retrospective study. Inclusion criteria were as follows: (1) patients with 1 or more aneurysms treated with PED, (2) available short-term (<12 mo) follow-up digital subtraction angiography (DSA), (3) complete (100%) or near-complete (>95%) occlusion on short-term follow-up DSA, and (4) available further angiographic follow-up (DSA, Magnetic Resonance Angiography (MRA), or Computed Tomography Angiography (CTA)). RESULTS A total of 146 patients were identified. Aneurysm size was 8.4 ± 5.1 mm on average. Mean angiographic follow-up time was 29.7 ± 12.2 mo. On short-term follow-up DSA images, 132 (90.4%) had complete aneurysm occlusion and 14 (9.6%) had near-complete occlusion. Four patients (3%) had further DSA follow-up alone, 30 patients (21%) had further DSA and MRA/CTA follow-up, and 112 patients (76%) had further MRA/CTA follow-up alone. On further angiographic follow-up (DSA, MRA, and/or CTA), no patient had a decrease in the degree of aneurysm occlusion (recurrence) or required retreatment. Of the 14 patients with near-complete occlusion on initial DSA images, 7 patients (50%) progressed to complete aneurysm occlusion on further angiographic follow-up. CONCLUSION This study did not find any diagnostic yield in repeating cerebral angiography in adequately occluded aneurysms with the PED. We do not recommend repeat angiographic follow-up once aneurysms have achieved complete occlusion with the PED unless clinically warranted.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Purvee D Patel
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Elias Atallah
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M Starke
- Department of Neurosurgery & Radiology, Miami Miller School of Medicine, Miami University Hospital, Miami, Florida
| | - Ameet Chitale
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Michael Lang
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | - Hekmat Zarzour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Michelle J Smith
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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19
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Sokolowski JD, Ilyas A, Buell TJ, Taylor DG, Chen CJ, Ding D, Raper DMS, Liu KC. SMART coils for intracranial aneurysm embolization: Follow-up outcomes. J Clin Neurosci 2018; 59:93-97. [PMID: 30414808 DOI: 10.1016/j.jocn.2018.10.132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/27/2018] [Indexed: 11/19/2022]
Abstract
The SMART coil (Penumbra Inc., Alameda, CA, USA) is a new microcoil designed to enhance deliverability. Although prior studies have described its perioperative safety and efficacy, the follow-up outcomes after embolization of intracranial aneurysms using SMART coils have not been reported. Therefore, the aim of this retrospective cohort study is to assess the angiographic outcomes at interim follow-up after aneurysm embolization with SMART coils. We reviewed data from consecutive patients with intracranial aneurysms who underwent endovascular treatment using SMART coils between June 2016 and August 2017. Baseline data and follow-up angiographic outcomes using the modified Raymond-Roy classification (MRRC) were recorded. The study cohort comprised 33 patients with 34 aneurysms who underwent SMART coil embolization and had sufficient follow-up data. The mean age was 57 years, and 82% were female. The mean aneurysm maximum diameter and neck width were 6.1 ± 2.2 mm and 3.2 ± 1.2 mm, respectively, and 14.7% of aneurysms were ruptured. The overall complication rate was 12%. Initial mean coil packing density was 26%, and the initial MRRC was I, II, IIIa, and IIIb in 24%, 26%, 35%, and 15%, respectively. At last follow-up (mean duration 7.7 ± 3.2 months), the MRRC was I, II, IIIa, and IIIb in 62%, 26%, 3%, and 9%, respectively. The retreatment rate was 14.7%. The SMART coil is efficacious for the treatment of appropriately selected aneurysms, with an acceptable risk profile. The majority of residual aneurysms after the initial embolization procedure will progress to complete or near-complete occlusion at interim follow-up.
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Affiliation(s)
- Jennifer D Sokolowski
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States.
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Davis G Taylor
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, KY, United States
| | - Daniel M S Raper
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Kenneth C Liu
- Department of Neurological Surgery, Pennsylvania State University, Hershey, PA, United States
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20
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Killer-Oberpfalzer M, Kocer N, Griessenauer CJ, Janssen H, Engelhorn T, Holtmannspötter M, Buhk JH, Finkenzeller T, Fesl G, Trenkler J, Reith W, Berlis A, Hausegger K, Augustin M, Islak C, Minnich B, Möhlenbruch M. European Multicenter Study for the Evaluation of a Dual-Layer Flow-Diverting Stent for Treatment of Wide-Neck Intracranial Aneurysms: The European Flow-Redirection Intraluminal Device Study. AJNR Am J Neuroradiol 2018; 39:841-847. [PMID: 29545252 DOI: 10.3174/ajnr.a5592] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/12/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Endoluminal reconstruction with flow-diverting stents represents a widely accepted technique for the treatment of complex intracranial aneurysms. This European registry study analyzed the initial experience of 15 neurovascular centers with the Flow-Redirection Intraluminal Device (FRED) system. MATERIALS AND METHODS Consecutive patients with intracranial aneurysms treated with the FRED between February 2012 and March 2015 were retrospectively reviewed. Complications and adverse events, transient and permanent morbidity, mortality, and occlusion rates were evaluated. RESULTS During the defined study period, 579 aneurysms in 531 patients (median age, 54 years; range, 13-86 years) were treated with the FRED. Seven percent of patients were treated in the acute phase (≤3 days) of aneurysm rupture. The median aneurysm size was 7.6 mm (range, 1-36.6 mm), and the median neck size 4.5 mm (range, 1-30 mm). Angiographic follow-up of >3 months was available for 516 (89.1%) aneurysms. There was progressive occlusion witnessed with time, with complete occlusion in 18 (20%) aneurysms followed for up to 90 ± 14 days, 141 (82.5%) for 180 ± 20 days, 116 (91.3%) for 1 year ± 24 days, and 122 (95.3%) aneurysms followed for >1 year. Transient and permanent morbidity occurred in 3.2% and 0.8% of procedures, respectively. The overall mortality rate was 1.5%. CONCLUSIONS This retrospective study in real-world patients demonstrated the safety and efficacy of the FRED for the treatment of intracranial aneurysms. In most cases, treatment with a single FRED resulted in complete angiographic occlusion at 1 year.
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Affiliation(s)
- M Killer-Oberpfalzer
- From the Research Institute of Neurointervention/Department of Neurology (M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - N Kocer
- Department of Neuroradiology (N.K., C.I.), Cerrahpasa Medical School, Istanbul University, Turkey
| | - C J Griessenauer
- From the Research Institute of Neurointervention/Department of Neurology (M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria.,Department of Neurosurgery (C.J.G.), Geisinger Health, Danville, Pennsylvania
| | - H Janssen
- Institute of Radiology and Neuroradiology (H.J., T.F.), Klinikum Nuernberg Sued, Paracelsus Medical University, Nuernberg, Germany
| | - T Engelhorn
- Department of Neuroradiology (T.E.), University Hospital, Erlangen, Germany
| | - M Holtmannspötter
- Department of Diagnostic Radiology (M.H.), Rigshospitalet, Copenhagen, Denmark
| | - J H Buhk
- Department of Neuroradiology (J.H.B.), University Hospital Hamburg, Eppendorf, Germany
| | - T Finkenzeller
- Institute of Radiology and Neuroradiology (H.J., T.F.), Klinikum Nuernberg Sued, Paracelsus Medical University, Nuernberg, Germany
| | - G Fesl
- Department of Neuroradiology (G.F.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - J Trenkler
- Department of Neuroradiology (J.T.), Kepler Universitätsklinikum, Linz, Austria
| | - W Reith
- Klinik für Diagnostische und Interventionelle Neuroradiologie (W.R.), Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - A Berlis
- Klinik für Diagnostische Radiologie und Neuroradiologie (A.B.), Klinikum Augsburg, Augsburg, Germany
| | - K Hausegger
- Department of Diagnostic and Interventional Radiology (K.H.), Klinikum Klagenfurt, Klagenfurt, Austria
| | - M Augustin
- Department of Radiology (M.A.), University Hospital, Graz, Austria
| | - C Islak
- Department of Neuroradiology (N.K., C.I.), Cerrahpasa Medical School, Istanbul University, Turkey
| | - B Minnich
- Department of Cell Biology and Physiology (B.M.), Universität Salzburg, Salzburg, Austria
| | - M Möhlenbruch
- Department of Neuroradiology (M.M.), Universitätsklinikum Heidelberg, Heidelberg, Germany
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21
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Alreshidi M, Cote DJ, Dasenbrock HH, Acosta M, Can A, Doucette J, Simjian T, Hulou MM, Wheeler LA, Huang K, Zaidi HA, Du R, Aziz-Sultan MA, Mekary RA, Smith TR. Coiling Versus Microsurgical Clipping in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis. Neurosurgery 2018; 83:879-889. [DOI: 10.1093/neuros/nyx623] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 12/12/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo.
OBJECTIVE
To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis.
METHODS
A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed.
RESULTS
Thirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different.
CONCLUSION
This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.
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Affiliation(s)
- Meshal Alreshidi
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, Massachusetts
| | - David J Cote
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hormuzdiyar H Dasenbrock
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Acosta
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anil Can
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joanne Doucette
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, Massachusetts
| | - Thomas Simjian
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, Massachusetts
| | - M Maher Hulou
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee A Wheeler
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kevin Huang
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hasan A Zaidi
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - M Ali Aziz-Sultan
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rania A Mekary
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, Massachusetts
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Cerejo R, Bain M, Masaryk T. Balloon sandwich technique for retrieval of fractured delivery wire of pipeline stent. Interv Neuroradiol 2017; 24:40-42. [PMID: 29065742 DOI: 10.1177/1591019917732287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Delivery wire fracture of flow-diverter stents are rare but have been described. We describe a video case of a successful technique to retrieve such a fractured delivery wire by using a balloon microcatheter and the intermediate catheter when other proven methods may fail.
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Affiliation(s)
| | - Mark Bain
- Cerebrovascular Center, 2569 Cleveland Clinic , OH, USA
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