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Barros G, Federico E, Fillingham P, Chanana P, Kaneko N, Zheng Y, Kim LJ, Levitt MR. Endothelial Cell Transcription Modulation in Cerebral Aneurysms After Endovascular Flow Diversion. Ann Biomed Eng 2024:10.1007/s10439-024-03591-0. [PMID: 39095638 DOI: 10.1007/s10439-024-03591-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE Flow diverting stents (FDS) are used to treat cerebral aneurysms, by promoting thrombosis and occlusion of the aneurysm sac. However, retreatment is required in some cases, and the biologic basis behind treatment outcome is not known. The goal of this study was to understand how changes in hemodynamic flow after FDS placement affect aneurysmal endothelial cell (EC) activity. METHODS Three-dimensional models of patient-specific aneurysms were created to quantify the EC response to FDS placement. Computational fluid dynamic simulations were used to determine the hemodynamic impact of FDS. Two identical models were created for each patient; into one a FDS was inserted. Each model was then populated with human carotid ECs and subjected to patient-specific pulsatile flow for 24 h. ECs were isolated from aneurysm dome from each model and bulk RNA sequencing was performed. RESULTS Paired untreated and treated models were created for four patients. Aneurysm dome EC analysis revealed 366 (2.6%) significant gene changes between the untreated and FDS conditions, out of 13909 total expressed genes. Gene set enrichment analysis of the untreated models demonstrated enriched gene ontology terms related to cell adhesion, growth/tensile activity, cytoskeletal organization, and calcium ion binding. In the FDS models, enriched terms were related to cellular proliferation, ribosomal activity, RNA splicing, and protein folding. CONCLUSION Treatment of cerebral aneurysms with FDS induces significant EC gene transcription changes related to aneurysm hemodynamics in patient-specific in vitro 3D-printed models subjected to pulsatile flow. Further investigation is needed into the relationship between transcriptional change and treatment outcome.
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Affiliation(s)
- Guilherme Barros
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Emma Federico
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Patrick Fillingham
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | - Pritha Chanana
- Bioinformatics Shared Resource, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Naoki Kaneko
- Division of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Ying Zheng
- Department of Bioengineering, University of Washington, Seattle, WA, USA
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
- Department of Radiology, University of Washington, Seattle, WA, USA.
- Department of Mechanical Engineering, University of Washington, Seattle, WA, USA.
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA.
- Department of Neurology, University of Washington, Seattle, WA, USA.
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Ramirez-Velandia F, Enriquez-Marulanda A, Filo J, Young M, Fodor TB, Sconzo D, Muram S, Granstein JH, Shutran M, Taussky P, Ogilvy CS. Comparison of Thromboembolic Events Between Pipeline Embolization Device (PED) Shield and PED/PED Flex: A Propensity Score-Matched Analysis. Neurosurgery 2024; 95:330-338. [PMID: 38391195 DOI: 10.1227/neu.0000000000002883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/04/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The pipeline embolization device (PED) Flex with Shield technology is a third-generation flow diverter used for intracranial aneurysm treatment designed to decrease thrombogenicity through a phosphorylcholine coating. Herein, we aim to compare the rate of thromboembolic events in PED with Shield technology and PED without it through propensity score matching. METHODS We conducted a retrospective analysis of aneurysms treated with PED first-generation/PED Flex and PED with Shield between 2013 and 2023 at a single academic institution. Patients were matched through propensity score by controlling for confounding factors including age, smoking history, diabetes, previous subarachnoid hemorrhage, modified Rankin Scale pretreatment, location, aneurysm size, previous treatment, and clopidogrel or aspirin resistance. After matching, we evaluated for periprocedural and postoperative thromboembolic events. Data analysis was performed using Stata 14. RESULTS A total of 543 patients with 707 aneurysms treated in 605 procedures were included in the analysis. From these, 156 aneurysms were treated with PED with Shield (22.07%) and 551 (77.93%) without Shield technology. Propensity score matching resulted in 84 matched pairs. The rate of thromboembolic events was 3.57% for PED Shield and 10.71% for PED first-generation/PED Flex ( P = .07), while retreatment rates were 2.38% for PED Shield and 8.32% for PED Flex ( P = .09). Complete occlusion at first ( P = .41) and last imaging follow-up ( P = .71), in-stent stenosis ( P = .95), hemorrhagic complications ( P = .31), and functional outcomes ( P = .66) were comparable for both groups. CONCLUSION This is the first study in the literature performing a propensity scored-matched analysis comparing PED with PED with Shield technology. Our study suggests a trend toward lower thromboembolic events for PED Shield, even after controlling for aspirin and clopidogrel resistance, and a trend toward lower aneurysm retreatment rates with PED Shield, without reaching statistical significance.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
| | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
| | - Daniel Sconzo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Boston University Chobanian and Avedisian School of Medicine, Boston , Massachusetts , USA
| | - Sandeep Muram
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
| | - Justin H Granstein
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
- Neurosurgery Department, Harvard Medical School, Boston , Massachusetts , USA
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Gaub M, Murtha G, Lafuente M, Webb M, Luo A, Birnbaum LA, Mascitelli JR, Al Saiegh F. Flow Diversion for Endovascular Treatment of Intracranial Aneurysms: Past, Present, and Future Directions. J Clin Med 2024; 13:4167. [PMID: 39064207 PMCID: PMC11278297 DOI: 10.3390/jcm13144167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/04/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Flow diversion for intracranial aneurysms emerged as an efficacious and durable treatment option over the last two decades. In a paradigm shift from intrasaccular aneurysm embolization to parent vessel remodeling as the mechanism of action, the proliferation of flow-diverting devices has enabled the treatment of many aneurysms previously considered untreatable. In this review, we review the history and development of flow diverters, highlight the pivotal clinical trials leading to their regulatory approval, review current devices including endoluminal and intrasaccular flow diverters, and discuss current and expanding indications for their use. Areas of clinical equipoise, including ruptured aneurysms and wide-neck bifurcation aneurysms, are summarized with a focus on flow diverters for these pathologies. Finally, we discuss future directions in flow diversion technology including bioresorbable flow diverters, transcriptomics and radiogenomics, and machine learning and artificial intelligence.
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Affiliation(s)
| | | | | | | | | | | | | | - Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX 78229, USA; (M.G.); (G.M.); (M.L.); (M.W.); (A.L.); (L.A.B.); (J.R.M.)
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Xue X, Liang X, Miao Y, Sun M, Liu H, Tong X, Liu A. The aneurysm occlusion and recurrence of posterior communicating artery aneurysms following the treatment with the pipeline embolization device. Neurosurg Rev 2024; 47:330. [PMID: 39007950 DOI: 10.1007/s10143-024-02580-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/16/2024] [Accepted: 07/08/2024] [Indexed: 07/16/2024]
Abstract
Despite advancements in treatment modalities such as flow diverters, the optimal management of posterior communicating artery (PComA) aneurysms remains uncertain. While PComA aneurysms treated with the Pipeline Embolization Device (PED) has been reported, the characteristics and progression of incomplete occluded aneurysms remain unclear. Therefore, our study aims to investigate the occlusion status and recurrence rates of PComA aneurysms treated with PED. A retrospective review of consecutive PComA aneurysm patients treated with PED was conducted between January 2015 and December 2020. Only patients with radiological follow-up were included. PComA aneurysms were categorized into incomplete occlusion and complete occlusion group. The primary outcomes included the characteristics of incomplete occlusion at the follow-up angiography. Among 121 PComA aneurysms treated with PED at our institution, 80 aneurysms were eligible in our study. During the follow-up period, 19 (23.8%) aneurysms demonstrated incomplete occlusion. Notably, there were no instances of recurrence among the 80 followed-up cases. Baseline characteristics of patients and aneurysms were comparable between the groups with complete and incomplete occlusion. However, the incomplete occlusion group showed a lower rate of assisted coils embolization (21.2% vs. 55.7%, P = 0.017) and shorter median operative time (91.0 vs. 145.5 min, P = 0.039). Differences in functional outcomes, complications, and PComA occlusion status between the groups were not significant. Multivariate analysis revealed the use of coils was associated with lower odds of incomplete PComA aneurysm occlusion (OR 0.01, 95% CI 0.001-0.12; P = 0.001), while aneurysm size was associated with higher odds of incomplete occlusion (OR 1.25, 95% CI 1.10-1.46; P = 0.002). The treatment of PED for PComA aneurysm demonstrated favorable outcomes, with an acceptable rate of incomplete occlusion and no instances of recurrence observed. However, further research is needed to explore the optimal procedural strategy for large-sized PComA aneurysms.
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Affiliation(s)
- Xiaopeng Xue
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Xin Liang
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yan Miao
- Department of Neurology, The Third Xiangya Hospital, Central South University, Beijing, Hunan, China
| | - Mingjiang Sun
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Hongyi Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
- Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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Sharashidze V, Raz E, Nossek E, Kvint S, Riina H, Rutledge C, Baranoski J, Khawaja A, Chung C, Nelson PK, Shapiro M. Comprehensive Analysis of Post-Pipeline Endothelialization and Remodeling. AJNR Am J Neuroradiol 2024; 45:893-898. [PMID: 38663989 DOI: 10.3174/ajnr.a8228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/06/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND AND PURPOSE Successful post-flow-diverter endoluminal reconstruction is widely believed to require endothelial overgrowth of the aneurysmal inflow zone. However, endothelialization/neointimal overgrowth is a complex process, over which we currently have very limited influence. Less emphasized is vascular remodeling of the target arterial segment, the dynamic response of the vessel to flow-diverter implantation. This process is distinct from flow modifications in covered branches. It appears that basic angiographic methods allow simple and useful observations. The purpose of this article was to quantitatively evaluate observable postimplantation changes in target vessels following deployment of Pipeline endoluminal constructs. MATERIALS AND METHODS One hundred consecutive adults with unruptured, previously untreated, nondissecting aneurysms treated with the Pipeline Embolization Device with Shield Technology and the availability of follow-up conventional angiography were studied with 2D DSA imaging. Target vessel size; Pipeline Embolization Device diameter; endothelial thickness; and various demographic, antiplatelet, and device-related parameters were recorded and analyzed. RESULTS The thickness of neointimal overgrowth (mean, 0.3 [SD, 0.1] mm; range, 0.1-0.7 mm) is inversely correlated with age and is independent of vessel size, smoking status, sex, and degree of platelet inhibition. The decrease in lumen diameter caused by neointimal overgrowth, however, appears counteracted by outward remodeling (dilation) of the target arterial segment. This leads to an increase in the diameter with a corresponding decrease in length (foreshortening) of the implanted Pipeline Embolization Device. This physiologic remodeling process affects optimally implanted devices and is not a consequence of stretching, device migration, vasospasm, and so forth. A direct, linear, statistically significant relationship exists between the degree of observed outward remodeling and the diameter of the implanted Pipeline Embolization Device relative to the target vessel. Overall, remodeled arterial diameters were reduced by 15% (SD, 10%) relative to baseline and followed a normal distribution. Clinically relevant stenosis was not observed. CONCLUSIONS Vessel healing involves both outward remodeling and neointimal overgrowth. Judicial oversizing could be useful in specific settings to counter the reduction in lumen diameter due to postimplant neointimal overgrowth; however, this overszing needs to be balanced against the decrease in metal coverage accompanying the use of oversized devices. Similar analysis for other devices is essential.
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Affiliation(s)
- Vera Sharashidze
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Eytan Raz
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Erez Nossek
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Svetlana Kvint
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Howard Riina
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurology (H.R., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Caleb Rutledge
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Jacob Baranoski
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Ayaz Khawaja
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Charlotte Chung
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Peter Kim Nelson
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Maksim Shapiro
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurology (H.R., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
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Liu C, Cai Y, Zang C, Guo K, Hu X. Innovations in intracranial aneurysm treatment: a pilot study on the Choydar flow diverter. Front Neurol 2024; 15:1413681. [PMID: 39026585 PMCID: PMC11254627 DOI: 10.3389/fneur.2024.1413681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 06/24/2024] [Indexed: 07/20/2024] Open
Abstract
Background The flow diverter (FD) has emerged as a promising treatment option for intracranial aneurysms. Recently, a novel flow-diverting stent, the Choydar FD device, has been developed within our nation. Objective To introduce the newly developed Choydar FD device and present our preliminary clinical experience with its application in the treatment of intracranial aneurysms. Methods A total of 23 patients with 23 unruptured intracranial aneurysms, comprising 20 (87.0%) aneurysms located at the internal carotid artery and 3 (13.0%) at the vertebral artery, were treated with the Choydar FD device between December 2021 and April 2022. Patient baseline data, clinical and angiographic outcomes were collected and analyzed. Results The Choydar FD device was successfully deployed in all patients (100%), with 18 aneurysms (78.3%) additionally treated with coils. One patient experienced an ischemic event with sensory disturbance during the perioperative period. At the 1-year follow-up, all patients demonstrated good clinical outcomes. Of the 23 aneurysms with available angiographic follow-up, 22 (95.7%) achieved complete occlusion, and one patient exhibited in-stent stenosis without neurological deficits. Conclusion The initial clinical results of the Choydar FD device are encouraging, and it appears to be a useful option for treating intracranial aneurysms with acceptable efficacy and safety. Future studies with larger sample sizes and longer follow-up durations are warranted to validate these findings.
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Affiliation(s)
- Changya Liu
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Emergency, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yike Cai
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chunguang Zang
- Department of Neurosurgery, Wuhan Red Cross Hospital, Wuhan, Hubei, China
| | - Kaikai Guo
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xuebin Hu
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Amoukhteh M, Hassankhani A, Jannatdoust P, Valizadeh P, Ghozy S, Bilgin C, Kallmes DF. Comparative meta-analysis of endovascular strategies for intracranial dissecting aneurysms: Flow diverters versus stents with or without coiling. Interv Neuroradiol 2024:15910199241262070. [PMID: 38873695 DOI: 10.1177/15910199241262070] [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: 06/15/2024] Open
Abstract
BACKGROUND Intracranial dissecting aneurysms present a challenging subset linked to considerable morbidity and mortality, necessitating effective therapeutic strategies to prevent complications. Traditional treatments face technical limitations, while emerging endovascular modalities like stent-assisted coiling, multiple stenting, and flow-diverting devices (FDDs) offer promise in reducing periprocedural risks and enhancing patient outcomes. The aim of this study is to compare the safety and efficacy outcomes of endovascular treatment for intracranial dissecting aneurysms using FDDs versus stents (with or without coiling). METHODS A systematic review and meta-analysis were conducted following established guidelines. The search included PubMed, Scopus, Web of Science, and Embase databases up to July 30, 2023. Eligible studies reporting outcomes of interest in both FDD and stent-treated groups were included, and the data was extracted and analyzed using STATA software. RESULTS Six studies were analyzed, involving 131 patients in the FDD group and 199 patients in the stent group. The pooled rates for favorable functional outcomes (86.8% vs. 86%), mortality (3.9% vs. 6%), adequate occlusion (79.7% vs. 86.3%), aneurysm recurrence (1.3% vs. 13.3%), in-stent stenosis/thrombosis (7% vs. 6.9%), ischemic events/infarctions (6.7% vs. 7.8%), retreatment (7% vs. 8.6%), and technical success (100% vs. 98.7%) were comparable in individuals treated with FDDs and stents (p > 0.05 in all cases). Additionally, complete occlusion rates were not significantly different between FDD (62.7%) and stent-treated patients (75.2%) (p = 0.06). However, after excluding one study in a leave-one-out analysis of the random effects meta-analysis, a significant difference in the pooled rates of this outcome was observed between the FDD (59.2%) and stent (75.2%) groups (p = 0.034). CONCLUSION FDDs present a promising approach for the treatment of intracranial dissecting aneurysms, yielding outcomes that are roughly comparable to stent-based methods. However, the absence of randomized trials and data limitations highlight the need for further research to enhance treatment strategies.
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Affiliation(s)
- Melika Amoukhteh
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Amir Hassankhani
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | | | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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8
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Çay F, Arat A. Appraisal of the Flow Diversion Effect Provided by Braided Intracranial Stents. J Clin Med 2024; 13:3409. [PMID: 38929937 PMCID: PMC11204822 DOI: 10.3390/jcm13123409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/01/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Objective: Comparison of the results of stent-assisted coiling (SAC) with braided stents (BS), flow diverters (FD), and laser-cut stents (LCS) to determine the relative flow-diverting capacity of BS (Leo baby and Accero). Methods: Saccular intracranial aneurysms treated by SAC and FD-assisted coiling were retrospectively evaluated. Aneurysm occlusion, as graded per Raymond-Roy score, was categorized as either recanalization/stable residual filling (Group A; lacking a flow diversion effect) or stable/progressive occlusion (Group B with a "flow diversion effect"). Factors predicting the flow diversion effect were evaluated. Results: Of the 194 aneurysms included, LCS, BS, and FD were used in 70 (36.1%), 86 (44.3%), and 38 (19.6%) aneurysms, respectively. Aneurysms treated by FD were larger, had wider necks, and were located on larger parent arteries (p < 0.01, 0.02, and <0.01, respectively). The mean imaging follow-up duration was 24.5 months. There were 29 (14.9%) aneurysms in Group A and 165 (85.1%) in Group B. Among a spectrum of variables, including sex, age, aneurysm size, neck width, parent artery diameter, follow-up duration, and stent type, the positive predictors for stable/progressive aneurysm occlusion were aneurysm size and placement of an FD or BS (p < 0.01 and p < 0.01, respectively, and were positive predictors over LCS: ORs 6.34 (95% CI: 1.62-24.76) and 3.11 (95% CI: 1.20-8.07), respectively) in multivariate analysis. Conclusions: The placement of BS was a predictor of flow diversion over laser-cut stents. However, the flow diversion effect was approximately half that of FDs, suggesting that BS may only be considered to have some (partial) flow diversion effects.
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Affiliation(s)
- Ferdi Çay
- Department of Radiology, Hacettepe University School of Medicine, Hacettepe Mh., A.Adnan Saygun Cd., Ankara 06230, Türkiye;
| | - Anıl Arat
- Department of Radiology, Hacettepe University School of Medicine, Hacettepe Mh., A.Adnan Saygun Cd., Ankara 06230, Türkiye;
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06520, USA
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Liu Z, Zhang M, Wang C, Wang Z, Liao X, Ou C, Si W. Flow diverters treatment planning of small- and medium-sized intracranial saccular aneurysms on the internal carotid artery via constraint-based virtual deployment. Int J Comput Assist Radiol Surg 2024; 19:1175-1183. [PMID: 38619792 DOI: 10.1007/s11548-024-03124-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE The internal carotid artery (ICA) is a region with a high incidence for small- and medium-sized saccular aneurysms. However, the treatment relies heavily on the surgeon's experience to achieve optimal outcome. Although the finite element method (FEM) and computational fluid dynamics can predict the postoperative outcomes, due to the computational complexity of traditional methods, there is an urgent need for investigating the fast but versatile approaches related to numerical simulations of flow diverters (FDs) deployment coupled with the hemodynamic analysis to determine the treatment plan. METHODS We collected the preoperative and postoperative data from 34 patients (29 females, 5 males; mean age 55.74 ± 9.98 years) who were treated with a single flow diverter for small- to medium-sized intracranial saccular aneurysms on the ICA. The constraint-based virtual deployment (CVD) method is proposed to simulate the FDs expanding outward along the vessel centerline while be constrained by the inner wall of the vessel. RESULTS The results indicate that there were no significant differences in the reduction rates of wall shear stress and aneurysms neck velocity between the FEM and methods. However, the solution time of CVD was greatly reduced by 98%. CONCLUSION In the typical location of small- and medium-sized saccular aneurysms, namely the ICA, our virtual FDs deployment simulation effectively balances the computational accuracy and efficiency. Combined with hemodynamics analysis, our method can accurately represent the blood flow changes within the lesion region to assist surgeons in clinical decision-making.
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Affiliation(s)
- Zehua Liu
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Xueyuan street 1068, Shenzhen University Town, Nanshan District, Shenzhen, 518000, China
| | - Meng Zhang
- Department of Neurosurgery, Shenzhen Second People's Hospital, Sungang West Road 3002, Futian District, Guangdong, 510000, China
| | - Chao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, TiantanXili 6, Dongcheng District, Beijing, 100000, China
| | - Zhongxiao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, TiantanXili 6, Dongcheng District, Beijing, 100000, China
| | - Xiangyun Liao
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Xueyuan street 1068, Shenzhen University Town, Nanshan District, Shenzhen, 518000, China
| | - Chubin Ou
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Zhongshan 2nd Road 106, Yuexiu District, Guangdong, 510000, China.
| | - Weixin Si
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Xueyuan street 1068, Shenzhen University Town, Nanshan District, Shenzhen, 518000, China.
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10
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Monteiro A, Khan A, Donnelly BM, Kuo CC, Burke SM, Waqas M, Housley SB, Cappuzzo JM, Davies JM, Snyder KV, Levy EI, Siddiqui AH. Treatment of ruptured intracranial aneurysms using the novel generation of flow-diverters with surface modification: A systematic review and meta-analysis. Interv Neuroradiol 2024; 30:350-360. [PMID: 35929825 PMCID: PMC11310723 DOI: 10.1177/15910199221117921] [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: 05/16/2022] [Accepted: 07/17/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Surface modification of flow diverters (FDs) has been explored as a solution for reducing thrombotic risk of these devices, without necessarily using dual antiplatelet therapy (DAPT). If effective, this could pose a promising alternative for treatment of ruptured aneurysms not amenable to other modalities. METHODS We performed a comprehensive search of PubMed, MEDLINE, and Embase databases following Preferred Reporting Items for Systematic reviews and Meta-analyzes guidelines. We included articles reporting use of surface-modified FDs for treatment of ruptured aneurysms. Demographics, subarachnoid hemorrhage (SAH) severity, aneurysm characteristics, devices used, periprocedural complications, angiographic outcomes, and mortality were extracted for sample size-based weighted analysis. RESULTS Six studies comprising 59 patients with 64 aneurysms were included. Mean patient age was 56.6 ± 6.3 years and 60.6% (95% confidence interval [CI], 46.7-72.9%) were women. The anterior circulation was the location in 60.4% (95%CI, 45.5-73.5%) of aneurysms; 41.8% of the aneurysms were saccular (95%CI, 29.3-55.4%), 16.7% were fusiform (95%CI, 8.3-30.8%), 29.9% were dissecting (95%CI, 12.8-55.4%), 24.4% were blood-blister (95%CI, 15.2-36.7%), and 5.7% were mycotic (95%CI, 2-15.1%). Poor SAH grade was reported in 46.9% (95%CI, 33.3-60.9%). Adjunctive coiling was used in 33.2% (95%CI, 12.4-63.6%). Periprocedural thromboembolic and hemorrhagic complications occurred in 20% (95%CI, 7.1-45.1%) and 8.8% (95%CI, 3.7-19.5%), respectively. Complete occlusion was achieved in 76.4% (95%CI, 58.1-88.3%); no retreatments during follow-up were reported. Overall mortality was 15.1% (95%CI, 7.7-27.6%). There were no differences between single antiplatelet therapy (SAPT) and DAPT regimens with respect to periprocedural thromboembolic complications (P = 0.09), hemorrhagic (P = 0.834) complications, and mortality (P = 0.312). CONCLUSION Surface-modified FD treatment of ruptured aneurysms resulted in high rates of thromboembolic complications and acceptable rates of hemorrhagic complications. A considerable proportion of aneurysms were nonsaccular. Rates of complete occlusion were high and retreatment were low. Importantly, no statistically significant difference was found between SAPT and DAPT with respect to complications and mortality.
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Affiliation(s)
- Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Brianna M Donnelly
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Samantha M Burke
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Steven B Housley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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11
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Zoppo CT, Epshtein M, Gounis MJ, Anagnostakou V, King RM. Longitudinal healing flow diverting stents with phosphorylcholine surface modification. J Neurointerv Surg 2024; 16:582-586. [PMID: 37402572 DOI: 10.1136/jnis-2023-020500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/18/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Flow diversion has become a standard treatment for cerebral aneurysms. However, major drawbacks include the need for dual antiplatelet therapy after implant and delayed complete occlusion of the aneurysm, which occurs when new tissue growth excludes the aneurysm from the parent artery. Biomimetic surface modifications such as the phosphorylcholine polymer (Shield surface modification) represent major advances in reducing thrombogenicity of these devices. However, in vitro studies have raised concerns that this modification may also delay endothelialization of flow diverters. METHODS Bare metal Pipeline, Pipeline Shield, and Vantage with Shield devices were implanted in the common carotid arteries (CCAs) of 10 rabbits (two in the left CCA, one in the right CCA). Following implant and at 5, 10, 15, and 30 days, the devices were imaged with high-frequency optical coherence tomography and conventional angiography to evaluate tissue growth. At 30 days the devices were explanted and their endothelial growth was assessed with scanning electron microscopy (SEM) at five locations along their length using a semi-quantitative score. RESULTS The average tissue growth thickness (ATGT) was not different between the three devices. Neointima was apparent at 5 days and all devices demonstrated similar ATGT at each time point. On SEM, no difference was found in the endothelium scores between the device types. CONCLUSION In vivo, neither the Shield surface modification nor the device design (Vantage) altered the longitudinal healing of the flow diverter.
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Affiliation(s)
- Christopher T Zoppo
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Mark Epshtein
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Vania Anagnostakou
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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12
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Ma L, Hoz SS, Al-Bayati AR, Nogueira RG, Lang MJ, Gross BA. Flow Diverters with Surface Modification in Patients with Intracranial Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 185:320-326.e17. [PMID: 38160909 DOI: 10.1016/j.wneu.2023.12.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/24/2023] [Accepted: 12/25/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Flow diverters with surface modification (FDSM) are increasingly being used in the treatment of intracranial aneurysms (ANs). We aimed to evaluate the effectiveness and safety across different devices and antiplatelet therapies using a systematic review and meta-analysis. METHODS A systematic review was performed to identify original studies of ≥10 patients with intracranial ANs treated with FDSM from database inception through August 2023. Primary effectiveness outcome was the rate of complete AN occlusion at follow-up ≥6 months. Safety outcomes included ischemic stroke, hemorrhage, and in-stent thrombosis, and were stratified by FDSM devices and antiplatelet therapies. Certainty of evidence was evaluated following the Grading of Recommendations, Assessment, Development, and Evaluations approach. RESULTS Twenty-seven studies were included, yielding 2161 patients with 2373 ANs. A total of 70.5% of the ANs were located on the internal carotid artery (ICA). Total 10.3% were acutely ruptured. The complete AN occlusion rate was 72.3% at follow-up ≥6 months. Sensitivity analysis in the ICA AN cohort yielded comparable occlusion rates between Pipeline Flex Embolization Device-Shield (80.4%) and Phenox-hydrophilic polymer-coated (77.5%, P = 0.54), but a lower 66.2% rate for Flow Redirection Endoluminal Device-X (P = 0.02). The rate of in-stent thrombosis and stenosis tended to be higher in Phenox-hydrophilic polymer-coated (3.4%) and Flow Redirection Endoluminal Device-X (4.3%) versus Pipeline Flex Embolization Device-Shield (0.8%, P = 0.05). CONCLUSIONS FDSM were safe with satisfactory effectiveness for intracranial ANs. More specific investigations are warranted to explore their performance in ANs beyond the ICA and optimal antiplatelet therapy.
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Affiliation(s)
- Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samer S Hoz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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13
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Meyer L, Stracke CP, Bester M, Kallmes KM, Zeleňák K, Rouchaud A, Martínez-Galdámez M, Jabbour P, Nguyen TN, Siddiqui AH, Fiehler J, Gellissen S. Predictors of aneurysm occlusion after treatment with flow diverters: a systematic literature review. J Neurointerv Surg 2024; 16:482-490. [PMID: 37316195 DOI: 10.1136/jnis-2022-019993] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/24/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Flow diverters (FDs) have become an integral part of treatment for brain aneurysms. AIM To summarize available evidence of factors associated with aneurysm occlusion (AO) after treatment with a FD. METHODS References were identified using the Nested Knowledge AutoLit semi-automated review platform between January 1, 2008 and August 26, 2022. The review focuses on preprocedural and postprocedural factors associated with AO identified in logistic regression analysis. Studies were included if they met the inclusion criteria of study details (ie, study design, sample size, location, (pre)treatment aneurysm details). Evidence levels were classified by variability and significancy across studies (eg, low variability ≥5 studies and significance in ≥60% throughout reports). RESULTS Overall, 2.03% (95% CI 1.22 to 2.82; 24/1184) of screened studies met the inclusion criteria for predictors of AO based on logistic regression analysis. Predictors of AO with low variability in multivariable logistic regression analysis included aneurysm characteristics (aneurysm diameter), particularly complexity (absence of branch involvement) and younger patient age. Predictors of moderate evidence for AO included aneurysm characteristics (neck width), patient characteristics (absence of hypertension), procedural (adjunctive coiling) and post-deployment variables (longer follow-up; direct postprocedural satisfactory occlusion). Variables with a high variability in predicting AO following FD treatment were gender, FD as re-treatment strategy, and aneurysm morphology (eg, fusiform or blister). CONCLUSION Evidence of predictors for AO after FD treatment is sparse. Current literature suggests that absence of branch involvement, younger age, and aneurysm diameter have the highest impact on AO following FD treatment. Large studies investigating high-quality data with well-defined inclusion criteria are needed for greater insight into FD effectiveness.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Paul Stracke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Aymeric Rouchaud
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thanh N Nguyen
- Departments of Radiology and Neurology, Boston Medical Center, Boston, Massachusetts, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Oliver AA, Senol YC, Bilgin C, Schaffer JE, Kadirvel R, Kallmes DF, Wainwright JM. Intraluminal Flow Diverter Design Primer for Neurointerventionalists. AJNR Am J Neuroradiol 2024; 45:365-370. [PMID: 38164542 PMCID: PMC11288553 DOI: 10.3174/ajnr.a8076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/29/2023] [Indexed: 01/03/2024]
Abstract
The clinical use of flow diverters for the treatment of intracranial aneurysms has rapidly grown. Consequently, the market and technology for these devices has also grown. Clinical performance characteristics of the flow diverter are well-known to the clinician. However, the engineering design principles behind how these devices achieve ideal clinical performance are less understood. This primer will summarize flow diverter design parameters for neurointerventionalists with the aim of promoting collaboration between clinicians and engineers.
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Affiliation(s)
- Alexander A Oliver
- From the Department of Biomedical Engineering and Physiology (A.A.O., D.F.K.), Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota
- Department of Radiology (A.A.O., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - Yigit Can Senol
- Department of Neurologic Surgery (Y.C.S., R.K.), Mayo Clinic, Rochester, Minnesota
| | - Cem Bilgin
- Department of Radiology (A.A.O., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | | | - Ramanathan Kadirvel
- Department of Radiology (A.A.O., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery (Y.C.S., R.K.), Mayo Clinic, Rochester, Minnesota
| | - David F Kallmes
- From the Department of Biomedical Engineering and Physiology (A.A.O., D.F.K.), Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota
- Department of Radiology (A.A.O., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - John M Wainwright
- MIVI Neuroscience (J.M.W.), Eden Prairie, Minnesota
- The Henry Samueli School of Engineering (J.M.W.), University of California, Irvine, California
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15
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Shekhtman O, Sioutas GS, Piavchenko G, Bhalla S, Cooke DL, Winkler E, Burkhardt JK, Srinivasan VM. Endovascular biopsy in neurointerventional surgery: A systematic review. Interv Neuroradiol 2024:15910199241240508. [PMID: 38515364 DOI: 10.1177/15910199241240508] [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: 03/23/2024] Open
Abstract
INTRODUCTION Endothelial cells (ECs) continuously line the cerebrovasculature. Molecular aberrations in the ECs are hallmarks and contributory factors to the development of cerebrovascular diseases, including intracranial aneurysms and arteriovenous malformations (AVMs). Endovascular biopsy has been introduced as a method to harvest ECs and obtain relevant biologic information. We aimed to summarize the literature on endovascular biopsy in neurointerventional surgery. METHODS We conducted a comprehensive literature search in multiple databases, identifying eligible studies focusing on neurosurgical applications of endovascular biopsy. The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The relevant information was collected, including study characteristics, biopsy techniques, and key findings. RESULTS Nine studies met the inclusion criteria and were included. The studies involved the collection of ECs using various endovascular devices including coils, guide wires, different stents, and forceps. Endothelial-enrichment techniques, such fluorescence-activated cell sorting (FACS), collected ECs and facilitated downstream applications of bulk or single-cell RNA sequencing (scRNAseq). The studies provided insights into gene expression profiles and identified potential biomarkers associated with intracranial aneurysms. However, challenges were observed in obtaining an adequate number of ECs and identifying consistent biomarkers. CONCLUSION Endovascular biopsy of endothelial cells (ECs) in cerebrovascular pathologies shows promise for gene expression profiling. However, many studies have been limited in sample size and underpowered to identify "signature genes" for aneurysm growth or rupture. Advancements in minimally invasive biopsy methods have potential to facilitate applications of precision medicine in the treatment of cerebrovascular disorders.
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Affiliation(s)
- Oleg Shekhtman
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gennadii Piavchenko
- Department of Human Anatomy and Histology, Sechenov University, Moscow, Russia
| | - Shubhang Bhalla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Daniel L Cooke
- Department of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Ethan Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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16
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Ramirez-Velandia F, Young M, Alwakaa O, Han K, Ogilvy CS. Flow Diversion as a Definitive Treatment for Recurrently Ruptured A1-A2 Anterior Cerebral Artery Aneurysm Following Clipping and Coiling. Cureus 2024; 16:e57103. [PMID: 38681287 PMCID: PMC11054312 DOI: 10.7759/cureus.57103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Even after clipping of intracranial aneurysms, patients may experience incomplete occlusion or the future recurrence of their treated aneurysm. This paper presents a distinctive case of a recurrent A1-A2 anterior cerebral artery aneurysm that underwent four interventions over 16 years. The aneurysm was treated with two clippings, subsequent coiling, and flow diversion for definitive treatment. The challenges encountered in managing bifurcation aneurysms are discussed, emphasizing the importance of considering hemodynamic factors, vessel geometry, and recurrence risk factors in treatment decisions. The case highlights the need for closer follow-up of ruptured bifurcation aneurysms due to the higher likelihood of recurrence. The role of flow diverters in reinforcing vessel anatomy and preventing recurrence is also highlighted.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Michael Young
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Omar Alwakaa
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Kimberly Han
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Christopher S Ogilvy
- Neurological Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
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17
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Hanel RA, Cortez GM, Benalia VHC, Sheffels E, Sutphin DJ, Pederson JM, Pereira VM. Patient outcomes after treatment of brain aneurysm in small diameter vessels with the silk vista baby flow diverter: A systematic review. Interv Neuroradiol 2024; 30:5-13. [PMID: 35392703 PMCID: PMC10956459 DOI: 10.1177/15910199221091645] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Silk Vista Baby (SVB, BALT) is a first-in-class flow-diverter device delivered using a 0.017" microcatheter, designed for the treatment of intracranial aneurysms, including those in small diameter vessels. This study reports a systematic literature review (SLR) to evaluate the safety and efficacy of using SVB to treat intracranial aneurysms in vessels less than 3.5 mm in diameter. METHODS We performed a PRISMA-compliant SLR to evaluate the outcomes of SVB in the treatment of aneurysms in small intracranial vessels. Primary outcomes were occlusion status and major stroke, and secondary outcomes included all-cause mortality, procedure-related neurologic death, and post-operative aneurysm rupture. Data were expressed as descriptive statistics only. RESULTS A total of four studies, including 163 patients with 173 intracranial aneurysms, were included. The most common aneurysm locations were the anterior cerebral artery (24.9% [43/173]), the middle cerebral artery (24.3% [42/173]), and the anterior communicating artery (23.1% [40/173]). Parent artery diameter ranged from 0.9 mm to 3.6 mm, and 29% were acutely or previously ruptured aneurysms. Overall, complete or near-complete occlusion was 72.1% on early-term follow-up. Mortality rate among the studies was 2.5%, with 3 instances adjudicated as neurologic deaths (1.8%). Major stroke was noted in 1.2% of cases, and branch occlusion or stent thrombus formation in 5.5%. CONCLUSION Our review suggests that SVB is a safe and effective treatment for intracranial aneurysms in small vessels. Further prospective and comparative studies with patient outcome data specific to aneurysm location are needed to confirm the safety and efficacy of SVB.
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Affiliation(s)
- Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
- Research Department, Jacksonville University, Jacksonville, FL, USA
| | - Victor H C Benalia
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
- Research Department, Jacksonville University, Jacksonville, FL, USA
| | | | | | | | - Vitor M Pereira
- Departments of Surgery and Medical Imaging, Division of Neurosurgery, St Michaels Hospital, University of Toronto, Ontario, Canada
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18
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Tong X, Xue X, Sun M, Han M, Jiang P, Liu A. Comparison of a covered stent and pipeline embolization device in intracranial aneurysm: a propensity score matching analysis. J Neurointerv Surg 2024:jnis-2023-020878. [PMID: 38233118 DOI: 10.1136/jnis-2023-020878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/23/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND The Willis covered stent (WCS) and pipeline embolization device (PED) have partly overlapping therapeutic indications. However, the differences of effect between these two treatments remain unclear. OBJECTIVE To compare clinical outcome, angiographic outcome, and complications following treatment with a WCS versus PED. METHODS Patients with intracranial aneurysms treated by a WCS or PED between January 2015 and December 2020 were included. The primary outcomes were complications, clinical outcome (modified Rankin Scale score >2), and angiographic outcome (incomplete aneurysm occlusion). Propensity score matching was conducted to adjust for potential confounding factors. RESULTS A total of 94 aneurysms treated by WCS and 698 aneurysms by PED were included. Compared with the PED group, patients in the WCS group are younger, a greater number have a poor condition at admission, a larger proportion of ruptured, non-saccular, and anterior circulation aneurysms, a smaller aneurysm neck width, and less coiling assistance is required. A total of 42 (44.7%) branches were covered by WCS. After adjustment for age, sex, aneurysm type, rupture status, neck size, aneurysm location, and coiling, 50 WCS and PED pairs were examined for internal carotid artery aneurysms. No significant differences were observed in clinical (10.4% vs 2.1%, P=0.206) and angiographic outcomes (12.8% vs 18.2%, P=0.713). However, 27 branches covered by WCS, including 22 ophthalmic arteries and five posterior communicating arteries. Patients in the WCS group had a higher intraoperative complication rate than those in the PED group (28% vs 6%, P=0.008), especially in the occlusion rate of covered branches (51.9% vs 11.1%, P<0.001). CONCLUSION The comparable clinical and angiographic outcomes of WCS or PED demonstrate the therapeutic potential of WCS as a viable alternative for aneurysms. However, the complication of occlusion of covered branches might not be negligible.
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Affiliation(s)
- Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaopeng Xue
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingjiang Sun
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingyang Han
- Department of Neurosurgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Peng Jiang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Guimaraens L, Saldaña J, Vivas E, Cifuentes S, Balaguer E, Mon D, Macias-Gómez A, Ois A, Guisado-Alonso D, Cuadrado-Godia E, Jiménez-Balado J. Flow diverter stents for endovascular treatment of aneurysms: a comparative study of efficacy and safety between FREDX and FRED. J Neurointerv Surg 2024:jnis-2023-021103. [PMID: 38228386 DOI: 10.1136/jnis-2023-021103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND The FRED X flow diverter (FREDX), as the second generation in the FRED series, aims to improve the treatment of cerebral aneurysms. This study compares the efficacy and safety of FREDX with its predecessor, FRED. METHODS This prospective registry included patients treated with FRED and FREDX devices. Efficacy was assessed using digital subtraction angiography with 3D volumetric reconstruction at immediate and 1 year follow-ups. Safety was evaluated by recording complications, analyzed through univariate contrasts, generalized mixed models, and Bayesian network analyses. RESULTS We treated 287 patients with 385 aneurysms, with 77.9% receiving FRED and 22.1% FREDX. The median age was 55 years (IQR 47-65) and 78.4% were women. The FREDX group showed a higher prevalence of saccular-like aneurysms (70.6% vs 52.7%, P=0.012) and a higher rate of complete occlusion compared with FRED interventions (79.4% vs 59.3%, P=0.022). After adjusting for confounders, these differences represented a 3.04-fold increased likelihood (95% CI 1.44 to 6.41, P=0.003) of achieving complete occlusion at 1 year with FREDX interventions. Regarding safety, two (3.5%) complications (both non-symptomatic) were observed in the FREDX group and 23 (10.4%) in the FRED group (P=0.166). Bayesian network analysis suggested a trend towards fewer complications for FREDX, with a median reduction of 5.5% in the posterior distribution of the prevalence of complications compared with FRED interventions. CONCLUSIONS The FREDX device shows improved complete occlusion rates at 1 year compared with the FRED device while maintaining a favourable safety profile, indicating its potential advantage in the treatment of cerebral aneurysms.
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Affiliation(s)
- Leopoldo Guimaraens
- J.J. Merland Department of Therapeutic Neuroangiography, Hospital del Mar and Hospital Universitari General de Catalunya, Barcelona, Spain
| | - Jesus Saldaña
- J.J. Merland Department of Therapeutic Neuroangiography, Hospital del Mar and Hospital Universitari General de Catalunya, Barcelona, Spain
| | - Elio Vivas
- J.J. Merland Department of Therapeutic Neuroangiography, Hospital del Mar and Hospital Universitari General de Catalunya, Barcelona, Spain
| | - Sebastián Cifuentes
- J.J. Merland Department of Therapeutic Neuroangiography, Hospital del Mar and Hospital Universitari General de Catalunya, Barcelona, Spain
| | - Ernest Balaguer
- Department of Neurology, Hospital Universitari General de Catalunya, Barcelona, Spain
| | - Dunia Mon
- Department of Neurology, Hospital Universitari General de Catalunya, Barcelona, Spain
| | - Adrià Macias-Gómez
- Department of Neurology, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Angel Ois
- Department of Neurology, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
| | - Daniel Guisado-Alonso
- Department of Neurology, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Department of Neurology, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
| | - Joan Jiménez-Balado
- Department of Neurology, Hospital del Mar Medical Research Institute, Barcelona, Spain
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20
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Gai Y, Nuerdong M, Jiang Y, Wang W, Pu B, Xu F, Song D. Flow diversion for unruptured fusiform aneurysms of the proximal middle cerebral artery. Front Neurol 2023; 14:1325983. [PMID: 38192574 PMCID: PMC10773848 DOI: 10.3389/fneur.2023.1325983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024] Open
Abstract
Background Managing fusiform aneurysms of the proximal (M1) segment of the middle cerebral artery (MCA) is challenging due to difficulties in both surgical and endovascular treatment. In this study, we present our experience using flow diverter stents for managing unruptured M1 segment fusiform aneurysms. Methods We conducted a retrospective review of the database of our institution to identify all patients who underwent flow diversion treatment for unruptured M1 segment fusiform aneurysms. We collected data on patient demographics, aneurysm characteristics, complications, angiographic follow-up results, and clinical outcomes. Results A total of 10 patients (five male and five female patients) with 10 unruptured M1 segment fusiform aneurysms were included in the study. The average age of the patients was 48 years (range: 16-64 years); five patients had aneurysms smaller than 10 mm, four had aneurysms measuring between 10 and 25 mm, and one patient had an aneurysm larger than 25 mm. The successful deployment of flow-diverting stents was achieved in all cases. Procedure-related morbidity was observed in 10% of patients, but there were no deaths. All patients showed good outcomes (modified Rankin Scale score of 0-1); eight out of 10 patients had available follow-up angiography results with a mean follow-up period of 11.6 months (range: 6-24 months). Complete occlusion occurred in six out of eight reviewed cases (75%). Conclusion Our preliminary findings suggest that using flow diversion for treating unruptured fusiform aneurysms in the proximal MCA is feasible and safe, with a satisfactory rate of complete occlusion. However, further studies involving larger case series are needed to validate the durability and efficacy of this treatment approach.
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Affiliation(s)
- Yanting Gai
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, China
| | | | - Yicheng Jiang
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, China
| | - Wei Wang
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, China
| | - Benfang Pu
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, China
| | - Feng Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China
- Neurological Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Donglei Song
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, China
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21
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Hanel RA, Cortez GM, Coon AL, Kan P, Taussky P, Wakhloo AK, Welch BG, Dogan A, Bain M, De Vries J, Ebersole K, Meyers PM. Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms - SCENT: 3-year outcomes. J Neurointerv Surg 2023; 15:1084-1089. [PMID: 36375835 DOI: 10.1136/jnis-2022-019512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/25/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND To report the 3-year safety and effectiveness of the Surpass Streamline flow diverter in the SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms). METHODS The Surpass Streamline flow diverter device was evaluated in a multicenter, prospective, single-arm, non-randomized interventional trial including patients with uncoilable or previously treated but failed aneurysms of the intracranial internal carotid artery. 3-year outcomes were tabulated with descriptive statistics and compared with 1-year outcomes. RESULTS Of 180 patients in the modified intent-to-treat (mITT) cohort, 36-month clinical and angiographic follow-up was available in 134 and 117 cases, respectively. Effectiveness endpoint of complete aneurysm occlusion without clinically significant stenosis or retreatment was met in 71.8% (79/110, 95% CI 62.4% to 80.0%) of cases. Safety composite endpoint was 12.2% (22/180) over the 3-year period, with two major safety events (ipsilateral ischemic strokes) occurring between 12-36 months. Complete aneurysm occlusion was noted in 77.8% (91/117), and 99.1% (116/117) of the patients demonstrated adequate aneurysm occlusion (complete occlusion or neck residual). There were four cases (2.2%) of aneurysm rupture, all occurring within the first month of the index procedure. Target aneurysm retreatment rate was 2.8% (5/180). CONCLUSION The present findings support the long-term safety and effectiveness of the Surpass Streamline flow diverter device. TRIAL REGISTRATION NCT01716117.
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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
| | - Alexander L Coon
- Carondelet Neurological Institute, Carondelet Saint Joseph's Hospital, Tucson, Arizona, USA
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston School of Medicine, Galveston, Texas, USA
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Ajay K Wakhloo
- Neurointerventional Radiology, Lahey Clinic Medical Center, Burlington, Massachusetts, USA
| | - Babu G Welch
- Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aclan Dogan
- Interventional Neuroradiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark Bain
- Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joost De Vries
- Neurosurgery, Radboud University Nijmegen, Nijmegen, Gelderland, The Netherlands
| | - Koji Ebersole
- Neurosurgery, Radiology, University of Kansas Medical Center Department of Neurosurgery, Kansas City, Kansas, USA
| | - Philip M Meyers
- Radiology and Neurological Surgery, Columbia University, New York, New York, USA
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22
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White TG, Santhumayor BA, Turpin J, Shah K, Toscano D, Teron I, Link T, Patsalides A, Woo HH. Flow diverter surface modifications for aneurysm treatment: A review of the mechanisms and data behind existing technologies. Interv Neuroradiol 2023:15910199231207550. [PMID: 37899636 DOI: 10.1177/15910199231207550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023] Open
Abstract
Flow diversion (FD) has become a mainstay treatment for large wide-necked aneurysms. Despite excellent safety and efficacy, the risk of thromboembolic complications necessitates the use of dual antiplatelet therapy (DAPT). The use of DAPT makes hemorrhagic complications of stenting carry high morbidity and mortality. Additionally, DAPT usage carries a risk of "nuisance" complications that do not directly impact intracranial circulation but need to be managed nonetheless. To circumvent this issue, the most recent generation of flow diverters have undergone surface modification with various compounds to confer blood compatibility to limit clotting and thrombosis. While these newer generation flow diverters are marketed to enhance ease of deployment, the goal is to eventually facilitate single antiplatelet use with flow diverter treatment. This generation of FDs have potential to expand indications beyond unruptured wide-necked aneurysms to include ruptured intracranial aneurysms without the necessity of DAPT. Currently, no comprehensive review details the molecular mechanisms and pre-clinical and clinical data on these modifications. We seek to fill this gap in the literature by consolidating information on the coating technology for four major FDs currently in clinical use-PipelineTM Flex and Vantage Shield TechnologyTM, FREDTMX, p48/64 hydrophilic coating, and Acandis Dervio® 2heal-to serve as a reference guide in neurointerventional aneurysm treatment. Although the Balt silkTM was one of the first FDs, it is uncoated, thus we will not cover this device in our review. A literature review was performed to obtain information on each coating technology for the major flow diverters currently on the market using international databases (PUBMED, Embase, Medline, Google Scholar). The search criteria used the keywords for each coating technology of interest "phosphorylcholine," "poly 2-methoxyethyl acrylate," "hydrophilic polymer coating," and "fibrin-heparin" Keywords related to the device names "Pipeline Shield," "Pipeline Shield with Flex Technology," "FRED," "FREDX," "p64," "p64-HPC," "Derivo 2heal" were also used. Studies that detailed the mechanism of action of the coating, any pre-clinical studies with surface-modified intravascular devices, and any clinical retrospective series, prospective series, or randomized clinical trials with surface-modified devices for aneurysm treatment were included.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Brandon A Santhumayor
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Kevin Shah
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Daniel Toscano
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Ina Teron
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Thomas Link
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Athos Patsalides
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
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23
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Salem MM, Khorasanizadeh M, Nwajei F, Gomez-Paz S, Akamatsu Y, Jordan N, Maroufi SF, Thomas AJ, Ogilvy CS, Moore JM. Predictors of aneurysmal occlusion following intracranial aneurysms treatment with pipeline embolization device. Acta Neurochir (Wien) 2023; 165:2801-2809. [PMID: 37615726 DOI: 10.1007/s00701-023-05740-1] [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: 05/04/2023] [Accepted: 07/28/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE Pipeline embolization device (PED) is thought to induce aneurysmal occlusion through diversion of flow away from the aneurysmal sac with subsequent thrombosis and endothelialization. The impact of different factors especially hypertension (HTN)-a known predisposing factor to hypercoagulability and altered endothelial function-on aneurysmal occlusion after flow diversion has not been studied. We sought to determine predictors of aneurysmal occlusion following PED treatment focusing on impact of blood pressure. METHODS Database of patients with cerebral aneurysms treated with PED from 2013 to 2019 at our institution was retrospectively reviewed. Patients were defined as hypertensive if (1) they had a documented history of HTN requiring anti-HTN medications or (2) average systolic blood pressure on three measurements was > 130 mmHg. The primary outcome was aneurysm occlusion status at the last imaging follow-up. Multivariable logistic regression model was constructed to assess the effect of HTN on occlusion, controlling for age, smoking, aneurysmal size, fusiform morphology, posterior circulation location, and incorporated branches. RESULTS A total of 331 aneurysms in 294 patients were identified for this analysis. The mean age was 59 years (79.9% female). Fifty-five percent of the cohort were classified as hypertensive. When controlling for other potential confounders, hypertensive patients trended toward higher odds of achieving complete occlusion compared to non-hypertensive patients (OR = 2.05; 95% CI = 0.99-4.25; p = 0.052). Meanwhile, age (OR = 0.91; 95% CI = 0.88-0.95; p < 0.001) and an incorporated branch into an aneurysm (OR = 0.22; 95% CI = 0.08-0.58; p < 0.002) were associated with decreased odds for complete aneurysmal occlusion. CONCLUSION Hypertensive patients show a trend toward higher odds of achieving complete occlusion when controlling for potential confounders. The HTN-induced hypercoagulable state, enhanced endothelial activation, and altered extracellular matrix regulation might be the contributing factors. Further research is warranted to explore clinical implications of these findings.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - MirHojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Felix Nwajei
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Noah Jordan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Hospital, Camden, NJ, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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24
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Forestier G, Cortese J, Bardet SM, Baudouin M, Janot K, Ratsimbazafy V, Perrin ML, Mounier J, Couquet C, Yardin C, Larragneguy Y, Souhaut F, Chauvet R, Belgacem A, Brischoux S, Magne J, Mounayer C, Terro F, Rouchaud A. Comparison of arterial wall integration of different flow diverters in rabbits: The CICAFLOW study. J Neuroradiol 2023:S0150-9861(23)00235-3. [PMID: 37634579 DOI: 10.1016/j.neurad.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/24/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND AND PURPOSE New coated flow diverters (FDs) claim antithrombotic properties and increased arterial wall integration. The aim of this study is to compare in vivo endothelial coverage of coated and uncoated FD in the context of different antiplatelet regimens. METHODS Different FDs (Silk Vista - SV, Pipeline with Shield technology - PED shield and Surpass Evolve - SE) were implanted in the aorta of rabbits, all 3 in each animal with 3 different antiplatelet regimens: no antiplatelet therapy, aspirin alone, or aspirin and ticagrelor. Four weeks after FD implantation, angiography, flat-panel CT, and optical coherence tomography (OCT) were performed before harvesting the aorta. Extensive histopathology analyses were performed including environmental scanning electron microscopy (ESEM), multiphoton microscopy (MPM) and histological staining with qualitative and/or quantitative assessment of device coverage. RESULTS All 23 FDs that were implanted remained patent without hyperplasia. Qualitative stent coverage assessment revealed that there were no statistically significant differences between the FD groups (p = 0.19, p = 0.45, p = 0.40, and p = 0.84 for OCT, ESEM, MPM and histology, respectively). Quantitative neointimal measurement of histological sections also showed similar results in all 3 FD groups (p = 0.70). However, there were significant differences between the 3 groups of antiplatelet regimens (p = 0.07) with a higher rate in the no antiplatelet group (p = 0.05 versus aspirin alone and p = 0.03 versus aspirin and ticagrelor). CONCLUSION Our study provides evidence that FD integration into the arterial wall is similar with coated (PED shield) and uncoated devices (SV, SE), regardless of the antiplatelet regimen. FD integration with specific surface coverage should be promoted. TRIAL REGISTRATION APAFIS #2022011215518538.
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Affiliation(s)
- Géraud Forestier
- University Hospital of Limoges, Neuroradiology Department, 2 avenue Martin Luther-King, Dupuytren, Limoges 87042, France; University of Limoges, XLIM UMR CNRS, Limoges 7252, France.
| | - Jonathan Cortese
- University of Limoges, XLIM UMR CNRS, Limoges 7252, France; NEURI Brain Vascular Center, Interventional Neuroradiology, Bicêtre University-Hospital, Le Kremlin-Bicêtre, France
| | | | - Maxime Baudouin
- University Hospital of Limoges, Neuroradiology Department, 2 avenue Martin Luther-King, Dupuytren, Limoges 87042, France
| | - Kévin Janot
- University of Limoges, XLIM UMR CNRS, Limoges 7252, France; Regional University Hospital Center Tours, Radiology, Diagnostic and Interventional Neuroradiology, France
| | - Voahirana Ratsimbazafy
- Service de Pharmacie, CHU de Limoges, Limoges, France; Université de Limoges, IFR 145 GEIST, Institut d'Epidémiologie Neurologique et de Neurologie Tropicale, INSERM, UMR, Limoges 1094, France
| | | | - Jérémy Mounier
- University of Limoges, XLIM UMR CNRS, Limoges 7252, France
| | - Claude Couquet
- University of Limoges, XLIM UMR CNRS, Limoges 7252, France
| | - Catherine Yardin
- University of Limoges, XLIM UMR CNRS, Limoges 7252, France; Cytology Department, Dupuytren Limoges University Hospital, France
| | | | - Flavie Souhaut
- University of Limoges, XLIM UMR CNRS, Limoges 7252, France
| | - Romain Chauvet
- University of Limoges, XLIM UMR CNRS, Limoges 7252, France
| | | | - Sonia Brischoux
- Service de pharmacie centrale, CHU Dupuytren, Limoges, France
| | - Julien Magne
- Department of Cardiology and CEBIMER, Limoges University Hospital, France; INSERM U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidémiologie des maladies chroniques en zone tropicale, OmegaHealth, Institut d'Epidémiologie et de Neurologie Tropicale, Limoges, France
| | - Charbel Mounayer
- University Hospital of Limoges, Neuroradiology Department, 2 avenue Martin Luther-King, Dupuytren, Limoges 87042, France; University of Limoges, XLIM UMR CNRS, Limoges 7252, France
| | - Faraj Terro
- University of Limoges, XLIM UMR CNRS, Limoges 7252, France
| | - Aymeric Rouchaud
- University Hospital of Limoges, Neuroradiology Department, 2 avenue Martin Luther-King, Dupuytren, Limoges 87042, France; University of Limoges, XLIM UMR CNRS, Limoges 7252, France
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25
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Lorga T, Pizzuto S, Coskun O, Sgreccia A, Cavazza M, Rahman MH, Rodesch G, Di Maria F, Consoli A. Reconstruction of the sphenoid sinus erosion or dehiscence after treatment of unruptured intracavernous aneurysms with flow diverter stents. J Neurointerv Surg 2023:jnis-2023-020734. [PMID: 37586819 DOI: 10.1136/jnis-2023-020734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Intracavernous carotid aneurysms (ICCAs) are rare, frequently asymptomatic, with a low rupture risk, which, however, can lead to life-threatening epistaxis. The aim of this study was to assess the effect of the treatment of asymptomatic ICCAs with flow diverters (FD) on sphenoid bone erosion or dehiscence in a selected cohort of patients. METHODS We retrospectively reviewed all asymptomatic ICCAs with sphenoid bone erosion or dehiscence detected on cone beam CT (CBCT) and treated with FD between December 2018 and December 2022. Patients were followed-up with CBCT and bone reconstruction was blindly evaluated by two interventional neuroradiologists and classified as unchanged, partial, or complete. RESULTS A total of 10 patients (women: 90%, mean age 58 years) treated with an FD for an asymptomatic ICCA with associated sphenoid bone erosion or dehiscence were included in this cohort. Sphenoid bone erosion was present in seven patients and dehiscence was observed in the remaining three. After treatment with FD, complete reconstruction of the sphenoid sinus wall occurred in seven cases, and partial reconstruction in two cases. Sphenoid bone erosion remained unchanged after treatment in only one patient. CONCLUSIONS The decision to treat asymptomatic and unruptured ICCAs remains challenging due to their benign natural history and low hemorrhagic risk. The presence of sphenoid sinus erosion or dehiscence should not be overlooked since it could be considered as an indication for prophylactic treatment of life-threatening epistaxis. The mechanisms of bone erosion by the aneurysm and of reconstruction after treatment are still to be fully elucidated.
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Affiliation(s)
- Tiago Lorga
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Neuroradiology, Centro Hospitalar Universitário de Lisboa Central EPE, Lisboa, Portugal
| | - Silvia Pizzuto
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Oguzhan Coskun
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Alessandro Sgreccia
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Martino Cavazza
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Diagnostic and Interventional Radiology, University Hospital Arcispedale Sant'Anna of Ferrara, Cona, Italy
| | - Mohammad Habibur Rahman
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Interventional Neurology, National Institute of Neurosciences and Hospital, Sher-E-Bangla Nagar, Bangladesh
| | - Georges Rodesch
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Federico Di Maria
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Versailles Saint-Quentin-en-Yvelines University, Versailles, France
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Fan Y, Lei J, Fei F, Liu J, Liu Y. A novel flow diverter device (Tubridge) for the treatment of intracranial aneurysms: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:198. [PMID: 37561213 DOI: 10.1007/s10143-023-02100-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
The flow diverter (FD) device has become a feasible and effective option for treating intracranial aneurysms. This study aimed to evaluate the efficacy and safety of Tubridge FD (TFD) in treating intracranial aneurysms and provide evidence for further research and clinical application. Electronic databases, including PubMed, Web of Science, Embase, and the Cochrane Library from inception to July 31, 2022, were searched. The eligible studies should include TFD investigations in treating intracranial aneurysms. Pooled technical success rate, complete occlusion rate, improvement rate, stable rate, symptom elimination rate, and adverse events rate were calculated with either the fixed-effects model or the random-effects model, depending on the results of tests for heterogeneity. Egger's tests were performed to assess the potential publication bias. A total of 7 studies (145 patients) were included in this study. The pooled technical success rate was 0.98, the complete occlusion rate was 0.79, the improvement rate was 0.21, and the stable rate was 0.05. One included study reported that the surgery-related mortality rate in the Tubridge group was higher than that in the control group (3.66% vs. 1.61%), while the surgery-related morbidity rate in the Tubridge group was 2.4% and that in the control group was 0. Findings of this meta-analysis indicate that TFD manifests promising and effective performance with acceptable adverse events in the treatment of intracranial aneurysms.
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Affiliation(s)
- Yingjun Fan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jun Lei
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Fan Fei
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jun Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yanhui Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Krishnakumar H, Mascitelli J, Hassan A, Leary J, Son C. Treatment of cerebral aneurysms with flow diversion or stent assisted coiling in patients on concurrent oral anticoagulation. Neuroradiol J 2023; 36:464-469. [PMID: 36409963 PMCID: PMC10588601 DOI: 10.1177/19714009221114443] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Flow diversion and stent assisted coiling are increasingly utilized strategies in the endovascular treatment of cerebral aneurysms. Ischemic and hemorrhagic complications play an important role in the outcome following such embolizations. Little is published regarding patients on concurrent oral anticoagulation and undergoing such embolizations and the rates of complications and patient outcomes. MATERIALS AND METHODS Retrospective data for consecutive patients on concurrent oral anticoagulation undergoing flow diversion or stent assisted coiling for cerebral aneurysms was accessed from databases at the participating sites. Patient demographics, comorbidities, antiplatelet regimens, aneurysm characteristics, complications, and radiographic results were recorded and descriptive statistics reported. RESULTS Eleven patients were identified undergoing embolization in the setting of preoperative anticoagulant use and included seven patients undergoing flow diversion and four patients undergoing stent assisted coiling. There was a wide range of antiplatelet and anticoagulant management strategies. There were four major complications in three patients (27.2%) to include two serious bleeding events in addition to ischemic strokes. Both serious bleeding events occurred in patients continued on oral anticoagulation with the addition of antiplatelets. At a mean follow-up of 9.6 months, three aneurysms had continued filling for a good radiographic outcome of 72.7%. CONCLUSIONS Anticoagulant and antiplatelet use in the setting of flow diversion or stent assisted coiling may carry increased risks as compared to historical norms and, for flow diversion, offer decreased efficacy.
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Affiliation(s)
- Hari Krishnakumar
- Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Ameer Hassan
- Department of Neurology, University of Texas Rio Grande Valley Medical School, Harlingen, TX, USA
- Valley Baptist Medical Center, Harlingen, TX, USA
| | - Jonathan Leary
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Colin Son
- Neurosurgical Associates of San Antonio, San Antonio, TX, USA
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA
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Suzuki Y, Toma N, Inoue K, Ichikawa T, Nishikawa H, Miura Y, Fujimoto M, Yasuda R, Maeda M, Suzuki H. Evaluation of Intra-Aneurysmal Residual Blood Flow with the iMSDE T1-Black Blood Imaging after Flow Diverter Treatment. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:159-166. [PMID: 37609573 PMCID: PMC10442175 DOI: 10.5797/jnet.oa.2023-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/25/2023] [Indexed: 08/24/2023]
Abstract
Objective We aimed to evaluate the efficacy of the "improved motion-sensitized driven-equilibrium (iMSDE)"-prepared T1-weighted black blood (T1-BB) MRI for monitoring treatment effect with a flow diverter (FD) for cerebral aneurysms. Methods Following the exclusion of concomitant coiling and retreatment cases from 60 consecutive cases of cerebral aneurysms treated with FDs at our institution, 32 with imaging data were included in the analysis. Detectability of residual blood flow within the aneurysms was validated as follows: 1) comparison of MRI sequences (iMSDE-prepared T1-BB images, T1-weighted images [ T1WI], and time-of-flight [ TOF]-MRA) in cases of incompletely occluded aneurysms and 2) comparison of angiography and MRI sequences in the same period. Results 1) The probability of diagnosing intra-aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB (iMSDE-prepared T1-BB vs. T1WI, p <0.001; iMSDE-prepared T1-BB vs. TOF-MRA, p <0.001). 2) The diagnostic accuracy of residual aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB than that with T1WI (p = 0.032). Furthermore, in cases of incomplete occlusion, the probability of detecting intra-aneurysmal blood flow was significantly higher with iMSDE-prepared T1-BB (iMSDE-prepared T1-BB vs. T1WI, p <0.001; iMSDE-prepared T1-BB vs. TOF-MRA, p = 0.023). Conclusion Our results demonstrated that iMSDE-prepared T1-BB could help distinguish between blood flow and thrombus within the aneurysms after FD treatment, especially in the early stages of FD treatment.
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Affiliation(s)
- Yume Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Naoki Toma
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Katsuhiro Inoue
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Tomonori Ichikawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hirofumi Nishikawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yoichi Miura
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masashi Fujimoto
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Ryuta Yasuda
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masayuki Maeda
- Department of Neuroradiology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Jin H, Lv J, Li C, Wang J, Jiang Y, Meng X, Li Y. Morphological features predicting in-stent stenosis after pipeline implantation for unruptured intracranial aneurysm. Front Neurol 2023; 14:1121134. [PMID: 37251217 PMCID: PMC10213215 DOI: 10.3389/fneur.2023.1121134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/25/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Elongation denotes the regularity of an aneurysm and parent artery. This retrospective research study was conducted to identify the morphological factors that could predict postoperative in-stent stenosis (ISS) after Pipeline Embolization Device (PED) implantation for unruptured intracranial aneurysms (UIAs). Methods Patients with UIA and treated with PED at our institute between 2015 and 2020 were selected. Preoperative morphological features including both manually measured shape features and radiomics shape features were extracted and compared between patients with and without ISS. Logistic regression analysis was performed for factors associated with postoperative ISS. Results A total of 52 patients (18 men and 34 women) were involved in this study. The mean angiographic follow-up time was 11.87 ± 8.26 months. Of the patients, 20 of them (38.46%) were identified with ISS. Multivariate logistic analysis showed that elongation (odds ratio = 0.008; 95% confidence interval, 0.001-0.255; p = 0.006) was an independent risk factor for ISS. The area under the curve (AUC) of the receiver operating characteristic curve(ROC) was 0.734 and the optimal cut-off value of elongation for ISS classification was 0.595. The sensitivity and specificity of prediction were 0.6 and 0.781, respectively. The ISS degree of elongation of less than 0.595 was larger than the ISS degree of elongation of more than 0.595. Conclusion Elongation is a potential risk factor associated with ISS after PED implantation for UIAs. The more regular an aneurysm and parent artery, the less likelihood of an ISS occurrence.
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Affiliation(s)
- Hengwei Jin
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurointerventional Engineering and Technology, Beijing Engineering Research Center, Beijing, China
| | - Jian Lv
- Department of Neurointerventional Engineering and Technology, Beijing Engineering Research Center, Beijing, China
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Conghui Li
- Department of Neurosurgery, The First Hospital, Hebei Medical University, Shijiazhuang, China
| | - Jiwei Wang
- Department of Neurosurgery, The First Hospital, Hebei Medical University, Shijiazhuang, China
| | - Yuhua Jiang
- Department of Neurointerventional Engineering and Technology, Beijing Engineering Research Center, Beijing, China
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyu Meng
- Department of Neurosurgery, The First Hospital, Hebei Medical University, Shijiazhuang, China
| | - Youxiang Li
- Department of Neurointerventional Engineering and Technology, Beijing Engineering Research Center, Beijing, China
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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30
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Hachem E, Meliga P, Goetz A, Rico PJ, Viquerat J, Larcher A, Valette R, Sanches AF, Lannelongue V, Ghraieb H, Nemer R, Ozpeynirci Y, Liebig T. Reinforcement learning for patient-specific optimal stenting of intracranial aneurysms. Sci Rep 2023; 13:7147. [PMID: 37130900 PMCID: PMC10154322 DOI: 10.1038/s41598-023-34007-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/22/2023] [Indexed: 05/04/2023] Open
Abstract
Developing new capabilities to predict the risk of intracranial aneurysm rupture and to improve treatment outcomes in the follow-up of endovascular repair is of tremendous medical and societal interest, both to support decision-making and assessment of treatment options by medical doctors, and to improve the life quality and expectancy of patients. This study aims at identifying and characterizing novel flow-deviator stent devices through a high-fidelity computational framework that combines state-of-the-art numerical methods to accurately describe the mechanical exchanges between the blood flow, the aneurysm, and the flow-deviator and deep reinforcement learning algorithms to identify a new stent concepts enabling patient-specific treatment via accurate adjustment of the functional parameters in the implanted state.
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Affiliation(s)
- E Hachem
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France.
| | - P Meliga
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France
| | - A Goetz
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France
| | - P Jeken Rico
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France
| | - J Viquerat
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France
| | - A Larcher
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France
| | - R Valette
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France
| | - A F Sanches
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - V Lannelongue
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France
| | - H Ghraieb
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France
| | - R Nemer
- MINES Paris, PSL Research University, Centre de mise en forme des matériaux (CEMEF), CNRS UMR 7635, 06904, Sophia Antipolis Cedex, France
| | - Y Ozpeynirci
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - T Liebig
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
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31
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Zhang J, He L, Xia X, Zhang L, Yu K. Braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in patients with unruptured complex intracranial aneurysms. Clinics (Sao Paulo) 2023; 78:100202. [PMID: 37130488 PMCID: PMC10172744 DOI: 10.1016/j.clinsp.2023.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 03/30/2023] [Accepted: 04/05/2023] [Indexed: 05/04/2023] Open
Abstract
PURPOSES Braided and laser-cut stents both are efficacious and safe for coiling intracranial aneurysms. The study aimed to compare outcomes following braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in 266 patients who were diagnosed with unruptured intracranial aneurysms of different types and locations. METHODS Patients with unruptured complex intracranial aneurysms underwent braided (BSE cohort, n = 125) or laser engraved (LSE cohort, n = 141) stent-assisted embolization. RESULTS The deployment success rate was higher for patients of the LSE cohort than those of the BSE cohort (140 [99%] vs. 117 [94%], p = 0.0142). Seventy-one (fifty-seven percentages) and 73 (52%) were coil embolization procedure success rates of the BSE and the LSE cohorts. Periprocedural intracranial hemorrhage was higher in patients of the BSE cohort than those of the LSE cohort (8 [6%] vs. 1 [1%], p = 0.0142). Four (three percentages) patients from the LSE cohort and 3 (2%) patients from the BSE cohort had in-stent thrombosis during embolization. Permanent morbidities were higher in patients of the LSE cohort than those of the BSE cohort (8 [6%] vs. 1 [1%], p = 0.0389). Higher successful procedures (76% vs. 68%) and fewer postprocedural intracranial hemorrhage (0% vs. 5%) and mortality (0% vs. 5%) were reported for patients of the BSE cohort in posterior circulation aneurysmal location than those of the LSE cohort. Laser engraved stent has fewer problems with deployment and may have better periprocedural and follow-up outcomes after embolization. CONCLUSIONS Braided stent-assisted embolization should be preferred when the aneurysm is present in the posterior circulation.
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Affiliation(s)
- Jie Zhang
- The First Affiliated Hospital of Chengdu Medical College, Department of Neurosurgery, Chengdu, Sichuan, China
| | - Ling He
- The First Affiliated Hospital of Chengdu Medical College, Department of Hematology, Chengdu, Sichuan, China
| | - Xun Xia
- The First Affiliated Hospital of Chengdu Medical College, Department of Neurosurgery, Chengdu, Sichuan, China.
| | - Lie Zhang
- The First Affiliated Hospital of Chengdu Medical College, Department of Neurosurgery, Chengdu, Sichuan, China
| | - Kai Yu
- The First Affiliated Hospital of Chengdu Medical College, Department of Neurosurgery, Chengdu, Sichuan, China
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32
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Schüngel MS, Hoffmann KT, Weber E, Maybaum J, Bailis N, Scheer M, Nestler U, Schob S. Distal Flow Diversion with Anti-Thrombotically Coated and Bare Metal Low-Profile Flow Diverters—A Comparison. J Clin Med 2023; 12:jcm12072700. [PMID: 37048781 PMCID: PMC10095446 DOI: 10.3390/jcm12072700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/23/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023] Open
Abstract
Background and purpose: The establishment of low-profile flow diverting stents (FDS), for example, the Silk Vista Baby (SVB) and the p48MW, facilitated endovascular treatment of peripheral cerebral aneurysms. This study therefore aims to compare the performance and outcomes of the SVB with those of the p48MW HPC, with a special focus on hemodynamic aspects of peripheral segments and bifurcations. Materials and methods: The study cohort comprises 108 patients, who were either treated with the SVB or the p48MW HPC between June 2018 and April 2021. Results: Sixty patients received a SVB and forty-eight patients a p48MW HPC. The SVB was used predominantly in the AcomA-complex, and the p48MW HPC in the MCA bifurcation. Immediately after implantation, significant hemodynamic downgrading (OKM A2-A3, B1-B3, C3) was achieved in 60% in the SVB group vs. 75.1% in the p48MW HPC group. At the second follow-up, after an average of 8.8 and 10.9 months, respectively, OKM D1 was observed in 64.4% of the SVB group vs. 27.3% in the p48MW HPC group. Only 1.7% vs. 6.8% of the aneurysms remained morphologically unaltered (OKM A1). Adverse events with persisting neurologic sequalae at last follow-up were largely comparable in both groups (5.0% vs. 4.2%). Conclusion: Immediately after implantation, the p48MW HPC had a more profound hemodynamic impact than the SVB; however, early complete occlusions were achieved in a greater proportion of lesions after implantation of the uncoated SVB.
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Affiliation(s)
- Marie-Sophie Schüngel
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle, 06120 Halle (Saale), Germany
| | - Karl-Titus Hoffmann
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, 04103 Leipzig, Germany
| | - Erik Weber
- Klinik für Anästhesie und Notfallmedizin, Universitätsklinikum Leipzig, 04103 Leipzig, Germany
| | - Jens Maybaum
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, 04103 Leipzig, Germany
| | - Nikolaos Bailis
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, 04103 Leipzig, Germany
| | - Maximilian Scheer
- Abteilung für Neurochirurgie, Universitätsklinikum Halle, 06120 Halle (Saale), Germany
| | - Ulf Nestler
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig, 04103 Leipzig, Germany
| | - Stefan Schob
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle, 06120 Halle (Saale), Germany
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33
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Turhon M, Kang H, Li M, Liu J, Zhang Y, Zhang Y, Huang J, Luo B, Liu J, Zhang H, Li T, Song D, Zhao Y, Guan S, Aximujiang A, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Zhang X, Gu Y, Yang X. Treatment of fusiform aneurysms with a pipeline embolization device: a multicenter cohort study. J Neurointerv Surg 2023; 15:315-320. [PMID: 35354575 DOI: 10.1136/neurintsurg-2021-018539] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/10/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intracranial fusiform aneurysms are less common than saccular aneurysms, but are associated with higher mortality and morbidity. We conducted this study to determine the safety and efficacy of the pipeline embolization device (PED) to treat intracranial fusiform aneurysms. METHODS This was a multicenter, retrospective, and observational study. Data for this study came from the PLUS study conducted from 2014 to 2019 across 14 centers in China. Univariate and multivariable logistic regression analyses were performed to evaluate predictors of the occlusion rate and complication. RESULTS A total of 1171 consecutive patients with 1322 intracranial aneurysms participated in this study. Among the participants, 104 patients with 109 fusiform aneurysms were eligible for this analysis (mean age 49 years, 36.5% women, aneurysm mean size 14.7 mm, 55% in the posterior circulation, and 6% in the basilar artery). Mean follow-up time was 9.0 months (range 3-36 months). The last DSA angiographic follow-up was available for 85 patients, and 58 aneurysms (68.2%) were completely occluded. The overall complication rate and mortality were 17.3% and 2.8%, respectively. Multivariate analysis demonstrated that age (OR=1.007, p=0.037) and cerebral atherosclerosis (OR=1.441, p=0.002) were associated with incomplete occlusion of fusiform aneurysms after PED treatment. CONCLUSION PEDs may be an effective treatment for intracranial fusiform aneurysms, with a favorable occlusion rate. However, because these treatments have a relatively high rate of complications, PED treatment for fusiform aneurysms should be carefully and strictly controlled. Our analysis showed that PEDs with adjunctive coiling did not significantly improve the occlusion rate of fusiform aneurysms.
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Affiliation(s)
- Mirzat Turhon
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Huibin Kang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Mengxing Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jiliang Huang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Bin Luo
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Neurosurgery, Peking University International Hospital, Beijing, People's Republic of China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Shanghai, Shanghai, People's Republic of China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Tianxiao Li
- Department of Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, Henan, People's Republic of China
| | - Donglei Song
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, People's Republic of China
| | - Yuanli Zhao
- Department of Neurosurgery, Peking University International Hospital, Beijing, People's Republic of China
| | - Sheng Guan
- Department of Intervention Neuroradiology, Zhengzhou University First Affiliated Hospital, Zhengzhou, Henan, People's Republic of China
| | - Axir Aximujiang
- Department of Neurosurgery, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, People's Republic of China
| | - Aisha Maimaitili
- Department of Neurosurgery, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, People's Republic of China
| | - Yunyan Wang
- Department of Neurosurgery, Qilu Hospital, Shandong University, Jinan, Shandong, People's Republic of China
| | - Wenfeng Feng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Yang Wang
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.,Department of Neurosurgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jieqing Wan
- Department of Neurosurgery, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, Shanghai, People's Republic of China
| | - Guohua Mao
- Department of Neurosurgery, Nanchang University Second Affiliated Hospital, Nanchang, Jiangxi, People's Republic of China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, People's Republic of China
| | - Xiaolong Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, Shanghai, People's Republic of China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, Shanghai, People's Republic of China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China .,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
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34
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Utility of flow diverters in treatment of acutely ruptured uncoilable aneurysms of the posterior circulation of the brain. Jpn J Radiol 2023:10.1007/s11604-023-01409-y. [PMID: 36920731 DOI: 10.1007/s11604-023-01409-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE Aim of this study is to evaluate safety and efficacy of flow diverters (FDs) in treatment of acutely ruptured posterior circulation aneurysms MATERIALS AND METHODS: Databases of three participating institutions were retrospectively scanned for patients in whom FD placement was attempted for treatment of acutely ruptured vertebrobasilar aneurysms. An interval of 14 days or fewer between the latest ictus and treatment was used as inclusion criterion. Patients with dolichoectasia of vertebrobasilar arteries were excluded. If necessary, adjunctive techniques including coiling or stenting were utilized. Clinical outcomes were graded using mWFNS (modified World Federation of Neurosurgical Societies Scale) and mRS (modified Rankin Scale). Aneurysmal occlusion was defined as Raymond-Roy Class 1. Spearman's (ρ) test was used to assess the correlation between variables. Univariate and multivariate logistic regression were used to assess outcomes. RESULTS 31 patients (25 women, mean age: 52.7 ± 15.2) harboring 32 aneurysms (16 non-saccular, mean size: 11.4 ± 7 mm) were included. Mean number of FDs used was 1.22 ± 0.42. In six cases, adjunctive coiling and in five cases, apposing stent placement were used. Overall mortality rate and procedure-related mortality rates were 22.5% (7/31) and 9.6% (3/31), respectively. At a mean imaging follow-up of 17.2 ± 12.6 months, total occlusion was achieved in 22 aneurysms (91.6%). Univariate analysis showed that mortality was positively correlated with vasospasm (ρ = 0.600, p < 0.05), higher mWFNS Scale (ρ = 0.685, p < 0.05), higher modified Fischer Score (ρ = 0.609, p < 0.05), higher mRS (ρ = 0.594, p < 0.05) on admission and negatively correlated with saccular morphology (ρ = -0.529, p < 0.05). Multivariate logistic regression identified mWFNS on admission as a significant predictor. (OR: 7.148, 95% CI 1.777-28.758, p: 0.01). Adjunctive coiling positively correlated with aneurysm occlusion. (ρ = 0.522, p < 0.05). CONCLUSION The procedure-related morbidity and mortality is not negligible. However, the risks and efficacy associated with FDs are acceptable, especially when adjunctive coiling is possible, given the lack of treatment alternatives.
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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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Flow Diverting Stents in Cerebral Small Caliber Vessels (< 2 mm) for Aneurysm Treatment : A Three Center Retrospective Study. Clin Neuroradiol 2023; 33:99-105. [PMID: 35768696 DOI: 10.1007/s00062-022-01187-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The off-label use of flow diverting stents (FDS) for treating cerebral aneurysms in small distal vessels is increasing in clinical practice with encouraging results; however, data directly addressing the parent vessel size are still scarce. Our aim was to evaluate the safety and efficacy of FDS placement in anterior and posterior circulation aneurysms with parent arteries ≤ 2 mm in a real-world representative setting. METHODS We retrospectively reviewed patients treated with FDS at the three participating university hospitals between 2009 and 2021. The inclusion criteria were the placement of at least one FDS in a parent vessel with a maximum diameter of 2 mm or less. The primary clinical safety endpoint was the absence of death, major or minor symptomatic stroke, transient ischemic attack and procedure-related intracranial hemorrhage. Clinical outcome was assessed using the modified Rankin Scale (mRS) score at the follow-up visit at 1 year. The primary efficacy endpoint was defined as complete and near-complete occlusion at the 1‑year follow-up. RESULTS We identified 55 patients harboring 56 aneurysms. The primary clinical safety endpoint was obtained in 93% of cases. The hemorrhagic and thromboembolic complication rates were 4% and 9%, respectively. No patient died or had a relevant discrepancy (> 1 point) at the pre-mRS and post-mRS. The primary efficacy endpoint was reached in 80% of cases. CONCLUSION The use of FDS in vessels < 2 mm is technically feasible with good aneurysm occlusion rates and an acceptable safety profile. Nevertheless, it is essential to be aware of the of the main complications associated when operating in small diameter vessels.
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Arai S, Fujii T, Teranishi K, Nonaka S, Kitamura T, Mitome-Mishima Y, Kondo A, Oishi H. Pipeline Flex with Shield Technology Placement for Small- and Medium-sized Aneurysms Achieves Early Complete Occlusion. Neurol Med Chir (Tokyo) 2023; 63:58-64. [PMID: 36543205 PMCID: PMC9995145 DOI: 10.2176/jns-nmc.2022-0217] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The flow diverter has been shown to be a safe and effective device for large cerebral aneurysms in the proximal internal carotid artery (ICA). Recently, its indication has been expanded to small- and medium-sized cerebral aneurysms in the distal segment of the ICA. In this study, we report a single-center, retrospective investigation of the safety and efficacy of the Pipeline Flex device to treat these aneurysms. Of the patients who underwent Pipeline implantation for small- and medium-sized ICA aneurysms (≤12 mm) at our hospital between July 2013 and October 2021, 102 patients with 104 aneurysms were included in this study. The mean age of the patients was 57.7 ± 12.1 years, and 94 (90.4%) were female. The mean aneurysmal dome diameter was 9.2 ± 2.3 mm, the mean neck diameter was 5.3 ± 1.6 mm, and the mean dome-to-neck ratio was 1.8 ± 0.5. Twenty-five patients (24.0%) had incorporated vessels from the aneurysm. Complete occlusion of the aneurysms was obtained in 96 patients (92.3%). There were no cases of parent artery stenosis or major stroke after the procedure. Absence of incorporated vessel from the aneurysm dome and adjunctive coil embolization are statistically significant factors indicating complete occlusion in multivariate analysis. The time to complete occlusion was determined earlier with the use of the Pipeline Shield (p = 0.0386) and with adjunctive coils (p = 0.0025). We showed that Pipeline implantation for small- and medium-sized aneurysms was safe and highly effective.
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Affiliation(s)
- Sho Arai
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Graduate School of Medicine, Juntendo University
| | - Kohsuke Teranishi
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | - Senshu Nonaka
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | - Takayuki Kitamura
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | | | - Akihide Kondo
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | - Hidenori Oishi
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University.,Department of Neuroendovascular Therapy, Graduate School of Medicine, Juntendo University
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Oliver AA, Carlson KD, Bilgin C, Arturo Larco JL, Kadirvel R, Guillory RJ, Dragomir Daescu D, Kallmes DF. Bioresorbable flow diverters for the treatment of intracranial aneurysms: review of current literature and future directions. J Neurointerv Surg 2023; 15:178-182. [PMID: 35636949 PMCID: PMC9708930 DOI: 10.1136/neurintsurg-2022-018941] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/15/2022] [Indexed: 01/17/2023]
Abstract
The use of flow diverters is a rapidly growing endovascular approach for the treatment of intracranial aneurysms. All FDA-approved flow diverters are composed of nitinol or cobalt-chromium, which will remain in the patient for the duration of their life. Bioresorbable flow diverters have been proposed by several independent investigators as the next generation of flow diverting devices. These devices aim to serve their transient function of occluding and healing the aneurysm prior to being safely resorbed by the body, eliminating complications associated with the permanent presence of conventional flow diverters. Theoretical advantages of bioresorbable flow diverters include (1) reduction in device-induced thrombosis; (2) reduction in chronic inflammation and device-induced stenosis; (3) reduction in side branch occlusion; (4) restoration of physiological vasomotor function; (5) reduction in imaging artifacts; and (6) use in pediatric applications. Advances made in the similar bioresorbable coronary stenting field highlight some of these advantages and demonstrate the feasibility and safety of bioresorbable endovascular devices in the clinic. The current work aims to review the progress of bioresorbable flow diverters, identify opportunities for further investigation, and ultimately stimulate the advancement of this technology.
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Affiliation(s)
- Alexander A Oliver
- Biomedical Engineering and Physiology, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent D Carlson
- Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Cem Bilgin
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Roger J Guillory
- Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
| | - Dan Dragomir Daescu
- Biomedical Engineering and Physiology, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
- Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Biomedical Engineering and Physiology, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Tatit RT, Ogilvy CS, Shutran MS, Tawk RG, Yasuda TA, Baccin CE. Plasticity of the adult circle of Willis in response to flow diversion stents. Surg Neurol Int 2023; 14:49. [PMID: 36895205 PMCID: PMC9990810 DOI: 10.25259/sni_1139_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 01/28/2023] [Indexed: 02/12/2023] Open
Abstract
Background We present five patients with remodeling of the adult circle of Willis in response to flow diverter stents (FDSs) at the anterior communicating artery (AComA) and the posterior communicating artery (PComA). The observed changes provide a paradigm of how flow change can institute anatomic changes in the adult circle of Willis vasculature. Case Description In the first two cases, after placement of the FDS covering the AComA, there was an increase in size and flow of the contralateral A1-anterior cerebral artery which had previously been hypoplastic. In one of the cases, this led to the filling of the aneurysm and required placement of coils within the lesion which was curative. In case three, the FDS effect led to asymptomatic occlusion of the PComA and associated aneurysm without change of the ipsilateral P1-segement of posterior-cerebral-artery (P1-PCA) caliber. In the fourth case, the FDS covering an aneurysm with a fetal PCA arising from its neck resulted in significant reduction of the aneurysm size, persistent flow and caliber of the fetal PCA, and the hypoplastic ipsilateral P1-PCA. Finally, in the fifth case, after FDS occlusion of the PComA and aneurysm there was increasement in diameter of the ipsilateral P1-PCA that was previously hypoplastic. Conclusion The use of FDS can affect vessels covered by the device and other arteries of the circle of Willis adjacent to the FDS. The phenomena illustrated in the hypoplastic branches appear to be a compensatory response to the hemodynamic changes induced by the divertor and to the altered flow in the circle of Willis.
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Affiliation(s)
- Rafael Trindade Tatit
- Department of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max S Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rabih G Tawk
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Thomas A Yasuda
- Department of Interventional Neuroradiology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Carlos Eduardo Baccin
- Department of Interventional Neuroradiology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Peng Q, Guo R, Zhou Y, Teng R, Cao Y, Mu S. Comparison of Gelatin/Polylysine- and Silk Fibroin/SDF-1α-Coated Mesenchymal Stem Cell-Seeded Intracranial Stents. Macromol Biosci 2022; 23:e2200402. [PMID: 36541928 DOI: 10.1002/mabi.202200402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/12/2022] [Indexed: 12/24/2022]
Abstract
Endothelialization of the aneurysmal neck is essential for aneurysm healing after endovascular treatment. Mesenchymal stem cell (MSC)-seeded stents can promote aneurysm repair. The biological effects of coated and uncoated nitinol intracranial stents seeded with MSCs on vascular cells and macrophage proliferation and inflammation are investigated. Two stent coatings that exert pro-aggregation effects on MSCs via different mechanisms are examined: gelatin/polylysine (G/PLL), which enhances cell adhesion, and silk fibroin/SDF-1α (SF/SDF-1α), which enhances chemotaxis. The aim is to explore the feasibility of MSC-seeded coated stents in the treatment of intracranial aneurysms. The G/PLL coating provides the highest cytocompatibility and blood compatibility substrate for MSCs and vascular cells and promotes cell adhesion and proliferation. Moreover, it enhances MSC secretion and regulation of vascular cell and macrophage proliferation and chemotaxis. Although the SF/SDF-1α coating promotes MSC secretion and vascular cell chemotaxis, it induces a greater degree of macrophage proliferation, chemotaxis, and secretion of pro-inflammatory factors. MSC-seeded stents coated with G/PLL may benefit stent surface endothelialization and reduce the inflammatory response after endovascular treatment of intracranial aneurysm. These effects may improve aneurysm healing and increase the cure rate.
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Affiliation(s)
- Qichen Peng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Ruimin Guo
- Healthina Academy of Biomedicine, Tianjin Economic-Technological Development Area, HAB-TEDA, Tianjin, 300457, China.,Tangyi holdings (Shenzhen) Co., LTD, Shenzhen, 518101, China
| | - Yangyang Zhou
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Ruidi Teng
- Healthina Academy of Biomedicine, Tianjin Economic-Technological Development Area, HAB-TEDA, Tianjin, 300457, China.,Tangyi holdings (Shenzhen) Co., LTD, Shenzhen, 518101, China
| | - Yulin Cao
- Healthina Academy of Biomedicine, Tianjin Economic-Technological Development Area, HAB-TEDA, Tianjin, 300457, China.,Tangyi holdings (Shenzhen) Co., LTD, Shenzhen, 518101, China
| | - Shiqing Mu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
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Piano M, Lozupone E, Milonia L, Pero G, Cervo A, Macera A, Quilici L, Visconti E, Valvassori L, Cenzato M, Boccardi E. Flow diverter devices in the treatment of complex middle cerebral artery aneurysms when surgical and endovascular treatments are challenging. J Stroke Cerebrovasc Dis 2022; 31:106760. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/17/2022] [Accepted: 09/04/2022] [Indexed: 11/21/2022] Open
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Abouelleil M, Lyons L, Deshpande N, Singer J. Commentary: Silk Vista Baby for the Treatment of Complex Posterior Inferior Cerebellar Artery Aneurysms. Neurosurgery 2022; 91:e168-e169. [PMID: 36286510 DOI: 10.1227/neu.0000000000002191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Mohamed Abouelleil
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA.,Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, USA
| | - Leah Lyons
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA.,Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, USA
| | - Nachiket Deshpande
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA.,Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, USA
| | - Justin Singer
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA.,Department of Neurosurgery, Spectrum Health, Grand Rapids, Michigan, USA
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Piano M, Trombatore P, Lozupone E, Pero G, Cervo A, Macera A, Quilici L, Peschillo S, Valvassori L, Boccardi E. Flow Diverter Devices in the Treatment of Anterior Communicating Artery Region Aneurysms: Would the Regional Anatomy and the Aneurysm Location Affect the Outcomes? Brain Sci 2022; 12:1524. [PMID: 36358450 PMCID: PMC9688233 DOI: 10.3390/brainsci12111524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND In this study, the authors evaluated the efficacy and the safety of flow diverter devices (FDD) in anterior communicating artery (ACoA) region aneurysms, focusing on anatomical factors that could affect the outcome, such as the location of the aneurysm along the ACoA (centered on ACoA or decentered on the A1-A2 junction) and the anatomy of the ACoA region. METHODS Clinical, procedural and follow-up data were analyzed. Aneurysms were classified according to the location along the ACoA (centered or decentered on the A1-A2 junction) and on the basis of the anatomical configuration of the ACoA region. Safety was assessed by recording intraprocedural, periprocedural and delayed complications to determine the morbidity and mortality rates. The functional outcome was evaluated with the modified Rankin scale (mRS) prior to and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded. Subgroup analysis according to the different ACoA regional anatomical configurations and the ACoA aneurysm locations were performed. RESULTS 33 patients (17 males; 16 females) with ACoA region aneurysms were treated with FDDs. 27 aneurysms were located at the A1-A2 junction (82%) while the remaining six aneurysms were centered on the ACoA. No mortality was recorded. The overall morbidity rate was 6% (2/33 procedures). Major complications occurred in 33% (2/6) of ACoA aneurysms and in the 0% of A1-A2 junction aneurysms. Mid-term and long-term neuroimaging follow-ups showed the occlusion of the aneurysm in 28/33 cases (85%). Complete occlusion rates were 93% in the A1-A2 junction aneurysms and 50% in ACoA aneurysms. CONCLUSIONS The FDD is a safe and effective tool that can be used in the treatment of selected cases of ACoA region aneurysms. The location of the aneurysm along the ACoA and the regional anatomy of the ACoA complex could affect the efficacy and safety.
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Affiliation(s)
- Mariangela Piano
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
| | - Pietro Trombatore
- Department of Neuroradiology, Ospedale San Gerardo, 20900 Monza, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Guglielmo Pero
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
| | - Amedeo Cervo
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
| | - Antonio Macera
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
| | - Luca Quilici
- Department of Neuroradiology, ASST Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Simone Peschillo
- Department of Neurosurgey, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy
- Endovascular Neurosurgery, Pia Fondazione Cardinale Giovanni Panico Hospital, 73039 Lecce, Italy
| | - Luca Valvassori
- Department of Neuroradiology, ASST Santi Paolo e Carlo, 20142 Milano, Italy
| | - Edoardo Boccardi
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
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Restrepo AF, Singer J. Commentary: The Pennsylvania Postmarket Multicenter Experience With Flow Redirection Endoluminal Device. Neurosurgery 2022; 91:e109-e110. [PMID: 36001777 DOI: 10.1227/neu.0000000000002114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Andres F Restrepo
- Neurosurgery Division, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA.,Department of Neurosurgery, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Justin Singer
- Neurosurgery Division, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA.,Department of Neurosurgery, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
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45
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Guo Z, Cheng X, Kadeer K, Wang K, Abulimiti M, Miao T, Aihemaiti Y, Aisha M. Hemodynamic analysis of intracranial aneurysms treated with flow diverter. Minerva Med 2022; 113:886-887. [PMID: 33464234 DOI: 10.23736/s0026-4806.20.07241-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Zhen Guo
- Department of Neurosurgery2, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaojiang Cheng
- Department of Neurosurgery2, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Kaheerman Kadeer
- Department of Neurosurgery2, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Kai Wang
- Department of Neurosurgery2, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Mireadilij Abulimiti
- Department of Neurosurgery2, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Tong Miao
- Department of Neurosurgery2, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yadikaer Aihemaiti
- Department of Neurosurgery2, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Maimaitili Aisha
- Department of Neurosurgery2, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China -
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Hohenstatt S, Ulfert C, Herweh C, Schönenberger S, Purrucker JC, Bendszus M, Möhlenbruch MA, Vollherbst DF. Acute Intraprocedural Thrombosis After Flow Diverter Stent Implantation: Risk Factors and Relevance of Standard Observation Time for Early Detection and Management. Clin Neuroradiol 2022; 33:343-351. [PMID: 36068407 DOI: 10.1007/s00062-022-01214-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Acute intraprocedural thrombosis (AIT) is a severe complication of flow diverter stent (FDS) implantation for the treatment of intracranial aneurysms. Even though device-related thromboembolic complications are well known, there are no acknowledged risk factors nor defined surveillance protocols for their early detection. This study aimed to demonstrate that an angiographic active surveillance is effective to detect and treat AIT. Furthermore, we investigated risk factors for the occurrence of AIT. METHODS A prospective institutional protocol consisting of a defined observation period of 30 min following FDS deployment was established to detect AIT. Overall incidence, as well as the efficacy and safety of AIT treatment were assessed. Moreover, radiological and clinical outcomes of patients with AIT were analyzed. The influence of various patient- and procedure-related factors on the occurrence of AIT was investigated using multivariable forward logistic regression. RESULTS During active surveillance twelve cases of AIT were observed among a total of 161 procedures (incidence: 7.5%). The median time of first observation was 15.5 min (IQR 9.5) after FDS implantation. The early recognition of AIT ensured a prompt treatment with intravenous application of a glycoprotein IIb/IIIa inhibitor, which led to complete thrombus resolution in all cases without hemorrhagic complications. Patients with pre-existing arterial hypertension and side branches originating from the aneurysmal sac had a higher risk of AIT (respectively OR, 9.844; OR, 3.553). There were two cases of re-thrombosis in the short-term postoperative period, of whom one died. The remaining patients with AIT had a good clinical outcome. CONCLUSION Active surveillance for 30 min after FDS implantation is an effective strategy for early detection and ensuing treatment of AIT and can thus prevent secondary sequalae. Hypertension and side branches originating from the aneurysmal sac may increase the risk of AIT.
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Affiliation(s)
- Sophia Hohenstatt
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Ulfert
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany.
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47
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Xu C, Wu P, Zou L, Xu S, Luo B, Yang X, Shi H. Anterior Circulation Fusiform Aneurysms Have a Lower Occlusion Rate After Pipeline Embolization Device Treatment Than Posterior Circulation Fusiform Aneurysms: A Multicenter Cohort Study. Front Neurol 2022; 13:925115. [PMID: 35720088 PMCID: PMC9202754 DOI: 10.3389/fneur.2022.925115] [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: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Objective:Intracranial fusiform aneurysms are uncommon and can occur in vessels of the anterior circulation (AC) or posterior circulation (PC). While flow diversion is one treatment option, research into Pipeline Embolization Device (PED) treatment is lacking. This study explored the efficacy and safety of PED treatment for intracranial fusiform aneurysms, and compared therapeutic effects between AC and PC aneurysms.MethodsIn the post-market multi-center cohort study of embolization of intracranial aneurysms with PED in China (PLUS) registry study, we retrospectively analyzed 71 fusiform aneurysms in 67 patients among 1,171 patients treated with a PED from November 2014 to October 2019. The general characteristics, perioperative status, aneurysm occlusion rate at the last follow-up angiography, and changes in modified Rankin Scale scores were analyzed. Aneurysms were divided into AC and PC groups, and univariate and multivariate analyses were conducted.ResultsThe study included 26 AC (25 patients) and 45 PC (42 patients) aneurysms. A total of 75 PEDs were used, an average of 1.1 PEDs were used, and the median follow-up was 6.7 months. Fifty aneurysms (71.4%) were occluded and twenty (28.5%) were incompletely occluded. There were significantly more occluded aneurysms in the PC group than in the AC group (12 vs. 38; P = 0.001). Risk factors for incomplete occlusion were AC aneurysms (P = 0.001) and a perforating artery originating from the aneurysm (P = 0.006). The mean modified Rankin Scale score was significantly lower at the last follow up than preoperatively (0.58 vs. 0.21; P = 0.0001).ConclusionNon-overlapping PED is a safe and effective treatment for both AC and PC fusiform aneurysms. The occlusion rate of AC fusiform aneurysms is lower than that of PC.
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Affiliation(s)
- Chao Xu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Pei Wu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Liang Zou
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shancai Xu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
- *Correspondence: Huaizhang Shi
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Tikhvinskii D, Kuianova J, Kislitsin D, Orlov K, Gorbatykh A, Parshin D. Numerical Assessment of the Risk of Abnormal Endothelialization for Diverter Devices: Clinical Data Driven Numerical Study. J Pers Med 2022; 12:jpm12040652. [PMID: 35455768 PMCID: PMC9025183 DOI: 10.3390/jpm12040652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 12/07/2022] Open
Abstract
Numerical modeling is an effective tool for preoperative planning. The present work is devoted to a retrospective analysis of neurosurgical treatments for the occlusion of cerebral aneurysms using flow-diverters and hemodynamic factors affecting stent endothelization. Several different geometric approaches have been considered for virtual flow-diverters deployment. A comparative analysis of hemodynamic parameters as a result of computational modeling has been carried out basing on the four clinical cases: one successful treatment, one with no occlusion and two with in stent stenosis. For the first time, a quantitative assessment of both: the limiting magnitude of shear stresses that are necessary for the occurrence of in stent stenosis (MaxWSS > 1.23) and for conditions in which endothelialization is insufficiently active and occlusion of the cervical part of the aneurysm does not occur (MaxWSS < 1.68)—has been statistacally proven (p < 0.01).
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Affiliation(s)
- Denis Tikhvinskii
- Lavrentyev Institute of Hydrodynamics SB RAS, Lavrentiev Avenue 15, 630090 Novosibirsk, Russia; (D.T.); (J.K.)
| | - Julia Kuianova
- Lavrentyev Institute of Hydrodynamics SB RAS, Lavrentiev Avenue 15, 630090 Novosibirsk, Russia; (D.T.); (J.K.)
| | - Dmitrii Kislitsin
- Neurosurgery Department, Meshalkin National Medical Research Center, 630055 Novosibirsk, Russia; (D.K.); (K.O.); (A.G.)
| | - Kirill Orlov
- Neurosurgery Department, Meshalkin National Medical Research Center, 630055 Novosibirsk, Russia; (D.K.); (K.O.); (A.G.)
| | - Anton Gorbatykh
- Neurosurgery Department, Meshalkin National Medical Research Center, 630055 Novosibirsk, Russia; (D.K.); (K.O.); (A.G.)
| | - Daniil Parshin
- Lavrentyev Institute of Hydrodynamics SB RAS, Lavrentiev Avenue 15, 630090 Novosibirsk, Russia; (D.T.); (J.K.)
- Correspondence: ; Tel.: +7-383-333-16-12
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Muram S, Corcoran R, Cooke J, Forrester K, Lapins E, Morrish R, Cheema OZA, Goyal M, Eesa M, Fiorella D, Wong JH, Sadasivan C, Mitha AP. Immediate flow-diversion characteristics of a novel primarily bioresorbable flow-diverting stent. J Neurosurg 2022; 137:1794-1800. [PMID: 35364565 DOI: 10.3171/2022.1.jns212975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow-diverting stents with a resorbable component have significant theoretical benefits over full metal stents, although currently there are none in clinical use. In this study, the authors sought to determine the immediate flow-diversion characteristics of a novel primarily bioresorbable flow-diverting stent. METHODS Bioresorbable stents were deployed into glass tube models to determine porosity and pore density. In vitro flow diversion behavior was evaluated using high frame rate angiography under pulsatile flow conditions in a patient-specific silicone aneurysm model treated with the resorbable stent as well as the Surpass Evolve stent. In vivo flow diversion was characterized by deployment into 20 rabbit saccular aneurysm models, and grading was based on the O'Kelly-Marotta scale and the 4F-flow diversion predictive score. RESULTS Porosities and pore densities of the bioresorbable stent were in the flow-diverting range for all target vessel diameters. Quantified results of immediate angiography after placement of the bioresorbable stent into a silicone aneurysm model demonstrated greater flow diversion compared to the Evolve stent. Bioresorbable stent placement in saccular aneurysm models resulted in an immediate O'Kelly-Marotta grade of A3 or better and a 4F-flow diversion predictive score of 4 or better in all cases. CONCLUSIONS The bioresorbable stent has immediate flow-diversion characteristics that are comparable to commercially available metal stents. Longer-term studies are underway to determine the ability of the resorbable fibers to act as a neointimal scaffold and result in long-term aneurysm occlusion.
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Affiliation(s)
- Sandeep Muram
- 1Department of Clinical Neurosciences, University of Calgary
| | | | | | | | - Elana Lapins
- 1Department of Clinical Neurosciences, University of Calgary
| | - Rosalie Morrish
- 1Department of Clinical Neurosciences, University of Calgary
| | | | - Mayank Goyal
- 1Department of Clinical Neurosciences, University of Calgary.,5Department of Radiology, University of Calgary, Alberta, Canada; and
| | - Muneer Eesa
- 1Department of Clinical Neurosciences, University of Calgary.,5Department of Radiology, University of Calgary, Alberta, Canada; and
| | - David Fiorella
- 6Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York
| | - John H Wong
- 1Department of Clinical Neurosciences, University of Calgary.,4Hotchkiss Brain Institute, University of Calgary.,5Department of Radiology, University of Calgary, Alberta, Canada; and
| | - Chander Sadasivan
- 6Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York
| | - Alim P Mitha
- 1Department of Clinical Neurosciences, University of Calgary.,3Biomedical Engineering Program, University of Calgary.,4Hotchkiss Brain Institute, University of Calgary.,5Department of Radiology, University of Calgary, Alberta, Canada; and
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50
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Roloff C, Berg P. Effect of flow diverter stent malposition on intracranial aneurysm hemodynamics—An experimental framework using stereoscopic particle image velocimetry. PLoS One 2022; 17:e0264688. [PMID: 35235597 PMCID: PMC8890739 DOI: 10.1371/journal.pone.0264688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/15/2022] [Indexed: 12/04/2022] Open
Abstract
Background Flow-diverting stents are increasingly used for the minimally-invasive treatment of intracranial aneurysms. However, a correct positioning of such devices can be challenging due to varying vessel diameters as well as the complex anatomy of the neurovasculature. As a consequence, unsuccessful treatment outcomes are increasingly reported requiring an improvement of the understanding of stent-induced flow modification. Methods To evaluate the effect of different degrees of flow diverter stent malposition on intra-aneurysmal hemodynamic changes, a controlled hemodynamic configuration was created using an idealized intracranial aneurysms model. Afterwards, four different treatment scenarios were reproduced comprising of 1) the ideal treatment, 2) an insufficient wall apposition in the region of the ostium, 3) a distorted device migrating into the aneurysm sac and 4) an inaccurately deployed stent due to wrong release location. For the assessment of the individual flow modifications, high-resolution stereoscopic particle image velocimetry (PIV) measurements were carried out. Results The analysis of the precise in-vitro PIV measurements reveals that in all cases a considerable reduction of the cycle-averaged and peak-systolic velocity was obtained. Compared to the untreated aneurysm configuration, the flow reduction ranged from 63% (scenario 4) up to 89% (scenario 3). The ideal treatment reached a reduction of 78%, which is known to be sufficient for a successful therapy. However, inaccurate device positioning leads to increased oscillating flow towards the lateral directions reducing the chances of sufficient thrombus formation. Conclusions High-resolution in-vitro PIV measurements enable an accurate quantification of the treatment efficacy for flow-diverting devices. Furthermore, insufficient treatment outcomes can be reproduces allowing for an assessment of intra-aneurysmal hemodynamic changes.
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Affiliation(s)
- Christoph Roloff
- Laboratory of Fluid Dynamics and Technical Flows, University of Magdeburg, Magdeburg, Germany
| | - Philipp Berg
- Laboratory of Fluid Dynamics and Technical Flows, University of Magdeburg, Magdeburg, Germany
- Research Campus STIMULATE, University of Magdeburg, Magdeburg, Germany
- * E-mail:
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