Pipeline embolization for definitive endoluminal reconstruction of blister-type carotid aneurysms after clip wrapping

Early surgical versus endovascular repair of ruptured blood-blister aneurysm of the internal carotid artery: a single-center 20-year experience

OBJECTIVE

Early repair of ruptured blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) remains challenging. Although both surgical and endovascular therapies have been established, their relative superiority remains debated. The authors assessed their single-center experience and compared early deconstructive versus reconstructive repair and early reconstructive surgical versus endovascular repair of ruptured BBAs of the ICA.

METHODS

The study included patients who underwent repair of ruptured BBAs of the ICA within 1 week after the ictus during a 20-year period. Multiple variables were recorded, including clinical state, severity of subarachnoid hemorrhage (SAH), characteristics of the BBA, treatment details, complication profile, need for secondary treatment, and clinical outcome.

RESULTS

In total, 27 patients underwent early surgical (n = 16) or endovascular (n = 11) repair of BBAs at a median of 24 hours (range 9-120 hours) after the ictus during the period from September 2000 to June 2021 (20.4 years). Primary deconstructive repair (n = 6) without bypass was accompanied by middle cerebral artery (MCA) territory infarction in 5 of 6 (83%) patients and a high mortality rate (4/6 [67%]). Among the 21 patients who underwent early reconstructive repair, surgery was performed in 11 patients (clipping in 6 and clip-wrapping in 5 patients) and endovascular repair in 10 patients (flow diversion in 7 and stent/stent-assisted coiling in 3 patients). No differences were found in complication profiles or clinical outcomes between the surgical and endovascular groups. The mortality rate was low (2/21 [9.5%]), with 1 fatality in each group.

CONCLUSIONS

From the authors' experience, both surgical and endovascular approaches permitted reconstructive repair of ruptured BBAs of the ICA, with no modality proving superior. Reconstructive treatment is preferable to ICA sacrifice, and if sacrifice is chosen, it should be accompanied with bypass surgery or delayed to the phase when cerebral vasospasm has resumed. The rare occurrence of this disease calls for prospective multicenter studies to improve treatment and delineate which modality is preferable in individual cases.

Microsurgical Clip Reconstruction of a Ruptured Internal Carotid Artery Terminus Blister Aneurysm Using a Reverse Picket Fence Technique

BACKGROUND

Blister aneurysms are rare, technically challenging lesions that are typically ill defined and arise at nonbranch points of arteries.

OBJECTIVE

To describe the microsurgical treatment of a ruptured blister aneurysm at the internal carotid artery (ICA) terminus using the reverse picket fence clipping technique.

METHODS

The patient was a 60-yr-old male. He presented with a Hunt and Hess Grade 2, Fisher Grade 3 subarachnoid hemorrhage located in the bilateral sylvian fissures (right > left) and suprasellar cisterns. Computed tomography angiography demonstrated 2 aneurysms: a 2-mm right middle cerebral artery (MCA) aneurysm and a 2.5-mm right internal carotid artery (ICA) terminus blister aneurysm. Transradial cerebral angiography was undertaken which showed these similar sized aneurysms. Microsurgical treatment was chosen, and the patient underwent a right pterional craniotomy for clipping of his aneurysms. The patient consented to the procedure.

RESULTS

The combination of stacked fenestrated clips repaired the vessel, with intraoperative fluorescein and indocyanine green angiography demonstrated normal filling of the MCA and ICA circulation with no delay. Intraoperative angiography confirmed induced moderate stenosis of the ICA terminus at about 50%, which is essential to close the blister aneurysm site by utilizing a portion of the normal vessel wall.

CONCLUSION

Ruptured blister aneurysms at the ICA terminus can be safely repaired using the reverse picket fence technique for clipping.

Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, and Carotid Cavernous Fistulas

Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.

Blister aneurysms of the internal carotid artery: Surgical treatment and management outcome from a single center experience

OBJECTIVE

Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) are rare entities, but clinically important cause of subarachnoid hemorrhage (SAH). Several surgical and endovascular strategies have been attempted for these heterogeneous lesions. In this study, the authors analyzed the treatment strategy and outcomes in a series of cases of ICA blister aneurysms treated microsurgically.

PATIENTS AND METHODS

We retrospectively reviewed 15 consecutive cases of patients harboring ruptured BBAs, microsurgically treated at our institution between 2014 and 2018. We performed an analysis of the clinical and surgical aspects, as well as post-operative angiograms and outcomes.

RESULTS

Fifteen patients were identified; 9 (60%) were female. The mean age of presentation was 43,8 years. Most patients presented in good clinical conditions (Hunt-Hess 1-3 = 86%). The most common Fisher grade at presentation was 3 (60% of cases). All patients underwent digital subtraction angiography (DSA), revealing broad-based aneurysms at non-branching sites on the dorsal wall of the ICA. Intraoperatively, BBAs were confirmed in all cases. The lesions were approached through pterional (11-73%) or lateral supraorbital (4-27%) craniotomy. Direct clipping was performed in all but one lesion, in which case the clip-wrapping technique was used. Final angiographic control revealed complete occlusion in 14 cases. One patient required reoperation due to residual aneurysm filling. At discharge, a good outcome (Glasgow Outcome Scale [GOS] 4 or 5) was observed in 12 (80%) patients. Three patients were discharged with a GOS of 3.

CONCLUSION

Blood-blister-type aneurysms are rare and challenging lesions. Preoperative knowledge and careful surgical planning can prevent poor clinical outcomes. Surgical treatment remains an effective and safe option in this context.

Contemporary endovascular and open aneurysm treatment in the era of flow diversion

Clinical outcomes have improved considerably over the last decade for patients with ruptured and unruptured aneurysms. Modern endovascular techniques, such as flow diversion, are associated with high aneurysm occlusion rates and have become a popular treatment modality for many types of aneurysms. However, the safety and effectiveness of flow diversion has not yet been established in trials comparing it with traditional aneurysm treatments. Moreover, there are some types of aneurysms that may not be appropriate for endovascular coiling, such as wide-necked aneurysms located at branch points of major vessels, large saccular aneurysms with multiple efferent arteries, dolichoectatic aneurysms, large aneurysms with mass effect, when there are technical complications with endovascular treatment, when patients cannot tolerate or have contraindications to antiplatelet therapy or in the setting of a subarachnoid haemorrhage. For these cases, open cerebrovascular surgery remains important. This review provides a discussion on the current trends and evidence for both flow diversion and open cerebrovascular surgery for complex aneurysms that may not be suitable for coiling. We emphasise a continued important role for surgical treatment in certain situations.

Pipeline embolization device for recurrence of previously treated aneurysms

OBJECTIVE

The utilization of the Pipeline embolization device (PED) has increased significantly since its inception and original approval for use in large, broad-necked aneurysms of the internal carotid artery. While microsurgical clipping and advances in endovascular techniques have improved overall efficacy in achieving complete occlusion, recurrences still occur, and the best modality for retreatment remains controversial. Despite its efficacy in this setting, the role of PED utilization in the setting of recurrent aneurysms has not yet been well defined. This study was designed to assess the safety and efficacy of PED in the recurrence of previously treated aneurysms.

METHODS

The authors reviewed a total of 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following prior treatment with another modality. The PEDs were used to treat aneurysm recurrence or residual following endovascular coiling in 7 cases, flow diversion in 2, and microsurgical clipping in 4. The mean time between initial treatment and retreatment with a PED was 28.1 months, 12 months, and 88.7 months, respectively. Clinical outcomes, including complications and modified Rankin Scale (mRS) scores, and angiographic evidence of complete occlusion were tabulated for each treatment group.

RESULTS

All PEDs were successfully placed without periprocedural complications. The rate of complete occlusion was 80% at 6 months after PED placement and 100% at 12 months in these patients who underwent PED placement following failed endovascular coiling; there were no adverse clinical sequelae at a mean follow-up of 26.1 months. In the 2 cases in which PEDs were placed for treatment of residual aneurysms following prior flow diversion, 1 patient demonstrated asymptomatic vessel occlusion at 6 months, and the other exhibited complete aneurysm occlusion at 12 months. In patients with aneurysm recurrence following prior microsurgical clipping, the rate of complete occlusion was 100% at 6 and 12 months, with no adverse sequelae noted at a mean clinical follow-up of 27.7 months.

CONCLUSIONS

The treatment of recurrent aneurysms with the PED following previous endovascular coiling, flow diversion, or microsurgical clipping is associated with a high rate of complete occlusion and minimal morbidity.

Endovascular treatment of blister aneurysms

Blister aneurysms are rare cerebrovascular lesions for which the treatment methods are reviewed here, with a focus on endovascular options. The reported pathogenesis of blister aneurysms varies, and hemodynamic stress, arterial dissection, and arteriosclerotic ulceration have all been described. There is consensus on the excessive fragility of blister aneurysms and their parent vessels, which makes clipping technically difficult. Open surgical treatment is associated with high rates of complications, morbidity, and mortality; endovascular treatment is a promising alternative. Among endovascular treatment options, deconstructive treatment has been associated with higher morbidity compared with reconstructive methods such as direct embolization, stent- or balloon-assisted direct embolization, stent monotherapy, and flow diversion. Flow diversion has been associated with higher technical success rates and similar clinical outcomes compared with non–flow diverting treatment methods. However, delayed aneurysm occlusion and the need for antiplatelet therapy are potential drawbacks to flow diversion that must be considered when choosing among treatment methods for blister aneurysms.

Current status of the treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery: A review

Currently, the treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) is challenging and utilizes many therapeutic methods, including direct clipping and suturing, clipping after wrapping, clipping after suturing, coil embolization, stent-assisted coil embolization, multiple overlapping stents, flow-diverting stents, covered stents, and trapping with or without bypass. In these therapeutic approaches, the optimal treatment method for BBAs has not yet been defined based on the current understanding of BBAs of the supraclinoid ICA. Therefore, in this study, we aimed to review the literature from PubMed to discuss and analyze the pros and cons of the above approaches while adding our own viewpoints to the discussion. Among the surgical methods, direct clipping was the easiest method if the compensation of the collateral circulation of the intracranial distal ICA was sufficient or direct clipping did not induce stenosis in the parent artery. In addition, the clipping after wrapping technique should be chosen as the optimal surgical modality to prevent rebleeding from these lesions. Among the endovascular methods, multiple overlapping stents (≥3) with coils may be a feasible alternative for the treatment of ruptured BBAs. In addition, flow-diverting stents appear to have a higher rate of complete occlusion and a lower rate of retreatment and are a promising treatment method. Finally, when all treatments failed or the compensation of the collateral circulation of the intracranial distal ICA was insufficient, the extracranial-intracranial (EC-IC) arterial bypass associated with surgical or endovascular trapping, a complex and highly dangerous method, was used as the treatment of last resort.

Endovascular treatment of previously clipped aneurysms: continued evolution of hybrid neurosurgery

Background/objective

The optimal management of residual or recurrent clipped aneurysms is infrequently addressed in the literature.

Methods

We reviewed our endovascular database from January 1998 to May 2016 to identify patients with clipped aneurysms undergoing subsequent endovascular treatment, evaluating treatment approach, and clinical and angiographic outcomes.

Results

60 patients underwent endovascular treatment of residual/recurrent clipped aneurysms; 7 rebled prior to endovascular therapy. Treatment was via coiling alone (n=25, 42%), stent assisted coiling (n=15, 25%), balloon assisted coiling (n=8, 13%), flow diversion (n=8, 13%), stenting alone (n=3, 5%), or flow diversion with coiling (n=1, 2%). The procedural permanent neurological morbidity and mortality rates were 3% and 2%, respectively. Over a clinical follow-up of 253.4 patient years (median 3.9 years), there was one rebleed in a patient who had declined further treatment. For 43 patients with at least 1 month of digital subtraction angiographic follow-up (median 3.4 years), complete aneurysm occlusion was seen in 79% of cases. Neck remnants were observed in 14%, and stable small dome remnants were observed in 7% of cases. In a subgroup of 18 patients with ‘clip induced’ narrow neck aneurysms, all domes were initially coil occluded (Raymond 1 or 2); there was no permanent procedural morbidity and no aneurysms required retreatment or recanalized over a median follow-up of 3.9 years.

Conclusions

Endovascular treatment of residual or recurrent clipped aneurysms is an excellent treatment approach in well selected patients; ‘clip induced’ narrow neck aneurysms fare particularly well after treatment both angiographically and clinically.

Techniques and Outcomes of Gore-Tex Clip-Wrapping of Ruptured and Unruptured Cerebral Aneurysms

OBJECTIVE

Some aneurysms without a definable neck and associated parent vessel pathology are particularly difficult to treat and may require clipping with circumferential wrapping. We report the largest available contemporary series examining the techniques of Gore-Tex clip-wrapping of ruptured and unruptured intracranial aneurysms and patient outcomes.

METHODS

The presentation, location, and shape of the aneurysm; wrapping technique; outcome at discharge and last follow-up; and any change in the aneurysm at last angiographic follow-up were reviewed retrospectively in 30 patients with Gore-Tex clip-wrapped aneurysms.

RESULTS

Gore-Tex clip-wrapping was used in 8 patients with ruptured aneurysms and 22 patients with unruptured aneurysms. Aneurysms included 23 fusiform, 3 blister, and 4 otherwise complex, multilobed, or giant aneurysms. Of the 30 aneurysms, 63% were in the anterior circulation. The overall mean patient age was 52.5 years (range, 17-80 years). Postoperatively, there were no deaths or worsening of neurologic status and no parent vessel stenoses or strokes. The mean Glasgow Outcome Scale score at last follow-up was 4.7. The mean follow-up time was 42.3 months (median, 37.0 months; range, 3-96 months). There were 105.8 patient follow-up years. Aneurysms recurred in 2 patients with Gore-Tex clip-wrapping. No patients developed rehemorrhage. Overall risk of recurrence was 1.9% annually.

CONCLUSIONS

Gore-Tex has excellent material properties for circumferential wrapping of aneurysms and parent arteries. It is inert and does not cause a tissue reaction or granuloma formation. Gore-Tex clip-wrapping can be used safely for microsurgical management of ruptured and unruptured cerebral aneurysms with acceptable recurrence and rehemorrhage rates.