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Dutta G, Singh D, Jagetia A, Srivastava AK, Singh H, Kumar A. Endovascular management of large and giant intracranial aneurysms: Experience from a tertiary care neurosurgery institute in India. J Cerebrovasc Endovasc Neurosurg 2021; 23:99-107. [PMID: 33993689 PMCID: PMC8256021 DOI: 10.7461/jcen.2021.e2020.08.008] [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: 08/27/2020] [Accepted: 01/14/2021] [Indexed: 11/23/2022] Open
Abstract
Objective With the development of endovascular technique and devices, large and giant intracranial aneurysms are increasingly being managed by this less invasive method. Here we discuss our experience on managing such aneurysms via endovascular technique. Methods Retrospective data on 42 patients with large and giant intracranial aneurysms managed by endovascular techniques between September 2015 to December 2017 at our neurosurgery institute were included in this analysis. Results There were a total 42 patients with 9 giant and 33 large aneurysms in this study. Eight aneurysms were treated by parent vessel occlusion, 22 aneurysms with coils and rest 12 aneurysms were treated with stent assisted coiling. Following the procedure, Raymond class I occlusion was accomplished in 31 (73.8%) patients while class Ⅱ in 9 (21.4%) and class Ⅲ in 2 (4.8%) patients. Overall morbidity and mortality were 9.5% and 14.3% respectively and favorable outcome was seen in 80.9% patients. Significant correlation was observed with clinical outcome and initial neurological status. Conclusions The study indicates that endovascular intervention is a safe and effective method in managing large and giant intracranial aneurysms with lesser morbidity and mortality.
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Affiliation(s)
- Gautam Dutta
- Department of Neuro-Surgery, Rajendra Institute of Medical Sciences (RIMS), Jharkhand, India
| | - Daljit Singh
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Anita Jagetia
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Arvind K Srivastava
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Hukum Singh
- Department of Neuro-Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Anil Kumar
- Department of Neuro-Surgery, Rajendra Institute of Medical Sciences (RIMS), Jharkhand, India
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Fiorella D, Gache L, Frame D, Arthur AS. How safe and effective are flow diverters for the treatment of unruptured small/medium intracranial aneurysms of the internal carotid artery? Meta-analysis for evidence-based performance goals. J Neurointerv Surg 2020; 12:869-873. [PMID: 32005761 PMCID: PMC7476367 DOI: 10.1136/neurintsurg-2019-015535] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/18/2019] [Accepted: 12/22/2019] [Indexed: 11/04/2022]
Abstract
Background The objective of this meta-analysis was to establish safety and effectiveness benchmarks for endovascular therapy of unruptured small-to-medium internal carotid artery (ICA) aneurysms using flow diverters. Methods A systematic literature review and subsequent meta-analysis were performed using best research methods. Studies of any design with at least 10 patients treated with flow diverters for predominantly (≥90%) unruptured small/medium ICA aneurysms and ≥6 month follow-up were included. The primary effectiveness endpoint was complete aneurysm occlusion rate at 12 months. The primary safety endpoint was a composite measure of cumulative events that could indicate a stroke or neurologic death: any death, stroke, intracranial hemorrhage, or worsening on the modified Rankin Scale. Results 41 studies (2614 patients) met eligibility criteria for the meta-analysis. The core lab adjusted complete occlusion rate was 74.9% (95% CI 69.6% to 79.8%) at 12 months for studies using any flow diverter. With an aim of generating performance goals for a US Investigational Device Exemption (IDE) study, a pre-specified analysis was conducted using only studies with flow diverters commercially available in the USA. In this cohort, 12 month complete occlusion was 74.6% (95% CI 66.8% to 81.7%). The primary safety event rate for flow diverters commercially available in the USA was 7.8% (95% CI 4.8% to 11.4%). Conclusions The treatment of small and medium-sized aneurysms with flow diverters is effective in achieving curative reconstruction in most cases and is associated with low rates of morbidity and mortality. This meta-analysis informs robust performance goals for evaluating new flow diverters in small/medium unruptured carotid aneurysms.
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Affiliation(s)
- David Fiorella
- Stony Brook University Hospital, Stony Brook, New York, USA
| | - Larry Gache
- CTI Clinical Trial and Consulting Services, Covington, Kentucky, USA
| | - Diana Frame
- CTI Clinical Trial and Consulting Services, Covington, Kentucky, USA
| | - Adam S Arthur
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA .,Semmes-Murphey Clinic, Memphis, Tennessee, USA
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Piano M, Valvassori L, Lozupone E, Pero G, Quilici L, Boccardi E. FRED Italian Registry: a multicenter experience with the flow re-direction endoluminal device for intracranial aneurysms. J Neurosurg 2019; 133:174-181. [PMID: 31075778 DOI: 10.3171/2019.1.jns183005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The introduction of flow-diverter devices (FDDs) has revolutionized the endovascular treatment of intracranial aneurysms. Here the authors present their Italian multicenter experience using the flow re-direction endoluminal device (FRED) in the treatment of cerebral aneurysms, evaluating both short- and long-term safety and efficacy of this device. METHODS Between February 2013 and December 2014, 169 consecutive aneurysms treated using FRED in 166 patients were entered into this study across 30 Italian centers. Data collected included patient demographics, aneurysm location and characteristics, baseline angiography, adverse event and serious adverse event information, morbidity and mortality rates, and pre- and posttreatment modified Rankin Scale scores, as well as angiographic and cross-sectional CT/MRI follow-up at 3-6 months and/or 12-24 months per institutional standard of care. All images were reviewed and adjudicated by an independent core lab. RESULTS Of the 169 lesions initially entered into the study, 4 were later determined to be extracranial or nonaneurysmal by the core lab and were excluded, leaving 165 aneurysms in 162 patients treated in 163 procedures. Ninety-one (56.2%) patients were asymptomatic with aneurysms found incidentally. Of the 165 aneurysms, 150 (90.9%) were unruptured. One hundred thirty-four (81.2%) were saccular, 27 (16.4%) were fusiform/dissecting, and the remaining 4 (2.4%) were blister-like. One hundred thirty-seven (83.0%) arose from the anterior circulation.FRED deployment was impossible in 2/163 (1.2%) cases, and in an additional 4 cases (2.5%) the device was misdeployed. Overall mortality and morbidity rates were 4.3% and 7.3%, respectively, with rates of mortality and morbidity potentially related to FRED of up to 2.4% and 6.2%, respectively. Neuroimaging follow-up at 3-6 months showed complete or nearly complete occlusion of the aneurysm in 94% of cases, increasing to 96% at 12-24 months' follow-up. Aneurysmal sac shrinkage was observed in 78% of assessable aneurysms. CONCLUSIONS This preliminary experience using FRED for endovascular treatment of complex unruptured and ruptured aneurysms showed a high safety and efficacy profile that is comparable to those of other FDDs currently in use.
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Affiliation(s)
| | | | - Emilio Lozupone
- 2UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Guglielmo Pero
- 1ASST Grande Ospedale Metropolitano Niguarda, Milan; and
| | - Luca Quilici
- 1ASST Grande Ospedale Metropolitano Niguarda, Milan; and
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Szikora I, Turányi E, Marosfoi M. Evolution of Flow-Diverter Endothelialization and Thrombus Organization in Giant Fusiform Aneurysms after Flow Diversion: A Histopathologic Study. AJNR Am J Neuroradiol 2015; 36:1716-20. [PMID: 26251428 DOI: 10.3174/ajnr.a4336] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 02/04/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Treatment of giant fusiform aneurysms with flow diverters has been associated with a relatively high rate of complications. Our goal was to study the evolution of flow-diverter endothelialization and thrombus organization at different time points after flow-diverter treatment in giant fusiform aneurysms to better understand reasons for flow-diverter thrombosis and delayed aneurysm ruptures. MATERIALS AND METHODS Two giant anterior and 2 posterior circulation aneurysms, all of which had partially thrombosed before treatment, were studied. An unruptured, untreated posterior circulation aneurysm was used as a control. Each specimen was removed at 7 days or at 6, 9, or 13 months after flow-diverter treatment. The 3 patients who survived longer than 7 days were followed up by angiography and MR imaging. Formaldehyde-fixed paraffin-embedded sections were stained by using H&E, Van Gieson elastic, CD34, h-Caldesmon, and Picrosirius stains and studied by light microscopy. RESULTS According to angiography, aneurysms were found to be obliterated partially at 6 and 9 months and completely at 13 months. MR imaging revealed that mass effect remained unchanged in each case. Sections of the flow diverter within the normal parent artery were covered by an endothelialized fibrous layer as early as 6 months, but there was no tissue coverage or endothelialization seen even at 13 months inside the aneurysm itself. Each treated aneurysm had a thin wall with complete lack of smooth muscle cells. No signs of thrombus organization were found at any of the time points studied. CONCLUSIONS Endothelialization of the flow diverter in giant fusiform aneurysms may not occur and thrombus organization may not be initiated inside these aneurysms for as long as 1 year, which explains delayed flow-diverter thrombosis and the possibility of delayed ruptures.
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Affiliation(s)
- I Szikora
- From the National Institute of Clinical Neurosciences (I.S., M.M.), Budapest, Hungary
| | - E Turányi
- 1st Department of Pathology (E.T.), Semmelweis University Medical School, Budapest, Hungary
| | - M Marosfoi
- From the National Institute of Clinical Neurosciences (I.S., M.M.), Budapest, Hungary
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Kalani MYS, Rangel-Castilla L, Ramey W, Nakaji P, Albuquerque FC, McDougall CG, Spetzler RF, Zabramski JM. Indications and Results of Direct Cerebral Revascularization in the Modern Era. World Neurosurg 2015; 83:345-50. [DOI: 10.1016/j.wneu.2014.10.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 10/16/2014] [Indexed: 11/29/2022]
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Bae HJ, Yoo DS, Huh PW, Lee TG, Cho KS, Lee SB. Endovascular treatment of the distal internal carotid artery large aneurysm. J Cerebrovasc Endovasc Neurosurg 2014; 16:200-8. [PMID: 25340021 PMCID: PMC4205245 DOI: 10.7461/jcen.2014.16.3.200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/02/2014] [Accepted: 09/03/2014] [Indexed: 12/05/2022] Open
Abstract
Objective According to the development of endovascular technique and devices, larger aneurysms on the distal internal carotid artery (ICA) can be treated using a less invasive method. The authors report on clinical and angiographic outcomes of these aneurysms treated using an endovascular technique. Materials and Methods Data on 21 patients with large aneurysms at distal ICA treated by endovascular method between January 2005 and December 2012 were included in this retrospective analysis. Results Clinical outcome of patients showed strong correlation with the initial neurologic status (p < 0.05). Aneurysm morphology showed saccular, fusiform, and wide-neck in 12, six and three patients. Six patients underwent stent assisted coiling and the other 15 patients underwent simple coiling. Aneurysm occlusion was performed immediately after embolization with near-complete (Raymond class 1-2) in 20 patients (95.2%) and incomplete (Raymond class 3) in one patient (4.8%). Delayed thrombotic occlusion occurred in two patients and their clinical result was fatal. Another five patients died in the hospital, from massive brain edema and/or increased intracranial pressure due to initial subarachnoid hemorrhage. Overall mortality was 30% (seven out of 21). Fatal complication related to the endovascular procedure occurred in two patients with thrombosis at middle cerebral artery (one with stent, the other without it). Conclusion Recent developed endovascular device and technique is safe enough and a less invasive method for distal large or giant aneurysms. Based on our analysis of the study, we suspect that coil embolization of large distal ICA aneurysms (with or without stenting) is effective and safe.
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Affiliation(s)
- Hong-Ju Bae
- Department of Neurosurgery, Uijongbu St. Mary's Hospital, School of Medicine, The Catholic University, Uijongbu, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Uijongbu St. Mary's Hospital, School of Medicine, The Catholic University, Uijongbu, Korea
| | - Pil-Woo Huh
- Department of Neurosurgery, Uijongbu St. Mary's Hospital, School of Medicine, The Catholic University, Uijongbu, Korea
| | - Tae-Gyu Lee
- Department of Neurosurgery, Uijongbu St. Mary's Hospital, School of Medicine, The Catholic University, Uijongbu, Korea
| | - Kyoung-Suok Cho
- Department of Neurosurgery, Uijongbu St. Mary's Hospital, School of Medicine, The Catholic University, Uijongbu, Korea
| | - Sang-Bok Lee
- Department of Neurosurgery, Uijongbu St. Mary's Hospital, School of Medicine, The Catholic University, Uijongbu, Korea
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Sorkin GC, Hopkins LN. Endovascular Nuances of the Treatment of Very Small Intracranial Aneurysms. World Neurosurg 2014; 81:676-7. [DOI: 10.1016/j.wneu.2013.03.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 03/14/2013] [Indexed: 11/26/2022]
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Moon K, Albuquerque FC, Ducruet AF, Webster Crowley R, McDougall CG. Treatment of ophthalmic segment carotid aneurysms using the pipeline embolization device: clinical and angiographic follow-up. Neurol Res 2014; 36:344-50. [PMID: 24617935 DOI: 10.1179/1743132814y.0000000322] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Aneurysms of the ophthalmic segment of the internal carotid artery (ICA) often present unique challenges to endovascular treatment due to their proximity to or involvement of the ophthalmic artery, and the subsequent risk of post-operative visual complications. The pipeline embolization device (PED) represents a paradigm shift and promising new therapy in the treatment of intracranial aneurysms. We reviewed the ophthalmic segment ICA aneurysms treated with the PED at Barrow Neurological Institute (BNI) to report outcome data, including patency of the ophthalmic artery and visual complications. METHODS The prospectively maintained BNI endovascular database was reviewed for all patients with ophthalmic segment ICA aneurysms treated with the PED since May 2011. Patient charts and digital subtraction angiograms were reviewed to report angiographic outcomes and visual complications. Only patients with at least 6 months of follow-up were included in the analysis. RESULTS Of 30 patients treated with ophthalmic segment aneurysms during the study period, sufficient follow-up was available for 29 patients with 38 aneurysms, all of which were treated electively. The PED was successfully deployed for all lesions, with 92·1% complete or near-complete obliteration rate at angiographic follow-up. All but one patient were found to have a patent ophthalmic artery at short-term follow-up and 100% of patients retained intact vision. Five patients had minor periprocedural hemorrhagic complications but no permanent morbidities. There were no intracranial hemorrhages, thromboembolic phenomena, vessel dissections, or mortalities. CONCLUSION Treatment of ophthalmic segment ICA aneurysms with the PED is safe and effective at short-term follow-up.
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Lin LM, Colby GP, Kim JE, Huang J, Tamargo RJ, Coon AL. Immediate and follow-up results for 44 consecutive cases of small (<10 mm) internal carotid artery aneurysms treated with the pipeline embolization device. Surg Neurol Int 2013; 4:114. [PMID: 24083050 PMCID: PMC3779399 DOI: 10.4103/2152-7806.117711] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 07/07/2013] [Indexed: 11/27/2022] Open
Abstract
Background: The pipeline embolization device (PED) provides effective, durable and safe endovascular reconstruction of large and giant intracranial aneurysms. However, 80% of all cerebral aneurysms found in the general population are less than 10 mm in size. Treatment of small aneurysms (<10 mm) with flow diverters may be advantageous over endosaccular modalities that carry risks of procedural rupture during aneurysm access or coil placement. Methods: We retrospectively reviewed a prospective, single-center aneurysm database to identify all patients with small (<10 mm) internal carotid artery (ICA) aneurysms who underwent endovascular treatment using the PED. Patient demographics, aneurysm characteristics, procedural details, complications, and technical and clinical outcomes were analyzed. Results: Forty-four cases were performed in 41 patients (age range 31-78 years). PED was successfully implanted in 42 cases. A single PED was used in 37/42 (88%) cases. Mean postprocedure hospital stay was 1.7 ± 0.3 days and 98% of patients were discharged home. Major complication occurred in one patient (2.3%), who died of early subarachnoid hemorrhage. Transient neurological deficit, delayed intracerebral hemorrhage (asymptomatic), and delayed groin infection occurred in one patient each. Follow-up rate was 91.8% (45 aneurysms in 35 patients) with a mean follow-up of 4.0 ± 1.9 months. By 6 months post-PED implantation, angiographic success (complete or near complete aneurysm occlusion) was observed in 80%. Mild (<50%), asymptomatic, nonflow limiting in-stent stenosis was observed in 5.4% (2/37 cases). All the 35 patients with follow-up remained at preprocedure neurological baseline. Conclusion: Small (<10 mm) ICA aneurysm treatment with PED implantation is safe and carries a high rate of early angiographic success.
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Affiliation(s)
- Li-Mei Lin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287, USA
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Kojima M, Irie K, Fukuda T, Arai F, Hirose Y, Negoro M. The study of flow diversion effects on aneurysm using multiple enterprise stents and two flow diverters. Asian J Neurosurg 2013; 7:159-65. [PMID: 23559981 PMCID: PMC3613636 DOI: 10.4103/1793-5482.106643] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Computer-based simulation is necessary to clarify the hemodynamics in brain aneurysm. Specifically for endovascular treatments, the effects of indwelling intravascular devices on blood stream need to be considered. The most recent technology used for cerebral aneurysm treatment is related to the use of flow diverters to reduce the amount of flow entering the aneurysm. To verify the differences of flow reduction, we analyzed multiple Enterprise stents and two kinds of flow diverters. MATERIALS AND METHODS In this research, we virtually modeled three kinds of commercial intracranial stents (Enterprise, Silk, and Pipeline) and mounted to fit into the vessel wall, and deployed across the neck of an IC-ophthalmic artery aneurysm. Also, we compared the differences among multiple Enterprise stents and two flow diverters in a standalone mode. RESULTS From the numerical results, the values of wall shear stress and pressure are reduced in proportion to the size of mesh, especially in the inflow area. However, the reduced velocity within the aneurysm sac by the multiple stents is not as significant as the flow diverters. CONCLUSIONS This is the first study analyzing the flow alterations among multiple Enterprise stents and flow diverters. The placement of small meshed stents dramatically reduced the aneurysmal fluid movement. However, compared to the flow diverters, we did not observe the reduction of flow velocity within the aneurysm by the multiple stents.
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Affiliation(s)
- Masahiro Kojima
- Department of Micro-Nano System Engineering, Nagoya University, Japan
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Sorkin GC, Hopkins LN. Endovascular correlates of cavernous sinus anatomy. World Neurosurg 2013; 82:e421-2. [PMID: 23376372 DOI: 10.1016/j.wneu.2013.01.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/28/2013] [Indexed: 10/27/2022]
Affiliation(s)
- Grant C Sorkin
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA
| | - L Nelson Hopkins
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Toshiba Stroke and Vascular Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA.
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Brisman JL. What's coming down the pipe--and should we be excited, concerned, or both? AJNR Am J Neuroradiol 2013. [PMID: 23179650 DOI: 10.3174/ajnr.a3425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J L Brisman
- Department of NeurosurgeryWinthrop University Hospital, Mineola, New York, USA
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Withers K, Carolan-Rees G, Dale M. Pipeline™ embolization device for the treatment of complex intracranial aneurysms: a NICE Medical Technology Guidance. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:5-13. [PMID: 23341264 PMCID: PMC3563954 DOI: 10.1007/s40258-012-0005-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
As part of its Medical Technologies Evaluation Programme, the National Institute of Health and Clinical Excellence (NICE) invited the manufacturer, Covidien, to provide clinical and economic evidence for the evaluation of the Pipeline™ embolization device (PED) for the treatment of complex intracranial aneurysms. Cedar; a consortium between Cardiff and Vale University Health Board and Cardiff University, was commissioned to act as an External Assessment Centre (EAC) for NICE to independently critique the manufacturers' submissions. This article gives an overview of the evidence provided, the findings of the EAC and the final guidance published by NICE. The scope issued by NICE considered PED as the intervention in a patient population with complex unruptured intracranial aneurysms (IAs), specifically large/giant, wide-necked and fusiform aneurysms. The comparator treatments identified were stent-assisted coiling, parent vessel occlusion, neurosurgical techniques and conservative management. The manufacturer claimed that PED fulfils a currently unmet clinical need in the treatment of large or giant, wide-necked or fusiform IAs. Thirteen studies were identified by the manufacturer as being relevant to the decision problem, with two of these included for data extraction. The EAC identified 16 studies as relevant, three of which had been published after the manufacturer's search. Data extraction was carried out on these studies as, although many were low level research comprising of case reports and case series, they provided useful, pertinent safety and outcome data. No relevant economic studies of the device were identified; therefore, a new economic model was designed by the manufacturer. The base-case scenario provided recognized the costs of PED to be higher than the costs for endovascular parent vessel occlusion, neurosurgical parent vessel occlusion, neurosurgical clipping and conservative management. However, PED was found to be cost saving compared with stent-assisted coiling, with a saving of £13,110 per patient. Analysis of the clinical data suggested that treatment with PED has high rates of clinical success with high rates of aneurysm occlusion and acceptable adverse events for the patient population. Economic evidence suggested that the costs in the base-case for PED may have been underestimated, meaning that PED would only become cost saving in patients who would otherwise require treatment with 32 coils or more. NICE Medical Technologies Guidance MTG10, issued in May 2012, recommends the adoption of PED in selected patients within the UK National Health Service (NHS).
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Affiliation(s)
- Kathleen Withers
- Cedar, Cardiff and Vale University Health Board, Cardiff Medicentre, Heath Park, Wales, UK.
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Leung GKK, Tsang ACO, Lui WM. Pipeline embolization device for intracranial aneurysm: a systematic review. Clin Neuroradiol 2012; 22:295-303. [PMID: 23124329 PMCID: PMC3505532 DOI: 10.1007/s00062-012-0178-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 10/04/2012] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The pipeline embolization device (PED) is a new endovascular stent designed for the treatment of challenging intracranial aneurysms (IAs). Its use has been extended to nonruptured and ruptured IAs of a variety of configurations and etiologies in both the anterior and posterior circulations. METHODS We conducted a systematic review of ten eligible reports on its clinical efficacy and safety. RESULTS There were 414 patients with 448 IAs. The majority of the IAs were large (40.2 %), saccular or blister-like (78.3 %), and were located mostly in the anterior circulation (83.5 %). The regimens of antiplatelet therapy varied greatly between and within studies. The mean number of the PED used was 2.0 per IA. Deployment was successful in around 95 % of procedures. Aneurysm obliteration was achieved in 82.9 % of IAs at 6-month. The overall incidences of periprocedural intracranial vascular complication rate and mortality rate were 6.3 and 1.5 %, respectively. CONCLUSION The PED is a safe and effective treatment for nonruptured IAs. Its use in the context of acute subarachnoid hemorrhage (SAH) should be cautioned. Its main limitations include the need for prolonged antiplatelet therapy, as well as the potential risks of IA rupture and non-IA-related intracerebral hemorrhages (ICH). Future studies should aim at identifying factors that predispose to incomplete obliteration, delayed rupture, and thromboembolic complications.
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Affiliation(s)
- G K K Leung
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, China.
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Briganti F, Napoli M, Tortora F, Solari D, Bergui M, Boccardi E, Cagliari E, Castellan L, Causin F, Ciceri E, Cirillo L, De Blasi R, Delehaye L, Di Paola F, Fontana A, Gasparotti R, Guidetti G, Divenuto I, Iannucci G, Isalberti M, Leonardi M, Lupo F, Mangiafico S, Manto A, Menozzi R, Muto M, Nuzzi NP, Papa R, Petralia B, Piano M, Resta M, Padolecchia R, Saletti A, Sirabella G, Bolgè LPV. Italian multicenter experience with flow-diverter devices for intracranial unruptured aneurysm treatment with periprocedural complications—a retrospective data analysis. Neuroradiology 2012; 54:1145-52. [PMID: 22569955 DOI: 10.1007/s00234-012-1047-3] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 04/26/2012] [Indexed: 10/28/2022]
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McAuliffe W, Wenderoth JD. Immediate and midterm results following treatment of recently ruptured intracranial aneurysms with the Pipeline embolization device. AJNR Am J Neuroradiol 2011; 33:487-93. [PMID: 22135131 DOI: 10.3174/ajnr.a2797] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A number of flow-diverting devices have become available for endovascular occlusion of cerebral aneurysms. This article reports immediate and midterm results in recently ruptured aneurysms treated with the PED. MATERIALS AND METHODS A prospective registry was established at 3 Australian neurointerventional sites to collect data on ruptured and unruptured aneurysms treated with PED during a 12-month period from August 2009. From this data base of 65 patients, 11 cases of recent aneurysmal SAH were examined. Relevant data including antiplatelet therapy, technical issues, complications, and imaging findings during at least a 6-month period of follow-up were collected and analyzed. RESULTS Eleven patients had acutely ruptured aneurysms with SAH. Clinical follow-up was available on all cases with imaging follow-up at 6 months in 9 patients. Two patients died from rebleeding during the acute illness. There was no other procedural or delayed significant symptomatic morbidity. Eight aneurysms were occluded with a single case of residual body filling. CONCLUSIONS PED should be used in SAH with caution, reserved for suitable patients concomitantly treated with endosaccular coiling if possible.
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Affiliation(s)
- W McAuliffe
- Neurological Intervention and Imaging Service Western Australia, Sir Charles Gairdner Hospital, Perth, Australia.
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McAuliffe W, Wycoco V, Rice H, Phatouros C, Singh TJ, Wenderoth J. Immediate and midterm results following treatment of unruptured intracranial aneurysms with the pipeline embolization device. AJNR Am J Neuroradiol 2011; 33:164-70. [PMID: 21979492 DOI: 10.3174/ajnr.a2727] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A number of flow-diverting devices have become available for endovascular occlusion of cerebral aneurysms. This article reports immediate and midterm results in treating unruptured aneurysms with the PED. MATERIALS AND METHODS A prospective registry was established at 3 Australian neurointerventional units. Aneurysms were treated on the basis of unfavorable anatomy or recurrence following previous treatment. Aneurysms were treated with PED or PED and coils. Data including antiplatelet therapy, technical issues, complications, and imaging findings were recorded during at least a 6-month period. RESULTS A total of 57 aneurysms in 54 patients were treated by 5 neurointerventional radiologists. Forty-one aneurysms were asymptomatic, and 16 patients had mass-induced neurological deficit. Clinical follow-up was available in 57 aneurysms with imaging follow-up at 6 months in 56. Permanent morbidity and mortality in the series was 0% at 6 months. Four TIAs and 1 small retinal branch occlusion occurred, but no stroke. The demonstrated aneurysm occlusion rate at 1 month was 61.9%, and the overall occlusion rate at 6 months was 85.7%. In cases previously untreated, the 6-month occlusion was 92.5%. Three of 6 aneurysms with a previous stent in situ were occluded. Two patients (3.5%) had asymptomatic in-construct stenosis of >50%. Acute aneurysm-provoked mass effect resolved or improved significantly in all cases. CONCLUSIONS Use of the PED is safe and efficacious in difficult aneurysms with a high occlusion rate at 6 months, but lower occlusion rates were seen in a small population with previous stents in situ.
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Affiliation(s)
- W McAuliffe
- Department of Neurological Intervention and Imaging, Sir Charles Gairdner Hospital, Perth, Australia.
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Wong GKC, Kwan MCL, Ng RYT, Yu SCH, Poon WS. Flow diverters for treatment of intracranial aneurysms: Current status and ongoing clinical trials. J Clin Neurosci 2011; 18:737-40. [PMID: 21514166 DOI: 10.1016/j.jocn.2010.10.011] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 10/22/2010] [Accepted: 10/22/2010] [Indexed: 12/01/2022]
Affiliation(s)
- George K C Wong
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
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