Endovascular Treatment of a Giant Intracranial Aneurysm with a Stent-Graft

Favorable Outcome of Endovascular Treatment for Intracranial Aneurysms: A Single-Center Study in Thailand

Purpose:

The purpose of this study is to collect the information on patients with intracranial aneurysm (IA) receiving endovascular management in Siriraj Hospital, Mahidol University, Thailand.

Materials and Methods:

We retrospectively reviewed data from patients with IA who underwent endovascular treatment from January 1997 through July 2013. We collected patients’ demographic data including age, sex, clinical presentations, and aneurysmal profiles, as well as endovascular treatment technique, complications, angiographic results, and regrowth rate. Treatment results included success rate, clinical findings during follow-up, and regrowth rate.

Results:

We reviewed data from 497 patients with 636 aneurysms (female:male ratio, 1.9:1; age range, 15–90 years; mean age, 59.18 years) and 69% presented with rupture. One hundred and twenty patients with 127 aneurysms received endovascular treatment. The most common location for endovascular treatment was the posterior communicating artery (15.8%), and endovascular techniques were used most often for posterior circulation and paraclinoid aneurysms. The success rate was approximately 99.2% with a 16.5% regrowth rate and no rebleeding. Regrowth rate did not correlate with immediate postoperative angiographic findings. We encountered 23 complications (18.1%); most commonly, intra-procedural rupture (7/23). Good outcomes occurred in approximately 95.9% of the patients.

Conclusions:

The success rate for endovascular treatment was >90%. Regrowth rate and clinical outcomes were within standard limits. Posterior circulation and paraclinoid aneurysms were our main targets. We tended to use fewer devices and simpler techniques to secure ruptured IA; however, the regrowth rate was similar to that using device-assisted techniques in other studies. We found no significant factors affecting regrowth rate, including immediate posttreatment angiographic results.

Application of dual Willis covered stents in the management of large fusiform carotid aneurysms in a canine model

This study evaluates the efficacy of dual Willis covered stents for the treatment of large fusiform carotid aneurysms in a canine model. Carotid fusiform aneurysms >10 mm long were surgically created in 10 dogs and were then repaired using either single or dual covered stents. Clinical results were assessed by scheduled angiography and histological features by light and electron microscopy. Angiography immediately post-op and 6 months after surgery revealed aneurysm isolation rates of 60 and 20% for the single stent technique and 60 and 100% for the dual stent technique, respectively. The rate of complete obliteration of the aneurysm sac differed significantly between treatments ( P = 0.048). The dual stent technique also resulted in greater endothelialization. For large carotid fusiform aneurysms in a canine model, endovascular repair using dual Willis covered stents is technically feasible and more effectively obliterates the aneurysm sac than the use of a single stent.

Reconstructive endovascular treatment of intracranial aneurysms with the Willis covered stent: medium-term clinical and angiographic follow-up

Object

Placement of covered stents has emerged as a promising therapeutic option for cerebrovascular diseases. However, the medium- and long-term efficacy and safety of covered stents in the treatment of these diseases remain unclear. The purpose of this study was to evaluate the medium-term clinical and angiographic outcomes of covered stent placement for the treatment of intracranial aneurysms.

Methods

The authors' institutional review board approved the study. Thirty-four patients (13 females and 21 males; mean age 41.9 years) with 38 intracranial aneurysms were treated with the Willis covered stent. Clinical and angiographic follow-up were performed at 3 months, at 6–12 months, and annually thereafter. The initial procedural and follow-up outcomes were collected and analyzed retrospectively.

Results

Forty-two covered stents were successfully implanted into the target artery in 33 patients with 37 aneurysms, and 1 covered stent navigation failed in 1 patient. A complete aneurysm exclusion was initially achieved in 24 patients with 28 aneurysms, and a minor endoleak occurred in 9 patients with 9 aneurysms. Postoperatively, 2 patients died of complications related to the procedure. Angiographic and clinical follow-up data are available in 30 patients. The angiographic follow-up (17.5 ± 9.4 months [mean ± SD]) exhibited complete occlusion in 28 patients with 31 aneurysms, and incomplete occlusion in 2 aneurysms, with an asymptomatic in-stent stenosis in 3 patients (10%). The clinical follow-up (26.7 ± 13 months [mean ± SD]) demonstrated that 16 patients (53.3%) experienced a full recovery, and 14 patients (46.7%) improved. No aneurysm rupture, thromboembolic events, or neurological deficits resulting from closure of a perforating vessel by covered stent placement occurred.

Conclusions

Endovascular reconstruction with the Willis covered stent represents a safe, durable, and curative treatment option for selected intracranial aneurysms, yielding an excellent medium-term patency of the parent artery and excellent clinical outcomes.

Placement of covered stents for the treatment of direct carotid cavernous fistulas

BACKGROUND AND PURPOSE

Endovascular detachable balloon occlusion and coil occlusion are 2 well-established options for the treatment of direct carotid cavernous fistulas (DCCFs). In recent years, covered stents have been applied in the treatment of neurovascular pathologies such as aneurysms, pseudoaneurysms, arterial dissections, and DCCFs. The purpose of this study was to investigate the clinical efficacy of covered stents for the treatment of DCCFs.

MATERIALS AND METHODS

Ten consecutive patients underwent covered-stent placement after failure of detachable balloon occlusion for the treatment of their DCCFs. Clinical and angiographic follow-up ranged from 5 to 48 months (mean, 18.2 months) after stent placement.

RESULTS

Stent placement was technically successful in all except 1 patient. In this patient, stent placement failed after multiple attempts because of rigidity of the Jostent GraftMaster Coronary Stent Graft and the tortuous anatomy of the internal carotid artery (ICA). Complete exclusion of the fistula was achieved in 6 patients immediately after stent deployment. Endoleak was observed in 3 patients. Re-dilation of the stent avoided the endoleak in 2 patients; in 1 of these 2 patients, formerly improved symptoms recurred the next morning and the ipsilateral ICA was occluded with detachable balloons. Spasm of the ICA was observed in most of the patients after stent placement; however, angioplasty was not required. Symptoms improved in all patients after treatment, without thromboembolic events. Follow-up cerebral angiography showed complete exclusion of all DCCFs and stent patency without intrastent stenosis in the 8 patients who had successful deployment of the stent.

CONCLUSIONS

Although a larger sample and expanded follow-up are needed, our series shows that covered stents can be used in the treatment of DCCFs with symptomatic relief.

Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms

Object

Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation.

Methods

Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically.

Results

Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement.

Conclusions

Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.

Surgical construction of a novel simulated carotid siphon in dogs

Object

The development and preclinical assessment of new endovascular devices necessitate readily available and reproducible animal models. The purpose of this study was to develop an in vivo carotid siphon model for testing the properties of covered stents specially designed for the intracranial vasculature.

Methods

Six carotid siphon–shaped devices were created. Six dogs underwent surgery to expose and isolate both common carotid arteries (CCAs). The right CCA origin was ligated and incised distal to the ligation point after temporary constriction of the distal right CCA. The distal left CCA was ligated and incised proximal to the ligation point after the left CCA origin was temporarily clamped. The proximal isolated left CCA was passed through the shaped device and then anastomosed end-to-end to the distal isolated right CCA. Finally, the shaped device was fixed and embedded in the neck. Intraarterial digital subtraction angiography was performed at 7 days, 2 weeks, and 1 month postprocedure. All models underwent endovascular interventional simulation. The carotid siphon models were evaluated.

Results

The animals tolerated the surgical procedure well. The mean time for surgical construction of the model was 90 minutes. The morphology and endovascular manipulation of the siphon models were similar to those in humans. Stenosis of anastomotic stoma occurred in 2 models, and mural thrombosis of anastomotic stoma occurred in 1 model; however, all models were patent at postprocedural follow-up angiography.

Conclusions

Surgical construction of an in vivo carotid siphon model in dogs with carotid siphon–shaped devices is feasible and potentially useful for testing neurovascular devices.

Stent graft treatment of cerebrovascular wall defects: intermediate-term clinical and angiographic results

OBJECTIVE

Endovascular stent graft (SG) deployment offers a useful vessel-preserving strategy for vascular wall lesions such as pseudoaneurysms and fistulae. Although deployment of expanded polytetrafluoro-ethylene-covered SGs within the carotid and vertebral arteries is technically feasible, data on long-term efficacy, safety, and patency rate remain sparse.

METHODS

Six patients with traumatic (n = 4), iatrogenic (n = 1), or spontaneous (n = 1) internal carotid and vertebral artery injuries (direct carotid-cavernous fistula, n = 2; pseudoaneurysms, n = 4) were treated with nine balloon-mounted coronary expanded polytetrafluoro-ethylene SGs. Angiographic (mean, 2.3 yr; range, 1.7-4.2 yr) and neurological follow-up (mean, 2.7 yr) was performed for all patients.

RESULTS

Complete angiographic exclusion of the lesion was achieved by the initial procedure in five of the six patients; one ruptured cavernous carotid aneurysm leading to a direct carotid-cavernous fistula showed persistent slow shunting despite tandem deployment of two SGs. All six patients revealed complete and persistent angiographic obliteration at delayed follow-up, with minimal in-stent stenosis (<20%) seen in two instances. Difficulty with SG navigation was encountered in five patients, resulting in one instance of guide catheter-induced intimal dissection. Type I endoleak was observed in five patients, requiring secondary angioplasty in four patients and deployment of an additional tandem SG in three.

CONCLUSION

Technical challenges in current-generation SG deployment include sizing, navigation, positioning, and propensity for endoleak. When managed successfully, stent grafting provides a valuable approach for the treatment of vascular wall defects for which vessel preservation is preferred. Intermediate-term safety is satisfactory, with no delayed complications and minimal in-stent stenosis in follow-up periods of more than 2 years.

Endovascular treatment of giant intracranial aneurysms with willis covered stents: technical case report

OBJECTIVE

To evaluate the efficacy of endovascular treatment of giant intracranial aneurysms with Willis covered stents (Micro-Port, Shanghai, China).

CLINICAL PRESENTATION

The endovascular treatment of two cases of giant intracranial aneurysm was successfully accomplished by the placement of Willis covered stents specially designed for intracranial use. Both patients presented with symptoms of cavernous mass effect that resulted from a giant aneurysm in the cavernous segment of the internal carotid artery.

INTERVENTION

Three Willis covered stents were successfully placed in two patients. Immediate postprocedure angiograms demonstrated some endoleak of the aneurysms. In one patient, the endoleak was eliminated and complete exclusion of the aneurysms was confirmed with follow-up angiography. However, the other patient required the placement of a new Willis covered stent.

CONCLUSION

The use of covered stents in intracranial vascular structures is a feasible method to treat selected cases of intracranial giant aneurysms. It is suggested that patients who present with compressive mass effect caused by large or giant aneurysms are the best candidates for covered stent placement, but potential complications should be considered carefully before the stenting procedure.

Endovascular embolization of intracranial aneurysms

Intracranial aneurysm (ICA) is a common condition but with a high mortality rate when rupture occurs. The treatment of ruptured or unruptured ICA, especially with an endovascular approach, has been evolving rapidly. The current generally accepted opinion suggests that endovascular embolization is an effective technique for preventing the recurrence of aneurysm rupture, but the rebleeding rate after endovascular embolization is found to be higher than that after surgical clipping. In addition, long-term follow-up data are required for the evaluation of the effectiveness of endovascular treatment in unruptured ICA. This review presents the current understanding of ICA, the selection of optimal treatment approaches, and in particular, the advances in endovascular embolization in the treatment of ICA, including embolic materials, therapeutic and assisting techniques, long-term effectiveness, and limitations.

Treatment of carotid cavernous fistulas using covered stents: midterm results in seven patients

BACKGROUND AND PURPOSE

Carotid cavernous fistulas (CCF) can be effectively treated by using different therapeutic alternatives such as detachable balloons and detachable coils, alone or in combination with N-butyl-2-cyanoacrylate (n-BCA) or Onyx. Stents have also been used in an attempt to improve preservation of the parent artery while still occluding the fistula. We present our experience using balloon-expandable covered stents to treat CCF, focusing on arterial wall reconstruction. To our knowledge, this is the first series with midterm follow-up between 3 months and 3.5 years.

MATERIALS AND METHODS

From the 46 CCF treated at our institution between November 1998 and September 2006, a total of 7 posttraumatic direct CCF were treated using polytetrafluoroethylene (PTFE)-covered stents between April 2003 and September 2006. Five were treated with covered stents alone. One patient with transection of the internal carotid artery (ICA) first underwent bare stent placement to provide support for the covered stent. One patient had to be treated with coils and n-BCA.

RESULTS

Control angiograms obtained in the 7 patients demonstrated occlusion of the fistula and preservation of the ICA in all cases. There was no mortality and no immediate postprocedural morbidity. There was 1 case of morbidity identified at 1-month follow-up with asymptomatic occlusion of the ICA; the other 6 patients had angiographic follow-up between 3 and 42 months (mean, 18.4 months), with persistent occlusion of the fistulas, patent stent grafts, and no significant intimal hyperplasia.

CONCLUSIONS

PTFE-covered stents are evolving as a promising intracranial therapeutic alternative to treat CCF and preserve the parent artery by reconstructing the arterial wall. They should be considered in patients in whom fistulas cannot be successfully occluded with detachable balloons or detachable coils. More investigation is required to further develop their specifications and indications.

Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases

INTRODUCTION

The aim of this retrospective study was to evaluate the clinical efficacy and limitations of different endovascular modalities in the treatment of very large and giant intracranial aneurysms.

METHODS

A group of 20 patients with very large and giant intracranial aneurysms treated by endovascular approaches were retrospectively analyzed. Of the 20 patients, 9 had been treated by parent artery occlusion, 8 by coil embolization, and 3 with an intracranial covered stent. Two recurrent aneurysms initially treated with coil embolization were retreated with an intracranial covered stent. Patients were followed for 9-83 months after the procedure.

RESULTS

Endovascular treatment was technically feasible in all 20 patients. One patient died 7 days after the procedure from rebleeding caused by incomplete aneurysmal occlusion. Immediate postprocedural angiograms showed that complete occlusion was achieved in 11 aneurysms, subtotal occlusion in 7, and incomplete occlusion in 2. The final angiographic results in the other 19 surviving patients confirmed complete occlusion of 15 aneurysms, subtotal occlusion in 3, and incomplete occlusion in 1. Clinical evaluations performed at the final follow-up visit showed an excellent outcome in 11 patients and a good outcome in 8.

CONCLUSION

Endovascular treatment of giant intracranial aneurysms with coil embolization is often associated with a low complete occlusion rate and a high recanalization rate, and parent artery occlusion remains a practical option in selected patients. Based on our limited experience, the use of an intracranial covered stent appears to be a relatively simple and safe procedure for occluding very large and giant aneurysms while still maintaining the patency of the parent artery.

Treatment of a giant vertebrobasilar artery aneurysm using stent grafts

✓This 65-year-old man presented to the authors' institution reporting neck swelling. Stage IIIA Hodgkin disease was diagnosed, and a computed tomography scan of the neck revealed a vertebrobasilar artery aneurysm. His medical history was significant for subarachnoid hemorrhage and coma 2 years earlier. Subsequent digital subtraction angiography demonstrated a giant fusiform vertebrobasilar junction aneurysm with associated basilar artery (BA) fenestration. Endovascular treatment of the giant aneurysm was performed by left vertebral artery (VA) occlusion and placement of two Jo-stent coronary stent grafts from the right VA to the BA. The postprocedure course was uneventful. Follow-up angiography performed 1 week postoperatively demonstrated complete exclusion of the aneurysm. This unique case is described and a review of the relevant literature is presented.

Extracranial-intracranial bypass for the treatment of cavernous sinus aneurysms

The optimal management of symptomatic cavernous sinus aneurysms remains controversial. Carotid occlusion is a simple procedure, but carries an ongoing risk of early and late stroke. Cerebral revascularisation is technically demanding and carries a risk of morbidity and mortality of around 10%. Eight patients treated with an extracranial-intracranial vascular bypass graft over a period of 44 months for symptomatic cavernous sinus aneurysms are reviewed. At a mean follow-up of 20 months, seven patients (87.5%) had an excellent outcome (Glasgow Outcome Score 5) while one patient suffered a perioperative stroke. In only one case, where the radial artery had been used, the graft became occluded. The results of this series seem to indicate that cerebral revascularisation is an effective treatment for patients with symptomatic cavernous sinus aneurysms.

Management of pseudoaneurysms in the intracranial segment of the internal carotid artery with covered stents specially designed for use in the intracranial vasculature: technical notes

Vascular diseases like aneurysms, pseudoaneurysms and direct high-flow carotid-cavernous fistulas on the intracranial segment of the internal carotid artery are usually managed through transarterial embolization with detachable coils or balloons. Utility of covered stents has been reported with good results in the treatment of selective cases. But the current generation of covered stents for coronary use is rather stiff and difficult to navigate in tortuous vessels particularly in the intracranial vasculature. Herein, we report on the use and technical respects of balloon-expanded covered stents specially designed for intracranial vasculature in the treatment of two pseudoaneurysms secondary to the successful obliteration of direct CCFs on the intracranial segment of the internal carotid artery. This is the first report of covered stents specially developed for use in intracranial vasculature.

Treatment of a middle cerebral artery giant aneurysm using a covered stent

✓ The authors report the case of a 60-year-old man harboring a wide-necked giant aneurysm of the M1 segment of the left middle cerebral artery (MCA); his symptoms included transient ischemic attacks characterized by right hemiparesis and aphasia. The aneurysm was treated by placing a covered stent across the orifice of the aneurysm. The 18-month follow-up examination showed a very good outcome, with perfect left MCA patency, no new ischemic lesion, and minor residual aphasia and right hemiparesis. This is the first report in the literature of an MCA aneurysm treated using a covered stent.

Long-term Outcome of Unruptured Giant Cerebral Aneurysms

The long-term outcome of 39 patients with unruptured giant aneurysm (>2.5 cm) treated during the last 12 years was retrospectively reviewed. The 7 male and 32 female patients, aged 32 to 81 years, presented with symptoms related to compression of the surrounding structures by the aneurysm in 28 cases, cerebral infarction in one, and asymptomatic in 10. The locations were the internal carotid artery (ICA) in 27 cases, middle cerebral artery in three, anterior cerebral artery in one, and basilar artery in eight. Therapeutic modalities were direct clipping in 11 patients, ICA occlusion combined with extracranial-intracranial bypass in 15, and conservative treatment in 13. The follow-up period ranged from 16 to 128 months (mean 54.0 months). The mortality was 9% (1/11), 0% (0/15), and 31% (4/13), and morbidity was 18% (2/11), 20% (3/15), and 8% (1/13), respectively. Surgery reduced the mortality (from 31% to 4%) but increased the morbidity (from 8% to 19%) as compared with conservatively treated patients (p < 0.05). Giant intracranial aneurysm has a poor prognosis if left untreated, but these lesions are difficult to treat with the present management options.

Advances in Stent-Assisted Management of Intracranial Occlusive Disease and Cerebral Aneurysms

The use of stents in the intracranial circulation has been made possible by rapid developments in stent technology in recent years. Considerable improvements in stent design, delivery devices, and technique have expanded the use of stenting to the treatment of intracranial disorders. This article reviews the indications for endovascular stenting for cerebral aneurysms and intracranial atherosclerosis and describes the peri-procedure management and technique applied at the Department of Neurosurgery at the University at Buffalo.