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Ramirez-Velandia F, Enriquez-Marulanda A, Young M, Orrego-González E, Filo J, Fodor TB, Sconzo D, Shutran M, Ogilvy CS, Taussky P. Thromboembolic Events After the Coverage of Anterior Cerebral Artery with Flow Diversion: A Single Institution Series and Systematic Review. World Neurosurg 2024; 187:e1040-e1053. [PMID: 38754548 DOI: 10.1016/j.wneu.2024.05.041] [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: 04/02/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Advances in the use of flow diversion (FD) now extend to bifurcation aneurysms; herein, we compare thromboembolic events in patients with internal carotid artery (ICA) aneurysms treated with and without exclusion of the anterior cerebral artery (ACA). METHODS Retrospective analysis of aneurysms in the terminal ICA treated with FD from 2013 to 2023 at a single-center study. Procedures were classified according to the coverage at the origin of the ACA and compared through bivariate-analysis. A review was also carried on PubMed, Web of Science, and EMBASE until April 2024, adhering to the PRISMA reporting guidelines. RESULTS Ninety-five patients harboring 113 aneurysms treated in 102 procedures were evaluated. Fifty-eight were treated covering the ACA origin. Dual antiplatelet regimens included aspirin-clopidogrel (50%), aspirin-ticagrelor (44.1%), and aspirin-prasugrel (4.9%). Thromboembolic events occurred in 6 patients (5.9%), all of which presented with large vessel occlusion of the ICA, but without reaching statistical difference in the 2 treated cohorts (P = 0.46). At a median clinical follow-up of 5.95 months, there were no differences in the functional outcomes in the 2 groups (P = 0.22). Contralateral angiographic runs post-treatment after covering the ACA origin demonstrated increase in the A1 (median: 0.45 mm; IQR = 0.4-1.2) and ICA diameter (median: 0.55 mm; IQR = 0.1-1.2). After pooling data from literature and our cohort, complete side branch occlusion after the coverage of ACA was seen in 25% of branches (95%CI = 0.16-0.36), and thromboembolic events were observed after 3% (95%CI = 0.01-0.04) of procedures. CONCLUSIONS Thromboembolic events can occur in distal ICA aneurysms treated with FD, but no significant association was seen with covering the ACA origin.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | | | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eduardo Orrego-González
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Sconzo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Lin Ma W, Deng X, Si An M, Liu S, Bin Guo X. Safety and anatomical outcome analysis after flow diverter coverage of the anterior cerebral artery. J Clin Neurosci 2024; 124:73-77. [PMID: 38669904 DOI: 10.1016/j.jocn.2024.03.027] [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: 03/01/2024] [Accepted: 03/24/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVES Few studies on ischemic complications and flow changes after a flow diverter covering the anterior cerebral artery. The purpose of the study was to explore the ischemic complications and anatomical alterations associated with the flow diverter after it covers the anterior cerebral artery. MATERIALS AND METHODS In this single-center study, patients treated with FD covering the anterior cerebral artery at the First Affiliated Hospital of Zhengzhou University were retrospectively collected. The primary endpoint was ischemic complications related to the anterior cerebral artery. Secondary endpoints were anatomical changes in the anterior cerebral artery postoperatively and at follow-up. RESULTS A total of 59 patients were included in this study. Four (6.8%) patients presented with ischemic stroke symptoms. Immediately after the procedure, complete occlusion of A1 and decreased blood flow was observed in 13 (22.0%) and 21 patients (35.6%), respectively. At follow-up, A1 artery was occluded in 34 patients (57.6%) and decreased blood flow was observed in 10 patients (16.9%). Symptoms of neurological deficits related to the anterior cerebral artery were not observed in all patients at follow-up. CONCLUSION Coverage of A1 is safe, with a low incidence of ischemic stroke, when using an FD to treat aneurysms. Risk of reduced perfusion of the anterior cerebral artery postoperatively even if the anterior communicating artery is open. In cases with A1 occlusion, the blood flow in the distal the anterior cerebral artery can be adequately compensated by opening the anterior communicating artery and good vascular anastomoses.
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Affiliation(s)
- Wu Lin Ma
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, 450052, China
| | - Xin Deng
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, 450052, China
| | - Meng Si An
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, 450052, China
| | - Shuo Liu
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, 450052, China
| | - Xin Bin Guo
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, 450052, China.
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Costa M, Schmitt P, N J, Baldoncini M, Vivanco-Suarez J, Chaurasia B, Douville C, Yince L, Patel A, Monteith S. Transcranial Doppler emboli monitoring for stroke prevention after flow diverting stents. J Cerebrovasc Endovasc Neurosurg 2024; 26:23-29. [PMID: 37813698 PMCID: PMC10995465 DOI: 10.7461/jcen.2023.e2023.05.002] [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: 05/11/2023] [Revised: 07/07/2023] [Accepted: 07/07/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE Flow diverting stents (FDS) are increasingly used for the treatment of intracranial aneurysms. While FDS can provide flow diversion of parent vessels, their high metal surface coverage can cause thromboembolism. Transcranial Doppler (TCD) emboli monitoring can be used to identify subclinical embolic phenomena after neurovascular procedures. Limited data exists regarding the use of TCDs for emboli monitoring in the periprocedural period after FDS placement. We evaluated the rate of positive TCDs microembolic signals and stroke after FDS deployment at our institution. METHODS We retrospectively evaluated 105 patients who underwent FDS treatment between 2012 and 2016 using the Pipeline stent (Medtronic, Minneapolis, MN, USA). Patients were pretreated with aspirin and clopidogrel. All patients were therapeutic on clopidogrel pre-operatively. TCD emboli monitoring was performed immediately after the procedure. Microembolic signals (mES) were classified as "positive" (<15 mES/hour) and "strongly positive" (>15 mES/hour). Clinical stroke rates were determined at 2-week and 6-month post-operatively. RESULTS A total of 132 intracranial aneurysms were treated in 105 patients. TCD emboli monitoring was "positive" in 11.4% (n=12) post-operatively and "strongly positive" in 4.8% (n=5). These positive cases were treated with heparin drips or modification of the antiplatelet regimen, and TCDs were repeated. Following medical management modifications, normalization of mES was achieved in 92% of cases. The overall stroke rates at 2-week and 6-months were 3.8% and 4.8%, respectively. CONCLUSIONS TCD emboli monitoring may help early in the identification of thromboembolic events after flow diversion stenting. This allows for modification of medical therapy and, potentially, preventionf of escalation into post-operative strokes.
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Affiliation(s)
- Matias Costa
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Paul Schmitt
- Department of Neurosurgery, University of Texas Medical Branch, Texas, USA
| | - Jaleel N
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, USA
- Division of Neurosurgery, Dartmouth-Hitchcock Medical Center, New Hampshire, USA
| | - Matias Baldoncini
- Department of Neurological Surgery, Hospital San Fernando, Buenos Aaires, Argentina
| | - Juan Vivanco-Suarez
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
| | - Colleen Douville
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Loh Yince
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Akshal Patel
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Stephen Monteith
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, USA
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Ma W, Deng X, Chen J, Guo X. Risk factor analysis of changes in blood flow in the A1 segment of the anterior cerebral artery after flow-diverter coverage of it. Neurosurg Rev 2024; 47:74. [PMID: 38315259 DOI: 10.1007/s10143-024-02306-2] [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: 10/28/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 02/07/2024]
Abstract
Few studies have explored the effect of a flow-diverter device (FD) on blood flow in the A1 segment of the anterior cerebral artery (ACA), after treatment of intracranial aneurysms in the bifurcation region of the internal carotid artery (ICA). The main objective of this article is to investigate the factors that affect A1 blood flow after FD covers the A1 artery. This is a single-center, retrospective study. Data were collected retrospectively from our center, and patients whose FDs were placed for treatment from the terminal of the ICA to the M1 segment were analyzed. A total of 42 patients were included in the study. Immediate post-procedural angiography following device placement revealed decreased blood flow in the A1 of 15 (35.7%) patients and complete occlusion of the A1 segment in 11 (26.2%) patients. During an average follow-up period of 9.8 months, the A1 segment was ultimately occluded in 25 patients (59.5%) and decreased blood flow in 4 patients (9.5%). When using FD to cover the A1 artery for the treatment of intracranial aneurysms, patients with preoperative opening of the anterior communicating artery (AcomA) are more prone to occlusion or decreased blood flow of the A1 artery, compared to patients without opening.
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Affiliation(s)
- WuLin Ma
- Department of Neurointervention, Erqi District, The First Affiliated Hospital of Zhengzhou University, No.1, East Construction Road, Zhengzhou City, 450052, Henan Province, China
| | - Xin Deng
- Department of Neurointervention, Erqi District, The First Affiliated Hospital of Zhengzhou University, No.1, East Construction Road, Zhengzhou City, 450052, Henan Province, China
| | - JunFan Chen
- Department of Neurointervention, Erqi District, The First Affiliated Hospital of Zhengzhou University, No.1, East Construction Road, Zhengzhou City, 450052, Henan Province, China
| | - XinBin Guo
- Department of Neurointervention, Erqi District, The First Affiliated Hospital of Zhengzhou University, No.1, East Construction Road, Zhengzhou City, 450052, Henan Province, China.
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Fu Y, Bian X, Zou R, Jin R, Leng X, Fan F, Wei S, Cui X, Xiang J, Guan S. Hemodynamic alterations of flow diverters on aneurysms at the fetal posterior communicating artery: A simulation study using CFD to compare the surpass streamline, pipeline flex, and tubridge devices. J Neuroradiol 2024; 51:74-81. [PMID: 37442272 DOI: 10.1016/j.neurad.2023.07.002] [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: 12/01/2022] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/15/2023]
Abstract
PURPOSE Traditional flow diverters (FDs) for treating aneurysms at the fetal posterior communicating artery are unsatisfactory. Surpass Streamline is a novel FD with different mesh characteristics; however, the outcomes for such aneurysms remain unclear. This study aimed to compare hemodynamic alterations induced by Surpass Streamline, Pipeline Flex, and Tubridge devices and explore possible strategies for aneurysms at the fetal posterior communicating artery. METHODS Two simulated aneurysms (Case 1, Case 2) were constructed from digital subtraction angiography (DSA). The three FDs were virtually deployed, and hemodynamic analysis based on computational fluid dynamics was performed. Hemodynamic parameters, including the sac-averaged velocity magnitude (Velocity), high-flow volume (HFV), and wall shear stress (WSS), were compared between each FD and the untreated model (control). Surpass Streamline was performed in real life for two aneurysms and the clinical outcomes were collected for analysis. RESULTS Compared to the control, the Surpass resulted in the most significant reduction in flow. In Case 1, the Velocity, HFV, and WSS were reduced by 51.6%, 78.1%, and 64.3%, respectively. In Case 2, the Velocity, HFV, and WSS were reduced by 48.0%, 81.1%, and 65.3%, respectively. Tubridge showed slightly larger changes in hemodynamic parameters than Pipeline. In addition, our analysis suggested that metal coverage was correlated with the WSS, Velocity, and HFV. The postoperative DSA showed that the aneurysm was nearly occluded in Case 1 and decreased in Case 2. CONCLUSION Compared to that with the Pipeline and Tubridge, the Surpass resulted in the greatest reduction in hemodynamic parameters and might be effective for aneurysms at the fetal posterior communicating artery. Virtual FD deployment and computational fluid dynamics analysis may be used to predict the treatment outcomes.
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Affiliation(s)
- Yu Fu
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Bian
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | - Rong Zou
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | - Rongbo Jin
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | | | - Feng Fan
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Sen Wei
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xuan Cui
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | - Sheng Guan
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Ma Y, Deng X, Chen Z, Yuan Y, Guan S, Guo X. Safety and efficacy analysis of the off-label use of pipeline embolization devices for intracranial aneurysms: a propensity score matching study. Front Neurol 2024; 14:1278366. [PMID: 38239324 PMCID: PMC10794508 DOI: 10.3389/fneur.2023.1278366] [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: 08/16/2023] [Accepted: 12/05/2023] [Indexed: 01/22/2024] Open
Abstract
Background and objective The safety and efficacy of on-label use of pipeline embolization devices (PEDs) are well established; however, there is much controversy over their off-label use. This study aimed to investigate the safety and efficacy of the off-label use of PEDs for treating intracranial aneurysms. Methods This single-center study retrospectively included patients with digital subtraction angiography, computed tomographic angiography, or magnetic resonance angiography confirmed intracranial aneurysms treated with PEDs who were admitted to our institution between 1 January 2018 and 1 July 2022. Patients were divided into on- and off-label groups according to the Food and Drug Administration criteria published in 2021. Propensity score matching (PSM) was used to balance disparities in baseline information between the two groups. Safety outcomes included postoperative mortality and complication rates, whereas effectiveness outcomes included aneurysm occlusion rate (O'Kelly-Marotta grading system C + D grades), retreatment rate within 12 months, and postoperative functional score [modified Rankin scale (mRS) score]. The study was approved by the Ethics Committee of Scientific Research and Clinical Trial of the First Affiliated Hospital of Zhengzhou University (Ethics number: KY 2018-098-02). All patients provided informed consent. Results A total of 242 patients with 261 aneurysms (160 on-label and 101 off-label aneurysms) were included in this study. PSM yielded 81 pairs of patients matched for baseline information. Postoperative hemorrhagic, ischemic, and procedure-related complication rates did not reach statistical significance. In addition, no statistically significant differences in the aneurysm occlusion rate, retreatment rate within 12 months, postoperative functional score (mRS score), or mRS score deterioration rate were observed between the two groups. A higher incidence of in-stent stenosis was observed in the off-label (4.9% vs. 21%, p = 0.002) group than in the on-label group; however, all patients were asymptomatic. Conclusion Compared with on-label use, off-label use of PEDs for treating intracranial aneurysms did not increase the risk of complications, and the occlusion rates were comparable. Therefore, decisions regarding clinical management should not rely solely on on- or off-label indications.
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Affiliation(s)
- Yajing Ma
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Xin Deng
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Zhen Chen
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Yongjie Yuan
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Sheng Guan
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Xinbin Guo
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
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Lv B, Sun M, Shan Y, Cao X, Du Z, Liu X, Zhang R, Leng X, Fiehler J, Siddiqui AH, Xiang J, Wang J. AneuGuide™ software-assisted vs. manual measurements in sizing for pipeline embolization device: An agreement study. Comput Biol Med 2024; 168:107715. [PMID: 38007975 DOI: 10.1016/j.compbiomed.2023.107715] [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: 06/18/2023] [Revised: 10/14/2023] [Accepted: 11/15/2023] [Indexed: 11/28/2023]
Abstract
Sizing of flow diverters (FDs) is a challenging task in the treatment of intracranial aneurysms due to their foreshortening behavior. The purpose of this study is to evaluate the difference between the sizing results from the AneuGuide™ software and from conventional 2D measurement. Ninety-eight consecutive patients undergoing pipeline embolization device (PED) treatment between October 2018 and April 2023 in the First Medical Center of Chinese PLA General Hospital (Beijing, China) were retrospectively analyzed. For all cases, the optimal PED dimensions were both manually determined through 2D measurements on pre-treatment 3D-DSA and computed by AneuGuide™ software. The inter-rater reliability between the two sets of sizing results for each methodology was analyzed using intraclass correlation coefficient (ICC). The degree of agreement between manual sizing and software sizing were analyzed with the Bland-Altman plot and Pearson's test. Differences between two methodologies were analyzed with Wilcoxon signed rank test. Statistical significance was defined as p < 0.05. There was better inter-rater reliability between AneuGuide™ measurements both for diameter (ICC 0.92, 95%CI 0.88-0.95) and length (ICC 0.93, 95%CI 0.89-0.96). Bland-Altman plots showed a good agreement for diameter selection between two methodologies. However, the median length proposed by software group was significantly shorter (16 mm versus 20 mm, p < 0.001). No difference was found for median diameter (4.25 mm versus 4.25 mm). We demonstrated that the AneuGuide™ software provides highly reliable results of PED sizing compared with manual measurement, with a shorter stent length. AneuGuide™ may aid neurointerventionalists in selecting optimal dimensions for FD treatment.
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Affiliation(s)
- Bin Lv
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Mingguang Sun
- Department of Neurology, Beijing Hospital of Integrated Traditional Chinese and Western Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Yejie Shan
- ArteryFlow Technology Co., Ltd, Hangzhou, China
| | - Xiangyu Cao
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhihua Du
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xinfeng Liu
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Rongju Zhang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | | | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | | | - Jun Wang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
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Nishimoto K, Ozaki T, Kidani T, Nakajima S, Kanemura Y, Yamazaki H, Fujinaka T. Flow Diverter Stenting for Symptomatic Intracranial Internal Carotid Artery Aneurysms: Clinical Outcomes and Factors for Symptom Improvement. Neurol Med Chir (Tokyo) 2023; 63:343-349. [PMID: 37286482 PMCID: PMC10482490 DOI: 10.2176/jns-nmc.2022-0389] [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: 12/12/2022] [Accepted: 03/22/2023] [Indexed: 06/09/2023] Open
Abstract
Flow diverter (FD) stenting is expected to improve cranial nerve symptoms caused by aneurysms via the theoretical reduction of the mass effect by promoting spontaneous thrombosis through the flow diversion effect. However, the factors involved in symptom improvement after treatment remain unclear. This study was performed to identify factors for symptom improvement after FD stenting and the symptom improvement rate of each impaired cranial nerve. We retrospectively evaluated 33 patients who underwent FD stenting for symptomatic internal carotid artery aneurysms at our institution from January 2016 to June 2021. Twenty-three (69.7%) patients had resolved or improved symptoms after 1 year of treatment. The optic nerve was affected in 12 patients; the oculomotor nerve, in 16; the trigeminal nerve, in 2; and the abducens nerve, in 13. There was no statistically significant difference in the symptom improvement rate of each impaired cranial nerve. The patients were classified into the improved and nonimproved groups based on their symptoms after 1 year of treatment, and the factors related to the symptoms were analyzed. The time from onset to treatment was significantly shorter in the improved group than in the nonimproved group (197.1 and 800 days, respectively; p = 0.023). There were no significant differences in age, aneurysm diameter, adjunctive coil embolization, partial thrombosis, change in mass diameter on magnetic resonance imaging, or aneurysm occlusion rate on angiography between the two groups. These results suggest that early treatment after the onset of aneurysm-induced cranial neuropathies increases the likelihood of symptom improvement.
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Affiliation(s)
- Keisuke Nishimoto
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
- Department of Neurosurgery, Osaka University Graduate School of Medicine
| | - Tomohiko Ozaki
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Tomoki Kidani
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Shin Nakajima
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Yonehiro Kanemura
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
- Department of Biomedical Research and Innovation, Institute for Clinical Research, National Hospital Organization Osaka National Hospital
| | - Hiroki Yamazaki
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
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Graffeo CS, Zavala B, Cole TS, Srinivasan VM, Lawton MT. Clip Reconstruction of a Previously Ruptured Basilar Bifurcation Aneurysm After Failure of Endovascular Coiling and Flow Diversion: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e430. [PMID: 36716057 DOI: 10.1227/ons.0000000000000617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 11/07/2022] [Indexed: 01/31/2023] Open
Affiliation(s)
- Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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10
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Willis covered stent in the treatment of a recurrent blood blister-like aneurysm after pipeline implementation: A case report. J Interv Med 2023. [DOI: 10.1016/j.jimed.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
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11
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Hanel RA, Cortez GM, Lopes DK, Saatci I, Cekirge HS. Brain aneurysm and parent vessel remodeling after flow diversion treatment: a proposed modification for Cekirge-Saatci classification (mCSC). J Neurointerv Surg 2023; 15:102-104. [PMID: 36597946 DOI: 10.1136/jnis-2022-019757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | | | - Isil Saatci
- Radiology Department, Koru Health Group, Ankara, Turkey
| | - H Saruhan Cekirge
- Radiology Department, Koru Health Group, Ankara, Turkey.,Private Office, Saruhan Cekirge, Ankara, Turkey
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12
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Ökçesiz İ, Dönmez H, Polat OA, Alpşahin M, Sönmez HK, Temizyürek Ö. Effect on ophthalmic imaging findings of flow-diverting stent treatment covering the origin of the ophthalmic artery. Photodiagnosis Photodyn Ther 2022; 41:103247. [PMID: 36539005 DOI: 10.1016/j.pdpdt.2022.103247] [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: 11/16/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Flow-diverting stents are devices that are increasingly used in the treatment of intracranial aneurysms and expand the spectrum of endovascular treatment. The patency of side branches and perforators is a major concern about flow-diverting stent (FDS) treatment. METHODS From 2011 to 2020, seventy-eight patients in whom the orifice of the ophthalmic artery was covered during FDS treatment were evaluated in this study. Bilateral retinal vascular parameters of study subjects were evaluated with OCT and OCTA. The FDS implanted-side eyes of the patients were defined as the procedure group, and the fellow eyes were considered as the control group. RESULTS Twenty-seven patients who were treated with FDS covering the ostium of the ophthalmic artery and who could undergo full ophthalmologic examination were included in the study. There was no statistically significant difference found in terms of visual acuity, retinal vascular parameters, and choroidal thickness between the procedure group and the control group (p>0.05). However, in one case, recanalized retinal artery branch occlusion was detected on the side where the FDS was implanted. CONCLUSION The orifice of the ophthalmic artery is often covered during FDS treatment for carotid-ophthalmic aneurysms; however, this treatment approach has no significant effect on ophthalmic vascular parameters.
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Affiliation(s)
- İzzet Ökçesiz
- Department of Radiology, Erciyes University School of Medicine, Kayseri, Turkiye.
| | - Halil Dönmez
- Department of Radiology, Erciyes University School of Medicine, Kayseri, Turkiye
| | - Osman Ahmet Polat
- Department of Ophthalmology, Erciyes University School of Medicine, Kayseri, Turkiye
| | - Mehmet Alpşahin
- Department of Radiology, Erciyes University School of Medicine, Kayseri, Turkiye
| | | | - Özge Temizyürek
- Department of Ophthalmology, Erciyes University School of Medicine, Kayseri, Turkiye
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13
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Li L, Gao BL, Shao QJ, Zhang GL, Wang ZL, Li TX, Zhu LF. Small Unruptured Intracranial Aneurysms Can Be Effectively Treated With Flow-Diverting Devices. Front Neurol 2022; 13:913653. [PMID: 35707031 PMCID: PMC9190436 DOI: 10.3389/fneur.2022.913653] [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: 04/06/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To investigate the effect and safety of flow diverters in the management of small (<10 mm in diameter) unruptured intracranial aneurysms. Materials and Methods One hundred and ten patients with 145 small intracranial aneurysms treated with flow diverters were retrospectively enrolled. The clinical, endovascular, and follow-up data were analyzed. Results One hundred twenty-one flow diverters were deployed for the treatment of 145 small intracranial aneurysms in 110 patients, and the stenting success rate was 99.1%. In 133 (91.7%) aneurysms, only flow-diverting devices were deployed, and in the rest 12 (8.3%) of aneurysms, coils were used to loosely pack the aneurysm after deployment of a flow-diverting device. Five patients (4.5%) experienced ischemic complications, but no hemorrhagic complications were occurred. All patients had clinical follow-up 6-18 (median 12) after the procedure, with the modified Rankin scale score (mRS) 0 in 101 patients, 1 in four patients, 2 in three patients, 4 in one patient, and 5 in one patient. Digital subtraction angiography was performed at follow-up in 90 (81.8%) patients with 118 (81.4%) aneurysms 6-18 months (median 12) after the procedure, with the Raymond grade I in 90 (76.2%) aneurysms and Raymond grade III in 28 (23.7%). Eighteen patients with 22 partially occluded aneurysms at the first angiographic follow-up experienced the second digital subtraction angiography 12-36 months (median 26) after the procedure, and 21 (95.5%) aneurysms were completely occluded. Two patients had asymptomatic in-stent stenosis. Conclusion Treatment of small unruptured intracranial aneurysms with flow diverters can be performed safely and effectively with satisfactory outcomes.
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Affiliation(s)
- Li Li
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Bu-Lang Gao
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Qiu-Ji Shao
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Guang-Lin Zhang
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Zi-Liang Wang
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Tian-Xiao Li
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Liang-Fu Zhu
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
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14
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Shi X, Huang J, Su X, Chang X, Dang Z, Yang G. Application of Transcranial Doppler in Patients after Stent-Assisted Coil Embolization. Clin Neurol Neurosurg 2022; 220:107347. [DOI: 10.1016/j.clineuro.2022.107347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/07/2022] [Accepted: 06/19/2022] [Indexed: 11/03/2022]
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15
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Nakayashiki A, Sakata H, Ezura M, Endo H, Inoue T, Saito A, Tominaga T. Rupture of an adjacent cerebral aneurysm following the deployment of a Pipeline embolization device: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21651. [PMID: 36303511 PMCID: PMC9379695 DOI: 10.3171/case21651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Although the Pipeline embolization device (PED) is effective for intracranial aneurysm treatment, its impact on the surrounding vascular structure is unknown.
OBSERVATIONS
A 71-year-old woman was incidentally found to have a simultaneous large posterior communicating artery aneurysm and an ipsilateral small anterior choroidal artery aneurysm. She underwent flow diversion therapy for both aneurysms with a PED, but the distal shortening of the PED after deployment led to the exposure of the anterior choroidal artery aneurysm. Follow-up angiography revealed complete obliteration of the posterior communicating artery aneurysm, but the anterior choroidal artery aneurysm remained. Three years after the endovascular surgery, the patient experienced a subarachnoid hemorrhage due to the rupture of the anterior choroidal artery aneurysm. Retrospective analysis of angiographic images revealed a change in the vascular geometry surrounding the ruptured aneurysm after PED deployment; this was further accompanied by an increase in the flow velocity inside the aneurysm.
LESSONS
Because PED use might induce the adverse effects on the adjacent uncovered aneurysm by changing the vascular geometry and hemodynamic stress, a cautious therapeutic strategy, such as proper placement of the stent and using a longer and appropriate-sized PED, should be chosen when deploying the PED.
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Affiliation(s)
- Atsushi Nakayashiki
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan; and
| | - Hiroyuki Sakata
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan; and
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan; and
| | - Hidenori Endo
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan; and
| | - Takashi Inoue
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan; and
| | - Atsushi Saito
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan; and
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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16
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Dowlati E, Pasko KBD, Liu J, Miller CA, Felbaum DR, Sur S, Chang JJ, Liu AH, Armonda RA, Mai JC. Treatment of In-Stent Stenosis Following Flow Diversion of Intracranial Aneurysms with Cilostazol and Clopidogrel. Neurointervention 2021; 16:285-292. [PMID: 34503310 PMCID: PMC8561031 DOI: 10.5469/neuroint.2021.00290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/26/2021] [Indexed: 12/01/2022] Open
Abstract
In-stent stenosis is a feared complication of flow diversion treatment for cerebral aneurysms. We present 2 cases of patients treated with pipeline flow diversion for unruptured cerebral aneurysms. Initial perioperative dual antiplatelet therapy (DAPT) consisted of standard aspirin plus clopidogrel. At 6-month follow-up cerebral angiography, the patients were noted to have developed significant in-stent stenosis (63% and 53%). The patients were treated with cilostazol and clopidogrel for at least 6 months. Subsequent angiography at 1-year post-treatment showed significant improvement of the in-stent stenosis from 63% to 34% and 53% to 21%. The role of cilostazol as treatment of intracranial in-stent stenosis has not been previously described. Cilostazol’s vasodilatory effect and suppression of vascular smooth muscle proliferation provides ideal benefits in this setting. Cilostazol plus clopidogrel may be a safe and effective alternative to standard DAPT for treatment of in-stent stenosis following flow diversion and warrants further consideration and investigation.
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Affiliation(s)
- Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Jiaqi Liu
- Georgetown University School of Medicine, Washington, DC, USA
| | - Charles A Miller
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Samir Sur
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ai-Hsi Liu
- Department of Radiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
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17
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Maragkos GA, Dmytriw AA, Salem MM, Tutino VM, Meng H, Cognard C, Machi P, Krings T, Mendes Pereira V. Overview of Different Flow Diverters and Flow Dynamics. Neurosurgery 2020; 86:S21-S34. [PMID: 31838536 DOI: 10.1093/neuros/nyz323] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/30/2019] [Indexed: 12/16/2022] Open
Abstract
Over the past decade, flow diverter technology for endocranial aneurysms has seen rapid evolution, with the development of new devices quickly outpacing the clinical evidence base. However, flow diversion has not yet been directly compared to surgical aneurysm clipping or other endovascular procedures. The oldest and most well-studied device is the Pipeline Embolization Device (PED; Medtronic), recently transitioned to the Pipeline Flex (Medtronic), which still has sparse data regarding outcomes. To date, other flow diverting devices have not been shown to outperform the PED, although information comes primarily from retrospective studies with short follow-up, which are not always comparable. Because of this lack of high-quality outcome data, no reliable recommendations can be made for choosing among flow diversion devices yet. Moreover, the decision to proceed with flow diversion should be individualized to each patient. In this work, we wish to provide a comprehensive overview of the technical specifications of all flow diverter devices currently available, accompanied by a succinct description of the evidence base surrounding each device.
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Affiliation(s)
- Georgios A Maragkos
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, Clinical and Translational Research Center, New York
| | - Hui Meng
- Canon Stroke and Vascular Research Center, University at Buffalo, Clinical and Translational Research Center, New York
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hopitalier de Toulouse, Toulouse, France
| | - Paolo Machi
- Department of Neuroradiology, Montpellier University Hospital, Montpellier, France
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Vitor Mendes Pereira
- Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
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18
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Luo B, Kang H, Zhang H, Li T, Liu J, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Yang X. Pipeline Embolization device for intracranial aneurysms in a large Chinese cohort: factors related to aneurysm occlusion. Ther Adv Neurol Disord 2020; 13:1756286420967828. [PMID: 33224273 PMCID: PMC7649855 DOI: 10.1177/1756286420967828] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: The Pipeline Embolization Device (PED, Covidien/Medtronic) is widely used to treat intracranial aneurysms. This PED in China post-market multi-center registry study (PLUS) investigated safety and effectiveness of the PED for intracranial aneurysms in the Chinese population. Methods: This was a panoramic, consecutive, real-world cohort registry study. Patients treated with PED with or without coils between November 2014 and October 2019 at 14 centers in China were included, and those treated by parent vessel occlusion or other stents were excluded. Study outcomes included angiographic evaluation of aneurysm occlusion, complications, in-stent stenosis, and predictors of aneurysm occlusion. A central committee reviewed all imaging and endpoint events. Results: In total, 1171 patients with 1322 intracranial aneurysms were included. The total occlusion rate was 81.4% (787/967) at mean follow-up of 8.96 ± 7.50 months, with 77.1% (380/493) occlusion in the PED alone and 85.9% (407/474) in the PED plus coiling group. On multi-variate analysis, female sex, hyperlipidemia, vertebral aneurysms, PED plus coiling, and blood flow detained to venous phase were significant predictors of aneurysm occlusion. In posterior circulation cohort, there was no variable associated with aneurysm occlusion. In-stent stenosis predictors included current smoking and cerebral sclerosis/stenosis. Conclusion: In the largest series on PED of multi-center date of China, data suggest that treatment with the flow-diverting PED in intracranial aneurysms was efficacious. The treatment of PED combined coiling and blood flow detained to venous phase after PED implant were associated with aneurysmal occlusion. The occlusion rate of vertebral aneurysms was higher than other location aneurysms. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT03831672.
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Affiliation(s)
- Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huibin Kang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Zhengzhou University People's Hospital, Zhengzhou, China
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jieqing Wan
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100050, China
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19
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Dmytriw AA, Phan K, Salem MM, Adeeb N, Moore JM, Griessenauer CJ, Foreman PM, Shallwani H, Shakir H, Siddiqui AH, Levy EI, Davies JM, Harrigan MR, Thomas AJ, Ogilvy CS. The Pipeline Embolization Device: Changes in Practice and Reduction of Complications in the Treatment of Anterior Circulation Aneurysms in a Multicenter Cohort. Neurosurgery 2020; 86:266-271. [PMID: 30860254 DOI: 10.1093/neuros/nyz059] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/05/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Pipeline Embolization Device (PED; Medtronic, Dublin, Ireland) has become an important tool for the treatment of cerebral aneurysms. Since FDA approval, there are ongoing efforts to increase aneurysm occlusion rates and reduce the incidence of complications. OBJECTIVE To assess aneurysm occlusion and complication rates over time. METHODS Retrospective analysis of consecutive anterior circulation aneurysms treated with a single PED between 2011 and 2016 at 3 academic institutions in the US was performed. Factors contributing to changes in aneurysm occlusion and complication rates over time were identified and evaluated. RESULTS A total of 284 procedures were performed on 321 anterior circulation aneurysms in 284 patients. At a median follow-up of 13 mo (mean 18 mo), complete or near complete occlusion (>90%) was achieved in 85.9% of aneurysms. There was no significant change in aneurysm occlusion rate or procedure length over time. Thromboembolic complication occurred in 8.1% of procedures, and there was a trend toward decreased incidence from 16.3% in 2011/2012 to 3.3% in 2016 (P = .14). Hemorrhagic complications significantly decreased from 8.2% in 2011/2012 to 0 to 1.0% in 2014-2016 (P = .1). CONCLUSION We report a notable drop in the rate of hemorrhagic and to a lesser extent thromboembolic complications with increased experience with PED in a multicenter cohort. Multiple factors are believed to contribute to this drop, including the evolved interpretation of platelet function testing, the switching of clopidogrel nonresponders to ticagrelor, and the reduced use of adjunctive coiling.
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Affiliation(s)
- Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Kevin Phan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nimer Adeeb
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Geisinger School of Medicine, Danville, Pennsylvania
| | - Paul M Foreman
- Department of Neurosurgery, University of Alabama, Birmingham, Birmingham, Alabama
| | - Hussain Shallwani
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Hakeem Shakir
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Jason M Davies
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama, Birmingham, Birmingham, Alabama
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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20
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Pressman E, De la Garza CA, Chin F, Fishbein J, Waqas M, Siddiqui A, Snyder K, Davies JM, Levy E, Kan P, Ren Z, Mokin M. Nuisance bleeding complications in patients with cerebral aneurysm treated with Pipeline embolization device. J Neurointerv Surg 2020; 13:247-250. [PMID: 32620576 DOI: 10.1136/neurintsurg-2020-016245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/03/2020] [Accepted: 06/15/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients with cerebral aneurysms treated with the Pipeline embolization device (PED) are maintained on dual antiplatelet therapy (DAPT) to prevent thromboembolic complications. Rates of minor, "nuisance" bleeding in these patients remain unknown. We sought to evaluate the frequency and factors associated with this bleeding and its effect on DAPT compliance. METHODS We performed a multicenter retrospective cohort study on consecutive cases of intracranial aneurysms treated with PED. Patient characteristics, aneurysm characteristics, and bleeding complications were analyzed. Severity of bleeding was defined according to a previously published classification defining nuisance bleeding as easy bruising, bleeding from small cuts, petechia, and ecchymosis. RESULTS 245 PED aneurysm procedures on 243 patients were retrospectively collected from three academic centers over a 4.25-year period. Sixty-seven patients (27%) had nuisance bleeds. Patients with a higher risk of nuisance bleeding were older (59.1±3.4 vs . 54.7±2.2, P=0.032). Patients with nuisance bleeds were more likely to have their DAPT regimen changed or dose lowered (29% vs 8.3%, P<0.001), were on DAPT for less time (10.0 months±2.60 vs. 14.6 months±1.95, P=0.005) and were more likely to have aneurysm occlusion at 6 months (P<0.001). Stepwise logistic regression found age predictive of a nuisance bleed (OR=1.033) CONCLUSIONS: Nuisance bleeding was a common complaint of PED-treated aneurysm patients maintained on DAPT. Increasing age and aneurysmal occlusion at 6 months were the only factors predictive of nuisance bleeds. Clinicians were more likely to adjust antiplatelet regimens or stop DAPT early given a nuisance bleed.
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Affiliation(s)
- Elliot Pressman
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA
| | - Carlos A De la Garza
- Neurology, Baylor College of Medicine Department of Neurology, Houston, Texas, USA
| | - Felix Chin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Jacob Fishbein
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Kenneth Snyder
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Elad Levy
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Zeguang Ren
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA.,Neurosciences Group, Tampa General Hospital, Tampa, FL, USA
| | - Maxim Mokin
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA .,Neurosciences Group, Tampa General Hospital, Tampa, FL, USA
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21
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Kan P, Sweid A, Srivatsan A, Jabbour P. Expanding Indications for Flow Diverters: Ruptured Aneurysms, Blister Aneurysms, and Dissecting Aneurysms. Neurosurgery 2019; 86:S96-S103. [DOI: 10.1093/neuros/nyz304] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The safety and efficacy of flow diversion (FD) in the treatment of cerebral aneurysms have been reported by many studies. FD has enabled the treatment of complex aneurysms and aneurysms that were previously untreatable by conventional means. It has achieved high rates of obliteration with essentially no recanalization, and its indications have continued to expand, now including ruptured aneurysms, blister aneurysms, and dissecting aneurysms.
OBJECTIVE
To provide a review on the outcomes of studies covering the use of FD in the settings of ruptured, blister, and dissecting aneurysms. In addition, to discuss dual antiplatelet therapy (DAPT) used in preparation for FD deployment in these scenarios, including associated complications with DAPT use in the acute rupture setting.
METHODS
References for this topical review were identified by PubMed searches between January 2000 and January 2019. The search terms “aneurysm”, “flow diverter”, “stent”, “pipeline”, “ruptured”, “blister”, and “dissecting aneurysms” were used.
RESULTS
FD carries a higher complication rate in the acute rupture setting than for unruptured aneurysms. Patient selection is of paramount importance for achieving good functional and angiographic outcomes. DAPT still remains challenging, especially in ruptured aneurysms. Advancements in surface modification of flow diverters can reduce the risk of thromboembolism and perhaps lead to a safer antiplatelet regimen.
CONCLUSION
In summary, FD shows promise to be an effective treatment for ruptured, blister, and dissecting aneurysms.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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22
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Sharma M, Ugiliweneza B, Fortuny EM, Khattar NK, Andaluz N, James RF, Williams BJ, Boakye M, Ding D. National trends in cerebral bypass for unruptured intracranial aneurysms: a National (Nationwide) Inpatient Sample analysis of 1998–2015. Neurosurg Focus 2019; 46:E15. [DOI: 10.3171/2018.11.focus18504] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/08/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe development and recent widespread dissemination of flow diverters may have reduced the utilization of surgical bypass procedures to treat complex or giant unruptured intracranial aneurysms (UIAs). The aim of this retrospective cohort study was to observe trends in cerebral revascularization procedures for UIAs in the United States before and after the introduction of flow diverters by using the National (Nationwide) Inpatient Sample (NIS).METHODSThe authors extracted data from the NIS database for the years 1998–2015 using the ICD-9/10 diagnostic and procedure codes. Patients with a primary diagnosis of UIA with a concurrent bypass procedure were included in the study. Outcomes and hospital charges were analyzed.RESULTSA total of 216,212 patients had a primary diagnosis of UIA during the study period. The number of patients diagnosed with a UIA increased by 128% from 1998 (n = 7718) to 2015 (n = 17,600). Only 1328 of the UIA patients (0.6%) underwent cerebral bypass. The percentage of patients who underwent bypass in the flow diverter era (2010–2015) remained stable at 0.4%. Most patients who underwent bypass were white (51%), were female (62%), had a median household income in the 3rd or 4th quartiles (57%), and had private insurance (51%). The West (33%) and Midwest/North Central regions (30%) had the highest volume of bypasses, whereas the Northeast region had the lowest (15%). Compared to the period 1998–2011, bypass procedures for UIAs in 2012–2015 shifted entirely to urban teaching hospitals (100%) and to an elective basis (77%). The median hospital stay (9 vs 3 days, p < 0.0001), median hospital charges ($186,746 vs $66,361, p < 0.0001), and rate of any complication (51% vs 17%, p < 0.0001) were approximately threefold higher for the UIA patients with bypass than for those without bypass.CONCLUSIONSDespite a significant increase in the diagnosis of UIAs over the 17-year study period, the proportion of bypass procedures performed as part of their treatment has remained stable. Therefore, advances in endovascular aneurysm therapy do not appear to have affected the volume of bypass procedures performed in the UIA population. The authors’ findings suggest a potentially ongoing niche for bypass procedures in the contemporary treatment of UIAs.
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