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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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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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3
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Bibi R, Bankole NDA, Donnard B, Giubbolini F, Boucherit J, Barrot V, Herbreteau D, Ifergan H, Janot K, Boulouis G, Bala F. Safety and efficacy of Surpass Evolve Flow diverter for intracranial aneurysms: A study of 116 patients. Neuroradiol J 2024; 37:184-191. [PMID: 38146676 DOI: 10.1177/19714009231224408] [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: 12/27/2023] Open
Abstract
BACKGROUND AND PURPOSE Flow diverter embolization is a recognized method for treating intracranial aneurysms. This study evaluates the safety and efficacy of the Surpass Evolve flow diverter in treating intracranial aneurysm. MATERIAL AND METHODS From May 2019 to June 2022, our center prospectively enrolled patients presenting with both ruptured and unruptured intracranial aneurysms. We assessed aneurysm occlusion, along with the occurrence of ischemic and hemorrhagic complications, and mortality at 6-months. The 3-month occlusion rate was determined using MR angiography, while the 6-month occlusion rate employed the O'Kelly-Marotta (OKM) grading scale on DSA. RESULTS A total of 116 patients with 120 aneurysms received treatment with the Surpass Evolve device. The average aneurysm size was 6.6 mm (range: 2-30 mm). All patients were administered two loading doses of ticagrelor (180 mg) one day before the procedure and 2 h pre-embolization. A procedural complication occurred in one case, involving wire-related perforation of an M3 branch distant from the giant aneurysm; however, this evolved favorably. There were no reported deaths linked to the treatment. Permanent neurological deficits were observed in 3 (2.5%) patients, primarily due to early in-stent thrombosis. MR angiography results at 3 months indicated complete occlusion for 87 out of 115 (75.6%) monitored aneurysms. The 6-month DSA showed neck remnant or complete occlusion (OKM grade C or D) in 86 out of the 107 (80.4%) patients who underwent follow-up. CONCLUSION The Surpass Evolve stands out as a reliable and effective flow diverter for the management of intracranial aneurysms.
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Affiliation(s)
- Richard Bibi
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Nourou Dine Adeniran Bankole
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
- Clinical Investigation Center (CIC), INSERM, University Hospital of Tours, Tours, France
| | - Baptiste Donnard
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Francesca Giubbolini
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Julien Boucherit
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
- Department of Neuroradiology, Rennes University Hospital, Rennes, France
| | - Valère Barrot
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Denis Herbreteau
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Héloïse Ifergan
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Kevin Janot
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Grégoire Boulouis
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
- Clinical Investigation Center (CIC), INSERM, University Hospital of Tours, Tours, France
| | - Fouzi Bala
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
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4
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Broadley L, Erskine B, Marshall E, Ewert K, Picker B. Optimising image quality in intravenous cerebral cone beam computed tomography. J Med Radiat Sci 2024; 71:26-34. [PMID: 37847044 PMCID: PMC10920929 DOI: 10.1002/jmrs.735] [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: 05/31/2023] [Accepted: 10/07/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION The efficacy of intravenous cerebral Cone Beam Computed Tomography (IV CBCT) is well established; however, image quality has only ever been authenticated by subjective evaluation. The aim of this study was to quantify the factors pertinent to achieving consistent and optimal image quality when performing IV CBCT. METHODS Between 1 March 2021 and 30 October 2022, 79 patients received IV CBCT. These candidates were divided into three main acquisition field size categories (22/32, 42 and 48 cm) according to the clinical indication. The images were analysed using both a quantitative assessment and a subjective evaluation. Here, a comparison of Hounsfield units (HUs), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and noise index was conducted for each study and compared relative to the acquisition field size. The subjective analysis was performed in a non-blinded fashion where the diagnostic value (DV) of the exam was determined according to a graded scale. A phantom analysis for each of the acquisition field sizes was conducted and modulation transfer function (MTF) graphed. RESULTS Significantly higher HU, SNR, CNR and lower noise indices were achieved with the 42-cm protocol than the 22/32 and 48-cm protocols. Here a greater DV was also reported. The MTF demonstrates marginally improved spatial resolution for the 22-cm protocol, but this is near equivocal for the 32-, 42 and 48-cm protocols. CONCLUSION The use of larger acquisition field sizes provides improved image quality when performing IV CBCT as an alternative to intra-arterial (IA) CBCT.
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Affiliation(s)
| | | | | | - Kyle Ewert
- Alfred HospitalMelbourneVictoriaAustralia
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5
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Solis F, Plasencia A, Wahlster S, Walker M, Levitt MR, Ecos R. Flow Diversion for the Treatment of Intracranial Aneurysms in a Peruvian Cohort: Experiences from a Limited-Resource Setting and Barriers to Implementation. World Neurosurg 2023; 180:79-85. [PMID: 37742718 DOI: 10.1016/j.wneu.2023.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Stenting with flow diverter devices (FDDs) has increasingly emerged as a treatment for intracranial aneurysms. The use of FDDs in the developing world has not been described. METHODS A retrospective review was performed of a cohort of patients who underwent flow diversion at 4 tertiary-care centers in Lima, Peru between January 2017 and June 2021. Demographics, clinical features, and aneurysm morphology were evaluated. Clinical outcomes were observed 3 months after discharge and occlusion rates were assessed 12 months after treatment. RESULTS Sixty-nine patients (mean age, 46 ±14.5 years; 17% female) were treated with FDDs; 4% (n = 3) of the treated aneurysms were ruptured. Most aneurysms were saccular (n = 65; 94%), <10 mm in maximum size (n = 60; 87%), and located in the anterior circulation (n = 67; 97%). Minor complications, such as groin hematoma, occurred in 7 cases. No serious complications or deaths occurred. Patients' functional status was excellent (modified Rankin Scale score 0-1) in 99% (n = 66) at discharge and 100% (n = 67) at 3 months. Although some patients were lost to follow-up, complete occlusion was seen in 76% (n = 31) of 41 treated patients at 12 months. CONCLUSIONS We report the largest multicenter experience of FDDs for cerebral aneurysm treatment in Peru, with reasonable outcomes that are comparable to other settings despite various challenges, suboptimal circumstances, and lack of resources.
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Affiliation(s)
- Frank Solis
- Neurological Surgery and Endovascular Neurosurgery, Clínica Internacional San Borja, Lima, Peru; Endovascular Neurosurgery Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru.
| | - Andres Plasencia
- Neurological Surgery and Endovascular Neurosurgery, Clínica Internacional San Borja, Lima, Peru
| | - Sarah Wahlster
- Neurology, Neurosurgery, and Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Melanie Walker
- Neurological Surgery and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Neurological Surgery, Radiology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - Rosa Ecos
- Vascular Neurology, Instituto Nacional de Ciencias Neurológicas, Lima, Peru; Medicine Faculty, Universidad Nacional Federico Villarreal, Lima, Peru
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Liu L, Xu L, Guo N, Yang Y, Liu X, Qi T, Liang F. Ticagrelor is related to nuisance bleeding after flow diversion of unruptured intracranial aneurysms. Neurosurg Rev 2023; 46:134. [PMID: 37269331 DOI: 10.1007/s10143-023-02043-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: 04/12/2023] [Revised: 05/12/2023] [Accepted: 05/27/2023] [Indexed: 06/05/2023]
Abstract
Nuisance bleeding (NB) without urgent medical attention is rarely characterized despite its frequent occurrence in patients with cerebral aneurysms undergoing flow diversion (FD) who are maintained on dual antiplatelet therapy (DAPT). This study explored the risk factors for NB. Patients with unruptured cerebral aneurysms who underwent intervention using FD (July 2018 to May 2022) and had follow-up data were enrolled. Patient demographics, clinical characteristics, aneurysm features and follow-up data were analysed. Bleeding complications were classified as NB, internal bleeding and alarming bleeding. NB was characterized by easy bruising, bleeding from small cuts and nonfatal petechiae and ecchymosis. Univariate and multivariate logistic regression analyses were performed to determine risk factors for NB. This study assessed 121 patients. Of these, 52 (43.0%) patients had NB. Compared with the non-bleeding group, the NB group had more females (82.7% vs. 56.5%; p = 0.003), lower smoking rate (7.7% vs. 23.2%; p = 0.027) and smaller aneurysms (6.65 mm [4.60-9.60 mm] vs. 8.82 mm [5.65-15.65 mm]; p = 0.007) and had more patients maintained on ticagrelor-containing DAPT regimen (90.4% vs. 66.7%; p = 0.002). Multivariate logistic regression revealed that ticagrelor-containing DAPT regimen (odds ratio, 3.91; 95% confidence interval, 1.29-11.87; p = 0.016) was associated with NB. These results suggest that NB is a common bleeding complaint in patients on DAPT. In patients undergoing FD, DAPT with ticagrelor was the only independent risk factor for NB.
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Affiliation(s)
- Linfeng Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Lin Xu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Ning Guo
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Yibing Yang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Xinman Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Tiewei Qi
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Feng Liang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China.
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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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A Meta-analysis: Cost Comparison of Flow Diversion and Coil Embolization for Intracranial Aneurysm. DISEASE MARKERS 2022; 2022:2925366. [PMID: 36284988 PMCID: PMC9588347 DOI: 10.1155/2022/2925366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/26/2022] [Indexed: 12/02/2022]
Abstract
Background Intracranial aneurysm serves as a prevalent cerebral disorder leading to the low-quality life and financial burden of the patients. Flow diversion and coil embolization have been confirmed as common therapeutic strategies for intracranial aneurysms. In this work, we identified and compared the cost between the flow diversion and coil embolization in the treatment of intracranial aneurysms in a meta-analysis. Methods We downloaded literatures that are published before Feb 2021 from Cochrane Library, Embase, and Pubmed using terms including “flow diversion”, “pipeline embolization device”, “coil embolization”, “coiling”, “Intracranial aneurysms”, and “Cerebral aneurysms”. The data were analyzed by STATA 15.1. Differences in treatment costs were determined by WMD (95% CI). Results A total of 1332 articles were included in the search of the limited terms, and 8 were selected after eliminating duplicate and unwanted studies. Our data indicated that the total cost of flow diversion for intracranial aneurysms is significantly lower than coil embolization (WMD = −4419.12, 95% CI: -6292.21 to -2546.03, p ≤ 0.001). In addition, we explored the retreatment hospitalization cost of flow diversion and coil embolization for intracranial aneurysms. We found that the retreatment hospitalization cost of flow diversion for intracranial aneurysms is significantly higher than coil embolization (WMD = 3203.85, 95% CI: 1904.60 to 4503.10, p ≤ 0.001). Conclusion We concluded that the total cost was lower, and the retreatment hospitalization costs of flow diversion were higher than coil embolization for the treatment of intracranial aneurysms. Our finding provides valuable insights into the application of flow diversion and coil embolization in intracranial aneurysm therapy. Flow diversion may be applied as a major treatment with the consideration of retreatment.
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9
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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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10
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Fatania K, Patankar DT. Comprehensive review of the recent advances in devices for endovascular treatment of complex brain aneurysms. Br J Radiol 2022; 95:20210538. [PMID: 34609898 PMCID: PMC8722252 DOI: 10.1259/bjr.20210538] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The International Subarachnoid Aneurysm Trial (ISAT) showed superiority for endovascular treatment of ruptured aneurysms and technology has since moved on rapidly. Many approaches and technology now exist for the endovascular management of ruptured and unruptured intracranial aneurysms, which reflects their varied nature - there is no one-size-fits-all technique. We aim to provide an overview of the various classes of device and the major developments over the past decade. Coiling is the oldest of the technology and continues to demonstrate high levels of occlusion and acceptable risks, making it the default treatment choice, particularly in the acutely ruptured aneurysm setting. Advances on coiling include the use of adjuncts such as balloons, stents and fully retrievable temporary neck-bridging devices, which have facilitated the treatment of more complex aneurysms. Flow divertors have also revolutionised complex aneurysm treatment with small added risk in acute aneurysm treatment and seek to remodel the aneurysm-vessel interface without accessing the aneurysm sac. The latest development and most promising avenue appears to be intrasaccular flow disrupting devices like WEB, Contour and Neqstent that provide excellent opportunities to treat wide neck complex aneurysm with minimal mortality and morbidity and good occlusion rates and may in future replace a significant number of stent-assisted coiling too.
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Affiliation(s)
- Kavi Fatania
- Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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11
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Abstract
The treatment of intracranial aneurysms (IA) began in the late 19th century. Some degree of controversy has always surrounded the best treatment modality for IA. Cushing and Dandy debated about cervical carotid ligation as the only surgical alternative before the introduction of microsurgical clipping. In the early 21st century, the debate has centered on surgical versus^ endovascular techniques. With the advent of newer endovascular techniques and devices, there has been a dramatic shift in treatment paradigms toward endovascular intervention that is preferred by both physicians and patients. However, there will always be a need for microsurgical cerebrovascular expertise since some aneurysms cannot or should not be embolized. This creates a difficult conundrum as only the most complex of aneurysms will require open surgery, but the lack of volume and training will be a challenge in teaching and maintaining the surgical expertise required to safely treat them. The purpose of this review is to discuss the history of IA treatment and critically evaluate the current state of the art of IA treatment, with a specific focus on the necessary role microsurgical clipping continues to play in the current treatment landscape.
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Affiliation(s)
- Pablo Harker
- From the Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Justin Vranic
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Aman B Patel
- From the Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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12
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Hufnagl C, Broussalis E, Cognard C, Grimm J, Hecker C, Oellerer A, Abdallah M, Griessenauer CJ, Killer-Oberpfalzer M. Evaluation of a novel flow diverter, the DiVeRt system, in an animal model. J Neurointerv Surg 2021; 14:384-389. [PMID: 33986108 DOI: 10.1136/neurintsurg-2021-017430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Using a surgical aneurysm model, this study assessed the performance of a new flow diverter (FD), the DiVeRt, and evaluated the angiographic and histologic features at different periods after stent deployment. METHODS Fifteen New Zealand White rabbits were treated 3 days prior to intervention and until euthanization with dual antiplatelets. DiVeRt was implanted in bilateral carotid aneurysms (n=30) as well as in the aorta (n=15). The rate of technical success, assessment of aneurysm occlusion (measured by the O'Kelly-Marotta grading (OKM) scale), and stent patency were examined using angiography and histologic examinations in three groups at 1, 3, and 6 months follow-up (FU). In each FU group one control animal was included and treated with the XCalibur stent (n=3). RESULTS Overall, DiVeRt placement was successful and without apparent intraprocedural complications. In total, four stents in the carotid artery were occluded and in-stent stenosis was registered in two carotid (7%) and one aortic (6%) vessels. Complete or near complete aneurysm occlusion (OKM scale D1 and C3) was seen in 100% in the 1-month FU group, 70% in the 2-month FU group, and 100% in the 3-month FU group. Histology showed loose, organizing fibrous tissue matrix within the sac and adequate neck endothelialization in all vessels. All branches covered by the DiVeRt remained patent. CONCLUSIONS The DiVeRt system appears to be feasible and effective for the treatment of aneurysms with high rates of complete aneurysm occlusion, excellent vessel patency, and evidence of high biocompatibility. Occurrences of parent artery occlusion at follow-up did not result in clinical consequences.
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Affiliation(s)
- Clemens Hufnagl
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Erasmia Broussalis
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, University Hospital Salzburg, Salzburg, Austria
| | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Jochen Grimm
- Department of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Constantin Hecker
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, University Hospital Salzburg, Salzburg, Austria
| | - Andreas Oellerer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Muhammed Abdallah
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Vascular and Endovascular Surgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA
| | - Monika Killer-Oberpfalzer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria .,Department of Neurology, University Hospital Salzburg, Salzburg, Austria
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13
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Gavrilovic V, Dapoto A, Marotti N, Pellegrin A, Pauro A, Vit A, Sponza M. Silk Vista Baby Is a Safe and Technically Feasible Flow Diverting Stent for Distal Aneurysm Treatment. Front Neurol 2021; 12:676749. [PMID: 34054714 PMCID: PMC8149904 DOI: 10.3389/fneur.2021.676749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/08/2021] [Indexed: 12/02/2022] Open
Abstract
Background and Purpose: Flow diverting stents are designed to divert blood flow from the aneurysm sac, allowing for eventual occlusion following endovascular therapy. This case series reports clinical experience using the Silk Vista Baby (SVB, Balt Extrusion, Montmorency, France), a flow diverter (FD) designed to treat intracranial aneurysms in small, distal vessels. Methods: All patients who underwent treatment with SVB at the University Hospital “Santa Maria della Misericordia” of Udine between July 2018 and September 2020 were retrospectively identified. Baseline patient and aneurysm characteristics, intraprocedural technical outcomes, periprocedural complications, modified Rankin Scale (mRS) at discharge, magnetic resonance imaging (MRI) results at 3-month follow-up, and angiographic results at 6-month follow-up were collected. Results: A total of 18 patients (55.6% [10/18] male; mean age 62.6 years, range: 42–77 years) were retrospectively identified, receiving treatment for 22 aneurysms. Most patients were symptomatic (14/18, 77.8%) and approximately half had subarachnoid hemorrhage (10/18, 55.6%). Sufficient aneurysm coverage was achieved in 88.9% (16/18) of patients with a single device. Mortality did not occur (0/18, 0%); adverse device-related events included side branch occlusion (1/18, 5.6%) and in-stent thrombosis (1/18, 5.6%). At discharge, 77.8% (14/18) had an mRS of 0. In most cases, patients showed complete occlusion (10/15, 66.7%) or a small aneurysmal remnant (3/15, 20.0%) upon MRI; upon angiography, most showed complete occlusion (10/13, 76.9%) or only a small aneurysmal remnant (2/13, 15.4%). Conclusion: This case series showed that the SVB FD is safe and feasible to use in patients with aneurysms in small, distal vessels. Additional randomized, prospective studies with larger cohorts are needed for the SVB.
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Affiliation(s)
- Vladimir Gavrilovic
- Angiography and Interventional Radiology Unit, Department of Radiology, University Hospital of Udine, Udine, Italy
| | - Annarita Dapoto
- Angiography and Interventional Radiology Unit, Department of Radiology, University Hospital of Udine, Udine, Italy
| | - Nicola Marotti
- Angiography and Interventional Radiology Unit, Department of Radiology, University Hospital of Udine, Udine, Italy
| | - Andrea Pellegrin
- Angiography and Interventional Radiology Unit, Department of Radiology, University Hospital of Udine, Udine, Italy
| | - Alessandro Pauro
- Angiography and Interventional Radiology Unit, Department of Radiology, University Hospital of Udine, Udine, Italy
| | - Alessandro Vit
- Angiography and Interventional Radiology Unit, Department of Radiology, University Hospital of Udine, Udine, Italy
| | - Massimo Sponza
- Angiography and Interventional Radiology Unit, Department of Radiology, University Hospital of Udine, Udine, Italy
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14
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Martínez-Galdámez M, Onal Y, Cohen JE, Kalousek V, Rivera R, Sordo JG, Echeverria D, Pereira VM, Blasco J, Mardighian D, Velioglu M, van Adel B, Wang BH, Gomori JM, Filioglo A, Čulo B, Lynch J, Binboga AB, Onay M, Galvan Fernandez J, Schüller Arteaga M, Guio JD, Bhogal P, Makalanda L, Wong K, Aggour M, Gentric JC, Gavrilovic V, Navia P, Fernandez Prieto A, González E, Aldea J, López JL, Lorenzo-Gorriz A, Madelrieux T, Rouchaud A, Mounayer C. First multicenter experience using the Silk Vista flow diverter in 60 consecutive intracranial aneurysms: technical aspects. J Neurointerv Surg 2021; 13:1145-1151. [PMID: 33832971 PMCID: PMC8606442 DOI: 10.1136/neurintsurg-2021-017421] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/16/2022]
Abstract
Background The aim of this study was to assess the technical success and procedural safety of the new Silk Vista device (SV) by evaluating the intraprocedural and periprocedural complication rate after its use in several institutions worldwide. Methods The study involved a retrospective review of multicenter data regarding a consecutive series of patients with intracranial aneurysms, treated with the SV between September 2020 and January 2021. Clinical, intra/periprocedural and angiographic data, including approach, materials used, aneurysm size and location, device/s, technical details and initial angiographic aneurysm occlusion, were analyzed. Results 60 aneurysms were treated with SV in 57 procedures. 66 devices were used, 3 removed and 63 implanted. The devices opened instantaneously in 60 out of 66 (91%) cases and complete wall apposition was achieved in 58 out of 63 (92%) devices implanted. In 4 out of 66 (6%) devices a partial opening of the distal end occurred, and in 5 (8%) devices incomplete apposition was reported. There were 3 (5%) intraprocedural thromboembolic events managed successfully with no permanent neurological morbidity, and 4 (7%) postprocedural events. There was no mortality in this study. The initial occlusion rates in the 60 aneurysms were as follows: O’Kelly–Marotta (OKM) A in 34 (57%) cases, OKM B in 15 (25%) cases, OKM C in 6 (10%) cases, and OKM D in 5 (8%) cases. Conclusions Our study demonstrated that the use of the new flow diverter Silk Vista for the treatment of intracranial aneurysms is feasible and technically safe.
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Affiliation(s)
- Mario Martínez-Galdámez
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Yilmaz Onal
- Radiology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - José E Cohen
- Neurosurgery & Radiology, Hadassah-Hebrew Univ Med Ctr, Jerusalem, Israel
| | - Vladimir Kalousek
- Department of Radiology, Clinical Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Rodrigo Rivera
- Neuroradiology, Instituto de Neurocirugia, Dr. Asenjo, Santiago, Chile
| | | | - Daniel Echeverria
- Neuroradiology, Instituto de Neurocirugia, Dr. Asenjo, Santiago, Chile
| | - Vitor M Pereira
- Interventional Neuroradiology, Radiology Department, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Jordi Blasco
- Neurointerventional Department C.D.I, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Dikran Mardighian
- Neuroradiology, Radiological imaging department, Spedali Civili of Brescia, Brescia, Italy
| | - Murat Velioglu
- Radiology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Brian van Adel
- Department of Surgery/Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Bill Hao Wang
- Department of Surgery/Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J Moshe Gomori
- Radiology, Hadassah-Hebrew Univ Med Ctr, Jerusalem, Israel
| | | | - Branimir Čulo
- Department of Radiology, Clinical Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Jeremy Lynch
- Interventional Neuroradiology, Radiology Department, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Ali Burak Binboga
- Radiology, Dr Ersin Arslan Training and Research Hospital, Sahinbey, Gaziantep, Turkey
| | - Mehmet Onay
- Radiology, Dr Ersin Arslan Training and Research Hospital, Sahinbey, Gaziantep, Turkey
| | - Jorge Galvan Fernandez
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Miguel Schüller Arteaga
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Jose David Guio
- Neurointerventional Department C.D.I, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, London, London, UK
| | - Levan Makalanda
- Department of Interventional Neuroradiology, Royal London Hospital, London, London, UK
| | - Ken Wong
- Department of Interventional Neuroradiology, Royal London Hospital, London, London, UK
| | - Mohamed Aggour
- Department of Interventional Neuroradiology, Royal London Hospital, London, London, UK
| | | | - Vladimir Gavrilovic
- Interventional Radiology, Azienda Sanitaria Universitaria Friuli Centrale, UDINE, Ud, Italy
| | - Pedro Navia
- Radiology- Interventional Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | | | - Eva González
- Interventional Neuroradiology. Radiology, Hospital de Cruces, Barakaldo, País Vasco, Spain
| | - Jesus Aldea
- Interventional Neuroradiology, Hospital Universitario de Burgos, Burgos, Castilla y León, Spain
| | - Jose Luis López
- Interventional Neuroradiology, Hospital Universitario de Burgos, Burgos, Castilla y León, Spain
| | - Antonio Lorenzo-Gorriz
- Interventional Neuroradiology, Hospital General Universitario de Castellon, Valencia, Castellon, Spain
| | - Thomas Madelrieux
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France.,University Limoges, CNRS, XLIM, UMR 7252, Limoges, France
| | - Aymeric Rouchaud
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France.,University Limoges, CNRS, XLIM, UMR 7252, Limoges, France
| | - Charbel Mounayer
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France.,University Limoges, CNRS, XLIM, UMR 7252, Limoges, France
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